Psychiatry Investig Search

CLOSE


Psychiatry Investig > Volume 19(6); 2022 > Article
Kim, Park, Kim, Jhon, Kim, Kang, Kim, Ryu, Lee, Shin, and Kim: Development of a Checklist for Predicting Suicidality Based on Risk and Protective Factors: The Gwangju Checklist for Evaluation of Suicidality

Abstract

Objective

The aim of the study was to develop a checklist for mental health clinicians to predict and manage suicidality.

Methods

A literature review of the risk and protective factors for suicide was conducted to develop a checklist for evaluating suicidality.

Results

The fixed risk factors included sex (male), age (older individuals), history of childhood adversity, and a family history of suicide. Changeable risk factors included marital status (single), economic status (poverty), physical illness, history of psychiatric hospitalization, and history of suicide attempts. Recent discharge from a mental hospital and a recent history of suicide attempts were also included. Manageable risk factors included depression (history and current), alcohol problems (frequent drinking and alcohol abuse), hopelessness, agitation, impulsivity, impaired reality testing, and command hallucinations. Protective factors included responsibility to family, social support, moral objections to suicide, religiosity, motivation to get treatment, ability to cope with stress, and a healthy lifestyle. A final score was assigned based on the sum of the risk and protective factor scores.

Conclusion

We believe that the development of this checklist will help mental health clinicians to better assess those at risk for suicidal behavior. Further studies are necessary to validate the checklist.

INTRODUCTION

Suicide is one of the leading causes of death worldwide. The suicide rate for the Republic of Korea is the highest among all Organisation of Economic Co-operation and Development countries over the past decade [1]. Suicide is the fifth-leading cause of death in Korea. Thus, suicide is a major public health problem, and its prevention is a public health priority [2].
To prevent suicide, it is important to be able to assess and predict the risk thereof. Numerous studies have attempted to identify suicide risk factors for the prediction and prevention of suicide [3]. Studies have shown that suicide risk is associated with biological, psychological, social, and environmental factors [4]. However, given the complex nature of suicidal behavior, the multitude of factors involved, and the dynamic interactions among them, predicting suicidality can be a difficult undertaking [5]. In addition, a relatively low incidence of suicidal deaths has limited the feasibility of developing a valid scale for assessing suicidal risk, which is further compounded by a lack of specificity.
Suicidality can be managed by reducing the factors that promote or precede suicidal behavior, and enhancing protective factors that inhibit suicidal behavior [6]. Suicidal risk and protective factors are closely associated, and comprehensive assessment of these factors is important for timely intervention. One of the most commonly used instruments is the SAD PERSON scale, which is a 10-item scale designed to have high content validity [7]. However, a systemic review found insufficient evidence to support its use for predicting suicide [8,9]. A well-validated and easily accessible tool to help Korean clinicians evaluate suicidality is necessary. The aim of the current study was to develop a checklist of risk and protective factors for suicide, for use by mental health clinicians, based on evidence from the literature (including studies conducted in Korea).

METHODS

We developed the Gwangju Checklist for Evaluation of Suicidality (G-CES) based on clinical interviews to evaluate suicidality risk. First, we searched the literature to identify factors associated with suicidality. Based on earlier studies, including ones conducted in Korea, we complied a checklist of items for suicidality evaluation. The items of this checklist were broadly classified into two types: risk and protective factors. Risk factors were then classified into subfactors based on whether they were fixed (internal/demographic), variable (changeable over time), or manageable (through intervention). We then evaluated potential protective factors against suicidal behaviors.
The preliminary version of the G-CES used 2- and 4-point Likert scales [10]. However, after analysis of the initial data and discussions with clinicians and other stakeholders, we simplified the scale into a “yes/no” checklist format. The final checklist score is calculated as the sum of the risk and protective factor scores. The risk factors were assigned a value of “0” (no effect/not applicable) or “1” (yes), depending on whether the risk factor was present. The protective factors were assigned a score of “-1” (high/strong protection) or “0” (low/no effect). The clinical significance of the score is currently under review for validation purposes. Here, we present G-CES version 1.1, which we expect to modify based on the validation analyses and additional studies. However, even before the final validation, we expect that mental health clinicians will find this checklist helpful when interviewing patients at risk for suicidal behavior; the checklist may also be useful for assessing longitudinal changes within individuals. The Institutional Review Board of Chonnam National University Hospital approved this study (no. TMP CNUH-2019-013).

RESULTS

Figure 1 lists the checklist items for the G-CES.

Fixed risk factors

Fixed risk factors included demographics and a clinical history of factor/s associated with an elevated risk of suicide. It is important to identify such factors when assessing suicidality, even though they cannot be changed. Here, the fixed risk factors were sex (male), age (older individuals), childhood adversity history, and family history of suicide.

Sex (male)

Suicide rates are higher among males than females in most countries, although suicide attempts are more common in females. Many studies have explained the gender gap in suicidal behavior in terms of lethality. Males are more likely to die when they attempt suicide because their suicide methods are more lethal; they also show a stronger intent to die than females [11]. In Korea, the male suicide rate is more than twice that of females [12].

Age (older individuals)

The suicide rate generally increases with age [13]. Many studies have reported that older people are at a greater risk of suicide [14,15]. Suicide risk is especially high for elderly males in Korea [2]. Predictors of suicide in older individuals include psychiatric disorders, physical illness, economic problems, functional impairment, and stressful life events [16].

Childhood adversities

Exposure to childhood adversity is a strong and independent risk factor for suicidal behavior [17,18]. Adverse childhood experiences can increase the risk of suicide attempts two- to five-fold. Early life trauma significantly increases the likelihood of suicidality throughout the life span [19]. Surveys have demonstrated that exposure to childhood physical or sexual abuse, or the witnessing of domestic violence, accounts for 50% and 33% of suicide attempts among women and men, respectively [20]. Our previous studies of the Korean general population and patients with schizophrenia and depression showed significant associations between childhood adversity and suicidal behavior [21-24]. Abuse in childhood may promote suicidal behavior in adulthood through heightened trait impulsivity, the family dynamics associated with childhood adversity, and psychiatric disorders including substance use disorder and depression [19,25,26]. For these reasons, it is extremely important to thoroughly assess the history of childhood adversity to mitigate suicidal behavior.

Family (first degree relative) history of suicide

Suicide and suicidal behavior often have familial tendencies and appear to be heritable. This may be associated with a family history of psychiatric disorders, impulsive aggression, or environmental factors such as abuse, imitation, or transmission of psychopathology [27]. A family history of suicide is an independent predictor of suicidality, i.e., is independent of mental disorders [28]. Genetic risk factors for suicide have also been examined [4,29].

Changeable risk factors

Changeable/variable risk factors are those that can change in severity over time but are not direct targets for psychiatric intervention and management. They include marital status (single), economic status (poverty), physical illness, history of psychiatric hospitalization, and a history of suicide attempts. While a history of suicide attempts or psychiatric hospitalizations obviously cannot be changed, these factors were classified as changeable herein given the nature of the checklist, which is concerned with the 3-month or 1 year period after the occurrence of an event/discharge).

Marital status (single)

Marital status is associated with the risk of suicide; divorced and separated individuals are the most likely groups to commit suicide in both Western and Eastern countries [30,31]. Living with a spouse can exert a protective effect against suicide [32-34]. Durkheim hypothesized that marriage promotes social integration and a more supportive social network [35]. Single status showed a stronger association with suicidality than being married in our previous study conducted in the Korean general population [36].

Economic problems (poverty)

Low socioeconomic status is directly associated with a higher risk of suicide and suicide attempts [37,38]. In previous Korean studies analyzing suicide mortality data, the hazard ratios of suicide showed an increasing trend with lower socioeconomic status [39], and the suicide rate was higher in areas where more Medicaid recipients lived [40]. In our previous study on the factors associated with suicide attempts in the general population, Medicaid recipients with low poor economic status were six times more likely to attempt suicide than people with Medicare general insurance [36]. Personal financial problems and unemployment have been reported to be associated with suicidality [37,41], similar to economic crises and inequalities [42].

Physical illness

Previous studies have reported that people who suffer from physical illness and pain are at an increased risk for suicidal behavior [43-46]. Clinical depression is a strong predictor of elevated suicide risk among physically ill people [47]. Furthermore, suicide risk is highly elevated in cases of concurrent physical and psychiatric illnesses [44]. Some studies have shown that nearly all physical health conditions are associated with increased suicide risk, even after adjustment for potential confounders [45,48].

History of psychiatric hospitalization

Many studies have reported that the risk of suicide is heightened after discharge from psychiatric inpatient care [49-51]. The incidence of post-discharge suicide is higher closer to the time of discharge [52]. Suicide risk is especially high within the 3-month period after psychiatric discharge [49,51,53,54]. Additionally, the suicide rate remains high for many years after discharge [51]. Thus, patients who have recently been discharged from a psychiatric hospital should be closely monitored for suicide risk [55]. Suicide soon after discharge is associated with a more severe psychopathology, poorer functioning, and use of more lethal and easily available methods [56]. In the G-CES, items pertaining to suicide after discharge from a psychiatric hospital are scored based on the time therefrom (3 months, 1 year, or lifetime). Thus, history of psychiatric hospitalization has a weighted score.

Previous suicide attempt

A previous suicide attempt is a strong predictor of future attempts and completed suicides [8,57]. Suicide is more common among previous attempters than non-attempters [58]. Studies of risk factors for suicide consistently suggest that a history of suicide attempts is the most salient risk factor for current suicidality [54,59,60]. The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition includes a new diagnostic category, i.e., suicidal behavior disorder, which captures the history of suicide attempts [61]. Suicide attempts with a highly lethal method, and recent suicide attempts, are strongly associated with the risk of suicide. Thus, the G-CES includes multiple items pertaining to a history of suicide attempts, including items on lifetime, recent, and use of lethal methods during attempts.

Manageable risk factors

Risk factors that can be managed are state risk factors, in this case for suicide, which should be targeted by clinical interventions. They include depression, alcohol problems, hopelessness, agitation, impulsivity, impaired reality testing, and command hallucinations.

Depression

Major depression is the most common underlying psychiatric condition of people exhibiting suicidal behavior [36,62]. A recent systemic review of psychological autopsy studies of suicide victims showed that major depressive disorder, dysthymia, anxiety disorders, bipolar disorder, and schizophrenia were significantly associated with suicide risk [63]. Suicide attempters with bipolar disorder had experienced more lifetime episodes of major depression; moreover, twice the number of attempters compared to non-attempters were currently experiencing depressive or mixed episode [64]. Multiple mental disorders greatly increases suicidal risk [65,66]. The risk of attempted suicide is particularly high in the first 3 months after the onset of a major depressive episode, and in the first 5 years after the onset of major depressive disorder, independent of the duration of depression [67]. Dysfunction of the serotonin system, which is involved in impulsive and aggressive traits and depressive disorder, is associated with suicidal behavior [68]. Additionally, the risk of suicide increases with the severity of depression [60,67]. Thus, the G-CES includes two items pertaining to depression, i.e., one that focuses on the history thereof and another focusing on current significant depressive symptoms.

Hopelessness

In most empirical investigations of suicide, hopelessness has been identified as the most reliable psychological risk factor and clinical endophenotype [25,68]. Hopelessness mediates the relationship between suicidal ideation and suicidal acts, and reduces the desire to live in the face of distress [69]. Individuals with high levels of hopelessness may isolate themselves and exhibit less help-seeking behaviors [70]. As such, hopelessness is a major predictor of suicidality, especially in patients with psychiatric disorders and the elderly [25,67,71].

Agitation or anxiety

Agitation may be a warning sign and acute risk factor for suicidal behavior [72,73]. Agitation further increases the risk of suicide in patients with depressive symptoms or schizophrenia [74,75]. Anxiety symptoms and disorders have consistently been associated with an elevated risk of suicidal behavior in community cross-sectional and clinical studies [76,77]. Suicide risk is also closely associated with the severity of panic/agoraphobia, generalized anxiety, social anxiety, and obsessivecompulsive symptoms.

Alcohol problems

Suicide risk is high in people with alcohol problems; those suffering from alcohol use disorder were 60-120 times more likely to attempt suicide compared to the general population [78]. Moreover, a positive breathalyzer test is common among individuals who completed (up to 69%) or attempted (up to 73%) suicide [79]. Social drinking, i.e., drinking not satisfying the criteria for addiction, can also increase suicidality [80]. Alcohol consumption predisposes individuals to suicidal behavior through its depressogenic effects, impairment of problemsolving skills, and exacerbation of impulsivity, possibly through its effects on serotonergic neurotransmission [81,82]. Comorbid alcohol problems also increase the risk of suicide when cooccurring with other psychiatric disorders such as depression and schizophrenia [66]. In previous studies on the Korean general population, hazardous alcohol consumption was associated with previous suicide attempts and suicide deaths [36,40,83,84]. The G-CES includes two items on alcohol problems: frequency of alcohol consumption and alcohol use disorders.

Impulsivity and aggression

Impulsivity and aggression are highly correlated with suicidal behavior in psychiatric and general populations [85]. Impulsivity may mediate suicidal behavior in younger people, and in patients with alcohol use, personality, or psychotic disorder. Individuals with high levels of impulsivity cannot manage their behavior or make appropriate decisions [86]. Greater impulsivity and impaired decision-making may underlie the tendency toward suicidal and aggressive acts [87]. Impulsivity is an important predictor of suicidal behavior, as it may precipitate suicide ideation and suicidal action [69].

Impaired reality testing

Impaired reality testing, sometimes in the form of delusions, in various psychiatric illnesses (including psychotic disorders) may promote suicidality [88-90]. Approximately 2%-12% of all suicides are attributable to schizophrenia [91]. Suicide is a cause of early mortality in nearly 5% of patients with schizophrenia, and 25%-50% of patients with schizophrenia attempt suicide in their lifetime [92]. In addition, when reality testing is impaired, various conditions can reduce the ability to manage risky behavior and lead to suicidal behavior.

Command hallucinations

Auditory hallucinations are seen in various psychiatric conditions such as schizophrenia, major depressive disorder, bipolar disorder, and alcohol withdrawal. Command hallucinations to kill oneself are common and can lead to suicidal behavior [89,93]. Thus, mental health clinicians should be aware of this type of hallucination [93].

Protective factors

There are also some protective factors against suicidality. In the G-CES, there are seven such factors: responsibility to family, social support, moral objections to suicide, religiosity, motivation to seek treatment, ability to cope with stress, and a regulated and healthy lifestyle.

Responsibility to family

Responsibility to family can reduce suicidality in patients with psychiatric disorders [94,67]. It enhances the motivation to live and degree of control over suicidal urges. In our previous study on the Korean general population, family cohesion was significantly negatively associated with a history of suicide attempts [83].

Social support

Many studies have reported that social support is associated with a decreased likelihood of a lifetime suicide attempt, while controlling for a variety of related predictors [95]. Strong connections with family and community support may protect against suicidal behavior [68,96]. In contrast, loneliness and living alone increase suicidality [97]. Another Korean study showed that low social support, and low frequency of family contact and leisure activities were associated with suicide attempts [36,37]. Our previous study on hospitalized patients with schizophrenia showed that the frequency of family visits to the hospital was inversely associated with suicidality [98].

Moral objections to suicide

Many view suicide as an immoral act. People who have a permissive attitude toward suicide or few moral objections thereto are more likely to have a history of suicide attempts and cite fewer reasons for living [99,100]. Meanwhile, people who have significant moral objections to suicide are more likely to have a religious affiliation and express less hopelessness [67,99,101].

Religiosity

The results of previous studies investigating the association between religious affiliation and suicide have been inconsistent. However, several studies have shown that high religiosity is associated with a substantially lower suicide risk, especially in clinical populations [102]. In recent longitudinal prospective studies, frequent attendance of religious services was an important protective factor against completed suicide over the long term [103,104]. Religious affiliation may lower aggression levels and promote moral objections to suicide, thus reducing suicidal behavior. In addition, religious commitments also promote social integration, meaningfulness, and healthier behaviors, and also reduce alienation [102,105]. However, this effect appears to be more significant in Western cultures that are religiously homogeneous [106]. In our previous study, religiosity was associated with fewer suicidal thoughts in psychiatric inpatients [10]. and less severe depression in patients with breast cancer [107]. Therefore, it is necessary to further investigate the potential protective role of religiosity against suicide.

Motivation to seek treatment

Because psychiatric disorders increase the risk of suicide, people experiencing these disorders must be treated appropriately to prevent suicide death. Poor adherence to psychiatric treatment is associated with increased suicidality [108], while motivation to seek psychiatric treatment may decrease suicidal behavior, as it provides a means of controlling psychiatric problems [93]. Therefore, when assessing suicidality in clinical populations, the patient’s motivation to seek treatment should be evaluated.

Ability to cope with stress

Life stress is associated with the onset of depression and suicide ideation; however, the ability to cope plays a mediating role [109,110]. People who have attempted suicide tend to have less useful coping strategies, such as avoidance. [111,112]. Problemfocused active coping strategies, in contrast, may protect against suicidality.

Regulated and healthy lifestyle

Lifestyle behaviors impact mental health and suicidal behavior by influencing emotions and judgement [113]. A sedentary lifestyle and addictive behaviors are associated with poorer mental health and suicidality [113,114], whereas increased physical activity and balanced life routines decrease suicidality [115]. Earlier studies of the Korean population showed that regular activity is a protective factor against depression and suicidal ideation [116,117].

DISCUSSION

In this study, we provide a rationale for the development of the G-CES, based on a literature review of the factors associated with suicidal behavior. The basic function of the G-CES is to predict and prevent suicidal behavior through comprehensive assessment of risk and protective factors. Risk and protective factors for suicide were derived from individual studies of variable quality and size. While some studies have shown that specific risk factors are important, others have provided equivocal results. These inconsistencies can be explained by the interactive effects of risk and protective factors for suicide. The G-CES includes the most replicable risk and protective factors.
The strengths of the G-CES are as follows: First, using this checklist during clinical interviews can help mental health clinicians obtain comprehensive data on people with suicidality, although clinicians must have the medical understanding necessary to appreciate the dynamic interactions among factors. Second, the G-CES includes not only risk factors for suicidality determined based on sociodemographic characteristics and clinical history, but also factors that can be changed or managed to mitigate behavior, as well as protective factors. Third, a score for the G-CES checklist can be calculated to aid prediction of suicidal behavior. Although validation is needed, the G-CES is expected to facilitate clinical decision-making regarding treatment and psychiatric hospitalization.
The limitations of the G-CES checklist are as follows: First, the definition of individual items may not be sufficiently clear. For example, social and clinical variables, such as economic problems, agitation, and impulsivity, are difficult to objectively define in terms of severity. However, given that the checklist was developed for mental health clinicians and screening interviews, clinical judgement could be exercised to assess severity. In addition, the items will be scored based on whether they are clinically significant or distressful to patients. Finally, at present there is insufficient clinical evidence to support the use of the G-CES scoring system, and some factors should have a weighted score if their associations with suicidality prove particularly strong. Therefore, the G-CES should be validated sufficiently before being applied for the prediction of suicidality; it may require further modification depending on the results of validation studies. We hope to publish the results of our retrospective review of medical records obtained from community mental health centers and psychiatric hospitals soon, for initial validation of the G-CES. We will then conduct a prospective longitudinal study of suicidality to further test it, in which algorithms will also be developed to aid clinical decision-making.
As well as risk and protective factors, suicidal ideation, plans, and intent are critical to suicidal behavior; even if a patient has few risk factors, if suicidal ideation or planning are present the risk of suicidality may be high. Thus, risk and protective factors should be considered together with suicidal ideation during clinical decision-making. After validating the G-CES, we will develop a clinical decision tree or algorithm taking account of the present level of suicidal ideation. In the future, the aim is to develop a scoring system through machine learning of extensive datasets, based on the G-CES.
In conclusion, it is important to investigate risk and protective factors for suicidal behavior. Suicide is highly complex and thus difficult to predict. Currently, the clinical tools available to mental health professionals in Korea are not sufficient for identifying those at risk for suicidal behavior. We believe that the G-CES will be helpful for clinicians in community mental health centers and hospitals, although validation studies are needed.

Notes

Availability of Data and Material

Data sharing not applicable to this article as no datasets were generated or analyzed during the study.

Conflicts of Interest

Sung-Wan Kim, Jae-Min Kim, contributing editors of the Psychiatry Investigation, were not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.

Author Contributions

Conceptualization: Sung-Wan Kim. Funding acquisition: Sung-Wan Kim. Investigation: Woo-Young Park. Project administration: Min Jhon, Ju-Wan Kim, Hee-Ju Kang, Seon-Young Kim, Seunghyong Ryu. Supervision: Ju-Yeon Lee, Il-Seon Shin, Jae-Min Kim. Writing—original draft: Woo-Young Park, Sung-Wan Kim. Writing—review & editing: all authors.

Funding Statement

This research was supported by a grant of Patient-Centered Clinical Research Coordinating Center (PACEN) funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI19C0481, HC19C0316).

Figure 1.
Gwangju Checklist for Evaluation of Suicidality.
pi-2022-0063f1.jpg

REFERENCES

1. Park SC, Na KS, Kwon SJ, Kim M, Kim HJ, Baik M, et al. “Suicide CARE” (standardized suicide prevention program for gatekeeper intervention in Korea): an update. Psychiatry Investig 2020;17:911-924.
crossref pmid pmc pdf
2. Kim SW, Yoon JS. Suicide, an urgent health issue in Korea. J Korean Med Sci 2013;28:345-347.
crossref pmid pmc pdf
3. Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull 2017;143:187-232.
crossref pmid
4. Turecki G, Brent DA, Gunnell D, O’Connor RC, Oquendo MA, Pirkis J, et al. Suicide and suicide risk. Nat Rev Dis Primers 2019;5:74.
crossref pmid pdf
5. Barros J, Morales S, Echávarri O, García A, Ortega J, Asahi T, et al. Suicide detection in Chile: proposing a predictive model for suicide risk in a clinical sample of patients with mood disorders. Braz J Psychiatry 2017;39:1-11.
crossref pmid pmc
6. Kim SW, Kim JM, Shin IS, Yoon JS. Suicide and crisis intervention. J Korean Med Assoc 2012;55:341-348.
crossref
7. Warden S, Spiwak R, Sareen J, Bolton JM. The SAD PERSONS scale for suicide risk assessment: a systematic review. Arch Suicide Res 2014;18:313-326.
crossref pmid
8. Bolton JM, Spiwak R, Sareen J. Predicting suicide attempts with the SAD PERSONS scale: a longitudinal analysis. J Clin Psychiatry 2012;73:e735-e741.
crossref pmid
9. Katz C, Randall JR, Sareen J, Chateau D, Walld R, Leslie WD, et al. Predicting suicide with the SAD PERSONS scale. Depress Anxiet 2017;34:809-816.
crossref pmid pdf
10. Kim H, Kim JW, Kang HJ, Kim SY, Lee JY, Kim JM, et al. Factors associated with suicidal behavior of psychiatric inpatients. J Korean Neuropsychiatr Assoc 2019;58:202-208.
crossref pdf
11. Freeman A, Mergl R, Kohls E, Székely A, Gusmao R, Arensman E, et al. A cross-national study on gender differences in suicide intent. BMC Psychiatry 2017;17:234.
crossref pmid pmc pdf
12. Cheong KS, Choi MH, Cho BM, Yoon TH, Kim CH, Kim YM, et al. Suicide rate differences by sex, age, and urbanicity, and related regional factors in Korea. J Prev Med Public Health 2012;45:70-77.
crossref pmid pmc
13. Shah A. The relationship between suicide rates and age: an analysis of multinational data from the World Health Organization. Int Psychogeriatr 2007;19:1141-1152.
crossref pmid
14. Conwell Y, Van Orden K, Caine ED. Suicide in older adults. Psychiatr Clin North Am 2011;34:451-468.
crossref pmid pmc
15. Chan MK, Bhatti H, Meader N, Stockton S, Evans J, O’Connor RC, et al. Predicting suicide following self-harm: systematic review of risk factors and risk scales. Br J Psychiatry 2016;209:277-283.
crossref pmid
16. Suresh Kumar PN, Anish PK, George B. Risk factors for suicide in elderly in comparison to younger age groups. Indian J Psychiatry 2015;57:249-254.
crossref pmid pmc
17. Roy A. Combination of family history of suicidal behavior and childhood trauma may represent correlate of increased suicide risk. J Affect Disord 2011;130:205-208.
crossref pmid
18. Zatti C, Rosa V, Barros A, Valdivia L, Calegaro VC, Freitas LH, et al. Childhood trauma and suicide attempt: a meta-analysis of longitudinal studies from the last decade. Psychiatry Res 2017;256:353-358.
crossref pmid
19. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the adverse childhood experiences study. JAMA 2001;286:3089-3096.
crossref pmid
20. Afifi TO, Enns MW, Cox BJ, Asmundson GJ, Stein MB, Sareen J. Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. Am J Public Health 2008;98:946-952.
crossref pmid pmc
21. Kim SW, Kang HJ, Kim SY, Kim JM, Yoon JS, Jung SW, et al. Impact of childhood adversity on the course and suicidality of depressive disorders: the CRESCEND study. Depress Anxiety 2013;30:965-974.
crossref pmid
22. Cui Y, Piao Y, Kim SW, Lee BJ, Kim JJ, Yu JC, et al. Psychological factors intervening between childhood trauma and suicidality in firstepisode psychosis. Psychiatry Res 2020;293:113465.
crossref pmid
23. Park C, Park IH, Yoo T, Kim H, Ryu S, Lee JY, et al. Association between childhood trauma and suicidal behavior in the general population. Chonnam Med J 2021;57:126-131.
crossref pmid pmc pdf
24. Cui Y, Kim SW, Lee BJ, Kim JJ, Yu JC, Lee KY, et al. Negative schema and rumination as mediators of the relationship between childhood trauma and recent suicidal ideation in patients with early psychosis. J Clin Psychiatry 2019;80:17m12088.
crossref pmid
25. Carballo JJ, Akamnonu CP, Oquendo MA. Neurobiology of suicidal behavior. An integration of biological and clinical findings. Arch Suicide Res 2008;12:93-110.
crossref pmid pmc
26. Brodsky BS, Oquendo M, Ellis SP, Haas GL, Malone KM, Mann JJ. The relationship of childhood abuse to impulsivity and suicidal behavior in adults with major depression. Am J Psychiatry 2001;158:1871-1877.
crossref pmid
27. Brent DA, Mann JJ. Family genetic studies, suicide, and suicidal behavior. Am J Med Genet C Semin Med Genet 2005;133C:13-24.
crossref pmid
28. Runeson B, Asberg M. Family history of suicide among suicide victims. Am J Psychiatry 2003;160:1525-1526.
crossref pmid
29. Murphy TM, Ryan M, Foster T, Kelly C, McClelland R, O’Grady J, et al. Risk and protective genetic variants in suicidal behaviour: association with SLC1A2, SLC1A3, 5-HTR1B & NTRK2 polymorphisms. Behav Brain Funct 2011;7:22.
crossref pmid pmc
30. Kposowa AJ. Marital status and suicide in the national longitudinal mortality study. J Epidemiol Community Health 2000;54:254-261.
crossref pmid pmc
31. Yamauchi T, Fujita T, Tachimori H, Takeshima T, Inagaki M, Sudo A. Age-adjusted relative suicide risk by marital and employment status over the past 25 years in Japan. J Public Health (Oxf) 2013;35:49-56.
crossref pmid
32. Smith JC, Mercy JA, Conn JM. Marital status and the risk of suicide. Am J Public Health 1988;78:78-80.
crossref pmid pmc
33. Corcoran P, Nagar A. Suicide and marital status in Northern Ireland. Soc Psychiatry Psychiatr Epidemiol 2010;45:795-800.
crossref pmid pdf
34. Masocco M, Pompili M, Vichi M, Vanacore N, Lester D, Tatarelli R. Suicide and marital status in Italy. Psychiatr Q 2008;79:275-285.
crossref pmid pdf
35. Durkheim E. Suicide: a study in sociology. Glencoe: Free Press; 1951.

36. Kim YH, Park IH, Kim H, Jhon M, Kang HJ, Lee JY, et al. Psychosocial correlates of suicidal attempts. J Korean Soc Biol Ther Psychiatry 2020;26:203-211.

37. Kim M, Oh GJ, Lee YH. Gender-specific factors associated with suicide attempts among the community-dwelling general population with suicidal ideation: the 2013 Korean Community Health Survey. J Korean Med Sci 2016;31:2010-2019.
crossref pmid pmc pdf
38. Blackmore ER, Munce S, Weller I, Zagorski B, Stansfeld SA, Stewart DE, et al. Psychosocial and clinical correlates of suicidal acts: results from a national population survey. Br J Psychiatry 2008;192:279-284.
crossref pmid
39. Lee SU, Oh IH, Jeon HJ, Roh S. Suicide rates across income levels: retrospective cohort data on 1 million participants collected between 2003 and 2013 in South Korea. J Epidemiol 2017;27:258-264.
crossref pmid pmc
40. Kim SW, Jhon M, Kim M, Paik JW, Kim JM, Yoon JS. A social psychiatric approach to suicide prevention. J Korean Med Assoc 2019;62:93-101.
crossref pdf
41. Seong Y, Lee ES, Park S. The association between unstable employment and suicidal behavior in young-adult precarious workers. Psychiatry Investig 2021;18:661-669.
crossref pmid pmc pdf
42. Burrows S, Auger N, Roy M, Alix C. Socio-economic inequalities in suicide attempts and suicide mortality in Québec, Canada, 1990-2005. Public Health 2010;124:78-85.
crossref pmid
43. Fegg M, Kraus S, Graw M, Bausewein C. Physical compared to mental diseases as reasons for committing suicide: a retrospective study. BMC Palliat Care 2016;15:14.
crossref pmid pmc
44. Qin P, Hawton K, Mortensen PB, Webb R. Combined effects of physical illness and comorbid psychiatric disorder on risk of suicide in a national population study. Br J Psychiatry 2014;204:430-435.
crossref pmid
45. Webb RT, Kontopantelis E, Doran T, Qin P, Creed F, Kapur N. Suicide risk in primary care patients with major physical diseases: a case-control study. Arch Gen Psychiatry 2012;69:256-264.
crossref pmid
46. Racine M. Chronic pain and suicide risk: a comprehensive review. Prog Neuropsychopharmacol Biol Psychiatry 2018;87(Pt B):269-280.
crossref pmid
47. Singhal A, Ross J, Seminog O, Hawton K, Goldacre MJ. Risk of selfharm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage. J R Soc Med 2014;107:194-204.
crossref pmid pmc pdf
48. Ahmedani BK, Peterson EL, Hu Y, Rossom RC, Lynch F, Lu CY, et al. Major physical health conditions and risk of suicide. Am J Prev Med 2017;53:308-315.
crossref pmid pmc
49. Chung DT, Ryan CJ, Hadzi-Pavlovic D, Singh SP, Stanton C, Large MM. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry 2017;74:694-702.
crossref pmid pmc
50. Swaraj S, Wang M, Chung D, Curtis J, Firth J, Ramanuj PP, et al. Meta-analysis of natural, unnatural and cause-specific mortality rates following discharge from in-patient psychiatric facilities. Acta Psychiatr Scand 2019;140:244-264.
crossref pmid pdf
51. Walter F, Carr MJ, Mok PLH, Antonsen S, Pedersen CB, Appleby L, et al. Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study. Lancet Psychiatry 2019;6:582-589.
crossref pmid pmc
52. Bickley H, Hunt IM, Windfuhr K, Shaw J, Appleby L, Kapur N. Suicide within two weeks of discharge from psychiatric inpatient care: a case-control study. Psychiatr Serv 2013;64:653-659.
crossref pmid
53. Olfson M, Wall M, Wang S, Crystal S, Liu SM, Gerhard T, et al. Shortterm suicide risk after psychiatric hospital discharge. JAMA Psychiatry 2016;73:1119-1126.
crossref pmid pmc
54. Nah G, Choi S, Kim H, Lee JY, Kim JM, Shin IS, et al. Characteristics of patients who died by suicide in a community mental health center. Korean J Schizophr Res 2017;20:55-60.
crossref pdf
55. Lee H, Lim J, Lee SM, Kim SN, Lee H, Lee KU, et al. Hospital-based case management for suicide high-risk group using Delphi survey. Psychiatry Investig 2021;18:986-996.
crossref pmid pmc pdf
56. Pirkola S, Sohlman B, Wahlbeck K. The characteristics of suicides within a week of discharge after psychiatric hospitalisation - a nationwide register study. BMC Psychiatry 2005;5:32.
crossref pmid pmc pdf
57. Carlborg A, Jokinen J, Nordström AL, Jönsson EG, Nordström P. Attempted suicide predicts suicide risk in schizophrenia spectrum psychosis. Nord J Psychiatry 2010;64:68-72.
crossref pmid
58. Christiansen E, Jensen BF. Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: a register-based survival analysis. Aust N Z J Psychiatry 2007;41:257-265.
crossref pmid pdf
59. Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 2011;168:1266-1277.
crossref pmid pmc
60. Kim SW, Stewart R, Kim JM, Shin IS, Yoon JS, Jung SW, et al. Relationship between a history of a suicide attempt and treatment outcomes in patients with depression. J Clin Psychopharmacol 2011;31:449-456.
crossref pmid
61. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed). Arlington: American Psychiatric Publishing; 2013.

62. Kessler RC, Berglund P, Borges G, Nock M, Wang PS. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. JAMA 2005;293:2487-2495.
crossref pmid
63. Moitra M, Santomauro D, Degenhardt L, Collins PY, Whiteford H, Vos T, et al. Estimating the risk of suicide associated with mental disorders: a systematic review and meta-regression analysis. J Psychiatr Res 2021;137:242-249.
crossref pmid pmc
64. Oquendo MA, Waternaux C, Brodsky B, Parsons B, Haas GL, Malone KM, et al. Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters. J Affect Disord 2000;59:107-117.
crossref pmid
65. Kim SW, Kim JJ, Lee BJ, Yu JC, Lee KY, Won SH, et al. Clinical and psychosocial factors associated with depression in patients with psychosis according to stage of illness. Early Interv Psychiatry 2020;14:44-52.
crossref pmid pdf
66. Coentre R, Talina MC, Góis C, Figueira ML. Depressive symptoms and suicidal behavior after first-episode psychosis: a comprehensive systematic review. Psychiatry Res 2017;253:240-248.
crossref pmid
67. Malone KM, Haas GL, Sweeney JA, Mann JJ. Major depression and the risk of attempted suicide. J Affect Disord 1995;34:173-185.
crossref pmid
68. Mann JJ. The serotonergic system in mood disorders and suicidal behaviour. Philos Trans R Soc Lond B Biol Sci 2013;368:20120537.
crossref pmid pmc pdf
69. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA 2005;294:2064-2074.
crossref pmid
70. Ibrahim N, Amit N, Che Din N, Ong HC. Gender differences and psychological factors associated with suicidal ideation among youth in Malaysia. Psychol Res Behav Manag 2017;10:129-135.
crossref pmid pmc pdf
71. Kim CH, Jayathilake K, Meltzer HY. Hopelessness, neurocognitive function, and insight in schizophrenia: relationship to suicidal behavior. Schizophr Res 2003;60:71-80.
crossref pmid
72. McClure JR, Criqui MH, Macera CA, Ji M, Nievergelt CM, Zisook S. Prevalence of suicidal ideation and other suicide warning signs in veterans attending an urgent care psychiatric clinic. Compr Psychiatry 2015;60:149-155.
crossref pmid
73. Rogers ML, Ringer FB, Joiner TE. A meta-analytic review of the association between agitation and suicide attempts. Clin Psychol Rev 2016;48:1-6.
crossref pmid
74. Eberhard J, Weiller E. Suicidality and symptoms of anxiety, irritability, and agitation in patients experiencing manic episodes with depressive symptoms: a naturalistic study. Neuropsychiatr Dis Treat 2016;12:2265-2271.
crossref pmid pmc
75. Hawton K, Sutton L, Haw C, Sinclair J, Deeks JJ. Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry 2005;187:9-20.
crossref pmid
76. Pfeiffer PN, Ganoczy D, Ilgen M, Zivin K, Valenstein M. Comorbid anxiety as a suicide risk factor among depressed veterans. Depress Anxiety 2009;26:752-757.
crossref pmid pmc
77. Nepon J, Belik SL, Bolton J, Sareen J. The relationship between anxiety disorders and suicide attempts: findings from the national epidemiologic survey on alcohol and related conditions. Depress Anxiety 2010;27:791-798.
crossref pmid pmc
78. Wiener CD, Moreira FP, Zago A, Souza LM, Branco JC, Oliveira JF, et al. Mood disorder, anxiety, and suicide risk among subjects with alcohol abuse and/or dependence: a population-based study. Braz J Psychiatry 2018;40:1-5.
crossref pmid pmc
79. Cherpitel CJ, Borges GL, Wilcox HC. Acute alcohol use and suicidal behavior: a review of the literature. Alcohol Clin Exp Res 2004;28(5 Suppl):18S-28S.
crossref pmid
80. Nakaya N, Kikuchi N, Shimazu T, Ohmori K, Kakizaki M, Sone T, et al. Alcohol consumption and suicide mortality among Japanese men: the Ohsaki Study. Alcohol 2007;41:503-510.
crossref pmid
81. Brady J. The association between alcohol misuse and suicidal behaviour. Alcohol Alcohol 2006;41:473-478.
crossref pmid
82. Sher L. Risk and protective factors for suicide in patients with alcoholism. ScientificWorldJournal 2006;6:1405-1411.
crossref pmid pmc pdf
83. Jhon M, Lee JY, Hong JE, Yoo TY, Kim SY, Kim JM, et al. Addictive behavior and personality among workers with hazardous alcohol drinking. J Korean Neuropsychiatr Assoc 2017;56:175-180.
crossref pdf
84. Lee M, Lee U, Park JH, Shin YC, Sim M, Oh KS, et al. The association between alcohol use and suicidal ideation among employees. Psychiatry Investig 2021;18:977-985.
crossref pmid pmc pdf
85. Gvion Y, Apter A. Aggression, impulsivity, and suicide behavior: a review of the literature. Arch Suicide Res 2011;15:93-112.
crossref pmid
86. Lin L, Zhang J, Zhou L, Jiang C. The relationship between impulsivity and suicide among rural youths aged 15-35 years: a case-control psychological autopsy study. Psychol Health Med 2016;21:330-337.
crossref pmid pmc
87. Mann JJ, Waternaux C, Haas GL, Malone KM. Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 1999;156:181-189.
crossref pmid
88. Kelleher I, Devlin N, Wigman JT, Kehoe A, Murtagh A, Fitzpatrick C, et al. Psychotic experiences in a mental health clinic sample: implications for suicidality, multimorbidity and functioning. Psychol Med 2014;44:1615-1624.
crossref pmid
89. Kjelby E, Sinkeviciute I, Gjestad R, Kroken RA, Løberg EM, Jørgensen HA, et al. Suicidality in schizophrenia spectrum disorders: the relationship to hallucinations and persecutory delusions. Eur Psychiatry 2015;30:830-836.
crossref pmid
90. Lee JY, Kim H, Kim SY, Kim JM, Shin IS, Kim SW. Non-suicidal selfinjury is associated with psychotic like experiences, depression, and bullying in Korean adolescents. Early Interv Psychiatry 2021;15:1696-1704.
crossref pmid pdf
91. Popovic D, Benabarre A, Crespo JM, Goikolea JM, González-Pinto A, Gutiérrez-Rojas L, et al. Risk factors for suicide in schizophrenia: systematic review and clinical recommendations. Acta Psychiatr Scand 2014;130:418-426.
crossref pmid
92. Berardelli I, Rogante E, Sarubbi S, Erbuto D, Lester D, Pompili M. The importance of suicide risk formulation in schizophrenia. Front Psychiatry 2021;12:779684.
crossref pmid pmc
93. Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors. J Psychopharmacol 2010;24(4 Suppl):81-90.
crossref pmid pmc pdf
94. Luo X, Wang Q, Wang X, Cai T. Reasons for living and hope as the protective factors against suicidality in Chinese patients with depression: a cross sectional study. BMC Psychiatry 2016;16:252.
crossref pmid pmc
95. Kleiman EM, Liu RT. Social support as a protective factor in suicide: findings from two nationally representative samples. J Affect Disord 2013;150:540-545.
crossref pmid pmc
96. Nock MK, Deming CA, Fullerton CS, Gilman SE, Goldenberg M, Kessler RC, et al. Suicide among soldiers: a review of psychosocial risk and protective factors. Psychiatry 2013;76:97-125.
crossref pmid pmc
97. Shaw RJ, Cullen B, Graham N, Lyall DM, Mackay D, Okolie C, et al. Living alone, loneliness and lack of emotional support as predictors of suicide and self-harm: a nine-year follow up of the UK Biobank cohort. J Affect Disord 2021;279:316-323.
crossref pmid pmc
98. Kim SW, Kim SJ, Mun JW, Bae KY, Kim JM, Kim SY, et al. Psychosocial factors contributing to suicidal ideation in hospitalized schizophrenia patients in Korea. Psychiatry Investig 2010;7:79-85.
crossref pmid pmc
99. Lizardi D, Dervic K, Grunebaum MF, Burke AK, Mann JJ, Oquendo MA. The role of moral objections to suicide in the assessment of suicidal patients. J Psychiatr Res 2008;42:815-821.
crossref pmid pmc
100. Kim SW, Kim SY, Kim JM, Suh TW, Shin IS, Kim SJ, et al. A survey on attitudes toward suicide and suicidal behavior in Korea. J Korean Soc Biol Ther Psychiatry 2008;14:43-48.

101. Dervic K, Carballo JJ, Baca-Garcia E, Galfalvy HC, Mann JJ, Brent DA, et al. Moral or religious objections to suicide may protect against suicidal behavior in bipolar disorder. J Clin Psychiatry 2011;72:1390-1396.
crossref pmid pmc
102. Dervic K, Oquendo MA, Grunebaum MF, Ellis S, Burke AK, Mann JJ. Religious affiliation and suicide attempt. Am J Psychiatry 2004;161:2303-2308.
crossref pmid
103. VanderWeele TJ, Li S, Tsai AC, Kawachi I. Association between religious service attendance and lower suicide rates among US women. JAMA Psychiatry 2016;73:845-851.
crossref pmid pmc
104. Chen Y, Koh HK, Kawachi I, Botticelli M, VanderWeele TJ. Religious service attendance and deaths related to drugs, alcohol, and suicide among US health care professionals. JAMA Psychiatry 2020;77:737-744.
crossref pmid pmc
105. Chen Y, Kim ES, VanderWeele TJ. Religious-service attendance and subsequent health and well-being throughout adulthood: evidence from three prospective cohorts. Int J Epidemiol 2021;49:2030-2040.
crossref pmid pmc pdf
106. Wu A, Wang JY, Jia CX. Religion and completed suicide: a meta-analysis. PLoS One 2015;10:e0131715.
crossref pmid pmc
107. Jang JE, Kim SW, Kim SY, Kim JM, Park MH, Yoon JH, et al. Religiosity, depression, and quality of life in Korean patients with breast cancer: a 1-year prospective longitudinal study. Psychooncology 2013;22:922-929.
crossref pmid
108. Herings RM, Erkens JA. Increased suicide attempt rate among patients interrupting use of atypical antipsychotics. Pharmacoepidemiol Drug Saf 2003;12:423-424.
crossref pmid
109. Huang HW, Wang RH. Roles of protective factors and risk factors in suicidal ideation among adolescents in Taiwan. Public Health Nurs 2019;36:155-163.
crossref pmid pdf
110. Zhang X, Wang H, Xia Y, Liu X, Jung E. Stress, coping and suicide ideation in Chinese college students. J Adolesc 2012;35:683-690.
crossref pmid
111. Bazrafshan MR, Jahangir F, Mansouri A, Kashfi SH. Coping strategies in people attempting suicide. Int J High Risk Behav Addict 2014;3:e16265.
crossref pmid pmc
112. Ambrus L, Sunnqvist C, Asp M, Westling S, Westrin Å. Coping and suicide risk in high risk psychiatric patients. J Ment Health 2020;29:27-32.
crossref pmid
113. Berardelli I, Corigliano V, Hawkins M, Comparelli A, Erbuto D, Pompili M. Lifestyle interventions and prevention of suicide. Front Psychiatry 2018;9:567.
crossref pmid pmc
114. Lee JY, Ban D, Kim H, Kim SY, Kim JM, Shin IS, et al. Sociodemographic and clinical factors associated with breakfast skipping among high school students. Nutr Diet 2021;78:442-448.
crossref pmid pdf
115. Vancampfort D, Hallgren M, Firth J, Rosenbaum S, Schuch FB, Mugisha J, et al. Physical activity and suicidal ideation: a systematic review and meta-analysis. J Affect Disord 2018;225:438-448.
crossref pmid
116. Kim SW, Park IH, Kim M, Park AL, Jhon M, Kim JW, et al. Risk and protective factors of depression in the general population during the COVID-19 epidemic in Korea. BMC Psychiatry 2021;21:445.
crossref pmid pmc pdf
117. Song HB, Lee SA. Socioeconomic and lifestyle factors as risks for suicidal behavior among Korean adults. J Affect Disord 2016;197:21-28.
crossref pmid
TOOLS
Share:
Facebook Twitter Linked In Google+
METRICS Graph View
  • 0 Crossref
  •   Scopus
  • 964 View
  • 46 Download


ABOUT
AUTHOR INFORMATION
ARTICLE CATEGORY

Browse all articles >

BROWSE ARTICLES
Editorial Office
#522, 27, Seochojungang-ro 24-gil, Seocho-gu, Seoul 06601, Korea
Tel: +82-2-717-0892    E-mail: psychiatryinvest@gmail.com                

Copyright © 2022 by Korean Neuropsychiatric Association.

Developed in M2PI

Close layer
prev next