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Journal of Mental Health
ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20
Coping and suicide risk in high risk psychiatric
patients
Livia Ambrus, Charlotta Sunnqvist, Marie Asp, Sofie Westling & Åsa Westrin
To cite this article: Livia Ambrus, Charlotta Sunnqvist, Marie Asp, Sofie Westling & Åsa Westrin (2017): Coping and suicide risk in high risk psychiatric patients, Journal of Mental Health, DOI: 10.1080/09638237.2017.1417547To link to this article: https://doi.org/10.1080/09638237.2017.1417547
Published online: 20 Dec 2017.
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ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, Early Online: 1–6
ß 2017 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2017.1417547
ORI G IN AL AR TI CLE
Coping and suicide risk in high risk psychiatric patients
Livia Ambrus1 , Charlotta Sunnqvist2, Marie Asp1, Sofie Westling1, and A˚ sa Westrin1 1
Department of Clinical Sciences, Section for Psychiatry, Lund University, Lund, Sweden, and2Faculty of Health and Society Sciences, Malmo¨ University, Malmo¨, Sweden
Abstract
Background: A dysfunctional use of coping strategies has repeatedly been linked to suicidal behaviour in non-psychiatric populations. However, data regarding association between coping strategies and suicidal behaviour in psychiatric populations are limited.
Aims: The aim of the study was to investigate the possible relationship between self-reported suicide risk, suicidal ideation and coping strategies in three psychiatric cohorts.
Method: Three cohorts of psychiatric patients were involved in the study; recent suicide attempters (n¼ 55), suicide attempters at follow-up 12 years after a suicide attempt (n ¼ 38) and patients with ongoing depression without attempted suicide (n¼ 72). Patients filled in the self-rating version of The Suicide Assessment Scale (SUAS-S) from which items no. 17–20 addressing current suicidal ideation were extracted. To investigate coping strategies, the Coping Orientation of Problem Experience Inventory (COPE) was used.
Results: In all cohorts, regression analyses showed that only avoidant coping was significantly correlated with the scores of SUAS-S adjusted for covariates. The items no. 17–20 correlated significantly to avoidant coping but not with other coping strategies in all cohorts.
Conclusion: The results of this study indicate that among coping strategies only avoidant coping may be associated with suicide risk in psychiatric patients independently of history of attempted suicide.
Keywords
Coping, avoidant coping, attempted suicide, suicide risk
History
Received 15 January 2017 Revised 26 May 2017 Accepted 9 November 2017 Published online 20 December 2017
Introduction
Suicide is a global public health problem resulting in approximately 800 000 deaths every year in the world, and is rated as one of the leading causes of death among young people (World Health Organization, 2014). In addition, several studies have reported that a significant part of suicide victims have had contact with mental health services nearly before death by suicide (Ahmedani et al., 2014; Leavey et al., 2016; Luoma et al., 2002; Schaffer et al., 2016; Vasiliadis et al., 2015). This may suggest that the identification and the treatment of persons with high suicide risk are insufficient. Taken together, these data indicate that there is a need to promote effective preventive actions, specifically directed toward those at most risk for suicide. As one of the most often replicated risk factors for suicide is previous suicide attempt (Beyer & Weisler, 2016; Hawton et al., 2013; Hor & Taylor, 2010; Nordentoft, 2007), suicide attempters may be the most important group for suicide research and prevention. Considering the fact that not all suicide attempters complete suicide in the future, it is of interest to identify those with the highest suicide risk.
A candidate risk factor for suicide is the dysfunctional use of strategies to deal with stressful situations (D’Zurilla et al.,
1998; Gandy et al., 2013; Kalichman et al., 2000; Kaslow et al., 2004; Khazem et al., 2015; Li & Zhang, 2012; Marty et al., 2010; Marusic & Goodwin, 2006; Pietrzak et al, 2011; Pollock & Williams, 1998; Rudd et al., 1994; Schotte & Clum, 1987; Sugawara et al., 2012; Svensson et al., 2014; Tang & Qin, 2015; Woodhead et al., 2014). Particularly, in non-psychiatric patients, it has repeatedly been found that an increased use of maladaptive strategies, like avoidant coping and/or decreased use of adaptive strategies involving emotion-focused or problem-emotion-focused strategies were associated with suicidal behaviour (D’Zurilla et al., 1998; Li & Zhang, 2012; Pietrzak et al., 2011; Sugawara et al., 2012; Tang & Qin, 2015). Indeed, the use of avoidant, but not adaptive coping has been linked to risk for subsequent suicide (Svensson et al., 2014), as well as risk for subsequent suicidal ideation (Woodhead et al., 2014) in the general population.
In addition, some studies investigating psychiatric patients have suggested that suicide attempters may be characterized by an increased use of avoidant coping, and decreased use of adaptive coping strategies compared to the control groups (Kaslow et al., 2004; Sunnqvist et al., 2013). As far as we know, there is only one study having studied whether there is an association between suicidal ideation and coping in psychiatric patients, however without any significant findings (D’Zurilla et al., 1998).
Taken together, the association between avoidant
coping and suicide risk appears to be well-established in
Correspondence: Livia Ambrus, Department of Clinical Sciences, Lund (IKVL), Psychiatry, Lund University, Barava¨gen 1, SE-222 40 Lund, Sweden. Tel: þ46 46 17 10 00. Fax: þ46 46 176048. E-mail: livia.ambrus@med.lu.se
non-psychiatric cohorts. However, the knowledge about coping strategies regarding suicidal behaviour in psychiatric patients, particularly in case of those with the highest suicide risk such as psychiatric patients with attempted suicide, is limited. We therefore aimed the present study to investigate the relationship between self-reported suicide risk, suicidal ideation and coping strategies in clinical cohorts of psychi-atric patients with or without attempted suicide. Furthermore, we hypothesised a positive association between self-reported suicide risk, suicidal ideation and avoidant coping strategies, as well as a negative association between self-reported suicide risk, suicidal ideation and adaptive coping strategies.
Method
Subjects
Two different cohorts of Swedish suicide attempters were involved in the present study. The first cohort consisted of 55 patients recruited from the medical intensive care unit or from a general psychiatric ward at the psychiatric clinic in Lund shortly after a suicide attempt. The second cohort included suicide attempters who were followed-up 12 years after a suicide attempt (called suicide attempters at follow-up). The recruitment process of suicide attempters at follow-up is described in details in a previous work (Sunnqvist et al., 2008). In the present study, only patients with data of coping strategies were included (n¼ 38). In both cohorts, a suicide attempt was regarded as an act with the intent of putting one’s own life at risk, or to give such an appearance, but without the result of death (Beck et al., 1972).
We further involved a group of depressed patients without a history of attempted suicide. These subjects were recruited from an ongoing study, starting in 2012. The study includes in- and outpatients at the psychiatric clinics in Skane, Sweden, with ongoing depression and insufficient response to antidepressant treatment, referred by their psychiatrists. The information about attempted suicide was based on the suicidality module of the Mini-International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) from which the question no. C9 ‘‘In your lifetime: Did you ever make a suicide attempt?’’ was extracted. At the time of the present study, 130 patients had been recruited. Seventy-two patients responded that they never had attempted suicide.
All patients filled in the self-rating version of The Suicide Assessment Scale (SUAS-S) (Nimeus et al., 2006) and the Coping Orientation of Problem Experience Inventory (COPE) (Carver et al., 1989). Patients in the cohort of recent suicide attempters and suicide attempters at follow-up were diag-nosed according to the Diagnostic and Statistical Manual of
Mental Disorders 4th edition (DSM-IV) (American
Psychiatric Association, 1994). In the group of depressed patients, the psychiatric diagnosis was set according to the Swedish version of the Mini-International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998). All patients were evaluated with the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) (First et al., 1990) for diagnosing personality disorders. The clinical and demo-graphic characteristics of cohorts of suicide attempters and depressed patients without a history of attempted suicide are presented in Table 1.
Table 1. Demographic, clinical variables and coping strategies in different psychiatric cohorts. Recent suicide attempters,
n¼ 55
Suicide attempters at follow-up, n¼ 38
Depressed patients without attempted suicide, n¼ 72
Gender: Males/Females 25/30 19/19 28/44
Age: Mean (SD) 39.4 (14.3) 50.7 (9.3) 41.1 (13.4)
SUAS-S (max scores 80)
Mean (SD) 38.5 (16.4) 12.7 (13.7) 29.6 (13.5)
Median (Min/Max) 39.0 (4/69) 8.0 (0/55) 29.0 (0/60)
SUAS-S items (17–20) (max scores 16)
Mean (SD) 8.4 (4.9) 2.2 (3.5) 3.8 (3.9)
Median (Min/Max) 9.0 (0/16) 1.0 (0/12) 2.0 (0/13)
Axis I diagnosis Yes/No 55/0 21/17 72/0
Affective disorders 38 13 72
Substance abuse disorders 9 4 0
Anxiety disorders 3 3 0
Psychotic disorders 1 1 0
Adjustment disorders 4 0 0
Comorbidity with Cluster B Yes/No 13/42 7/31 12/60
Problem-focused coping (max scores 60)
Mean (SD) 28.8 (11.1) 39.6 (10.8) 31.6 (11.5)
Median (Min/Max) 29.0 (0/56) 41.5 (11/58) 32.0 (3/58)
Emotion-focused coping (max scores 60)
Mean (SD) 32.0 (10.5) 38.2 (10.1) 31.6 (10.4)
Median (Min/Max) 34.0 (3/53) 39.5 (8/52) 31.0 (11/56)
Socially-supported (max scores 60)
Mean (SD) 27.1 (12.1) 30.2 (12.8) 31.8 (11.3)
Median (Min/Max) 29.0 (0/52) 33.5 (2/50) 32.0 (2/55)
Avoidant coping (max scores 60)
Mean (SD) 23.6 (10.3) 13.2 (10.7) 18.3 (8.9)
Median (Min/Max) 24.0 (4/52) 11.0 (1/37) 17.0 (2/43)
SUAS-S: self-rate version of the Suicide Assessment Scale; SD: standard deviation.
Rating scales COPE
COPE is a frequently used scale for assessing the ways in which people typically deal with stress/stressful situations (Carver et al., 1989; Kato, 2015). The inventory interprets 15 types of coping-styles. A five-point scale ranging from 0 (not at all) to 5 (a lot) was used. COPE was translated from English into Swedish by support from the Lund University Department of Languages. We used the four-factorial model which was suggested in the original work of Carver et al. (1989) and was replicated later in several other studies summarized in the work of Litman (2006). The four factors are the following: problem-focused coping (Factor I),
socially-supported coping (Factor II), avoidant coping
(Factor III) and emotion-focused coping (Factor IV). A short description of the Factors is presented in Table 2. SUAS-S
To investigate the suicide risk we used the self-rating version of The Suicide Assessment Scale (Nimeus et al., 2006). The SUAS-S is a 20-item self-report rating scale measuring the patient’s attitude towards suicide, suicide-related behaviour and suicidal ideation on the day of reporting and during the previous seven days. Each item is scored in the range of 0–4 on a Likert-type scale and resulting in a scale sum score with a range of 0–80. In the present study, we used the whole scale. Furthermore, we extracted items no. 17–20 evaluating addressing current suicidal ideation.
Statistical analyses
All statistical analyses were conducted using SPSS statistical software version 21.0 (SPSS IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY). Some of the data regarding coping strategies or total scores of SUAS-S were not normally distributed. However, after logarithmic trans-formations (suicide attempters at follow-up: avoidant coping, socially-supported coping and SUAS-S) or the exclusion of outliers (recent suicide attempters: emotion-focused coping) all linear data become normally distributed. Outliers were defined as data which fall more than 1.5 times the interquar-tile range above the third quarinterquar-tile or below the first quarinterquar-tile. To test the correlation between coping strategies and the total scores of SUAS-S, series of regression analyses with the scores of coping strategies as independent variables and SUAS-S as the dependent variable, were used. As age (Beyer & Weisler, 2016; Diehl et al., 2014; Turecki & Brent, 2016), gender (Nolen-Hoeksema, 2012; Schaffer et al., 2015) and comorbidity with personality disorder belonging to Cluster B (Hakim Shooshtari et al., 2016; Teti et al., 2014) are known to affect coping strategies, as well as are associated with suicide risk, these factors were included into the regression analyses as independent variables. As data of age were not normally distributed even after log-transformation in the cohort of suicide attempters at follow-up, we choose to divide patients
into subgroups such as age40 and 440.
As the data regarding SUAS-S items addressing suicidal ideation (items no. 17–20) were not normally distributed, even after logarithmic transformation in any of the cohorts, to study the relationship between coping strategies and these items, a series of Spearman’s rank correlation was used. All statistical analyses were tested for two-tailed level of significance. Alpha-level of significance was set at p50.05. As the investigation of the possible association between SUAS-S items and coping strategies resulted in a high number of statistical analyses, to reduce the chances of obtaining false-positive results, Bonferroni correction was used.
Ethical approval
The studies were approved by the Ethical Review Board in Lund (the numbers of the approval: 479/2006-11-01, LU81-012001-04-24, 2011/6732012-01-24). Participants gave writ-ten informed consent to participate.
Results
SUAS-S and coping strategies
In Table 3, results of regression analyses are presented. As it is seen, regarding coping strategies in all three cohorts of psychiatric patients, avoidant coping was the only significant predictor of the total scores of SUAS-S among coping strategies, in all three cohorts.
Coping strategies and current suicidal ideation assessed by SUAS-S
As it is seen in Table 4, according to the Bonferroni corrected p value 50.0041, SUAS-S items addressing current suicidal
Table 2. COPE factors and subscales according to Carver and colleagues (1989).
Factors Subscales Description
Problem-focused coping (I) Active coping Planning Suppression of compet-ing activities
Taking active steps to remove or circum-vent the stressor How to cope with a
stressor and which step to take Putting other projects
aside Socially-supported
coping (II)
Seeking social support-instrumental Seeking social
support-emotional
Focus on & venting of emotions
For advice or informa-tion
Getting moral support and/or understanding To focus on distress or
upset feelings and to ventilate those feelings Avoidant coping (III) Denial Behavioural disengage-ment Mental disengagement
The person refuses, pretends or acts as if the problem has not Happened
A wish to give up Using alternative
activ-ities to bring the mind off a problem Emotion-focused coping (IV) Restraint coping Positive reinterpretation & growth Acceptance
Waiting until an appro-priate opportunity Ability to manage
coping with emotions Ability to accept the
reality of a stressful situation
ideation were significantly correlated with avoidant coping but not with other coping strategies in all three cohorts of psychiatric patients.
Discussion
In the present study, we investigated the possible association between self-reported suicide risk, current suicidal ideation and coping strategies in three clinical cohorts of psychiatric patients.
The most interesting finding of this study is the significant correlations between increased use of avoidant coping strategies and the total scores of S, as well as SUAS-S items addressing current suicidal ideation. These findings were replicated in patients with a recent suicide attempt, as well as in suicide attempters at follow-up and in depressed patients without attempted suicide. Although concordant with findings in non-psychiatric cohort, this has not previously been shown in psychiatric patients. According to regression analyses, the association between the increased use of avoidant coping and higher scores on total scores of SUAS-S appear to be independent of age, gender and comorbidity with Cluster B personality disorders. Furthermore, as other coping strategies did not correlate significantly with the total scores or the items addressing current suicidal ideation in the SUAS-S, this indicates that avoidant coping may be the only coping strategy associated with self-reported suicide risk and current suicidal ideation in psychiatric patients with or without attempted suicide.
There are several limitations of the study, the most important one being the small sample sizes in all cohorts. Another limitation is that we used self-report scales to
evaluate suicide risk and coping strategies. Furthermore, we did not control our data for educational level and childhood trauma which both have been found to affect coping strategies (Min et al., 2007; Roohafza et al., 2009). Another possible limitation is the absence of the comparison of coping strategies between cohorts. Despite the similar study design of the three studies which from participants of the present study have been recruited, there are several methodological differences between studies like the process of recruitment or the type of the studied population. Therefore, we chose to not perform such comparisons.
Interestingly, several previous studies have investigated the possible association between coping strategies, suicidal behaviour, suicidal ideation and suicide risk (D’Zurilla et al., 1998; Li & Zhang, 2012; Pietrzak et al., 2011; Sugawara et al., 2012; Tang & Qin, 2015). Similarly to our study, some of them have investigated the association between suicidal behaviour, suicidal ideation or suicide risk and various coping strategies simultaneously, that is, in the same statistical analysis (Gandy et al., 2013; Khazem et al., 2015; Svensson et al., 2014; Woodhead et al., 2014). Among others, Gandy and co-workers (2013), using a regression analysis including several coping strategies as independent variables, have reported that escape avoidance was the only coping strategy associated with suicide risk among patients with epilepsy. Also in line with the study of Gandy et al. (2013) and our study, Khazem and colleagues observed that maladaptive coping strategies consisting of avoidant coping strategies, but not other coping strategies, were associated with suicidal ideation among military personnel (Khazem et al., 2015). The beta-value of the regression analysis in that
Table 3. Results of the regression analyses.
Total scores of SUAS-S
Recent suicide attempters Suicide attempters at follow-upa Depressed patients without attempted suicide
Beta p Beta p Beta p
Problem-focused coping 0.055 0.791 0.007 0.964 0.079 0.644 Emotion-focused coping 0.231 0.195 0.176 0.247 0.298 0.050 Avoidant coping 0.310 0.028 0.680a 50.001 0.489 0.001 Socially-supported coping 0.058 0.680 0.022a 0.882 0.077 0.548 Gender 0.256 0.049 0.152 0.486 0.133 0.644 Age subgroups 0.270 0.038 0.012 0.926 0.020 0.859 Cluster B Y/N 0.004 0.974 0.206 0.195 0.108 0.361
SUAS-S: self-rate version of the Suicide Assessment Scale.
p50.05. Significant results regarding coping strategies are highlighted with bold. Age subgroups:40 and 440.
aLog-transformed data.
Table 4. Spearman’s rank order correlation between coping strategies and current suicidal ideation assessed by SUAS-S.
Problem-focused coping Emotion-focused coping Avoidant coping Socially-supported coping
rs p rs p rs p rs p
SUAS-S items 17–20
Recent suicide attempters 0.350 0.009 0.340 0.012 0.419 0.001 0.102 0.461 Suicide attempters at follow up 0.288 0.079 0.396 0.014 0.484 0.002 0.107 0.522 Depressed patients 0.297 0.015 0.284 0.020 0.429 50.001 0.039 0.755 SUAS-S: the self-rate version of the Suicide Assessment Scale; rs: Spearman’s rank order correlation coefficient.
Bonferroni corrected p50.0041. Significant results are highlighted with bold.
study indicates that the association between maladaptive coping and suicidal ideation was positive (Khazem et al., 2015). Furthermore, Marty and co-workers, using the same statistical analyses, found that suicidal ideation was signifi-cantly and positively associated with maladaptive coping including avoidant coping strategies and significantly and negatively with emotion-focused coping in older people (Marty et al., 2010). Interestingly, according to the beta and p values of the regression analyses the association between maladaptive coping and suicidal ideation was stronger and more significant than the association between emotion-focused coping and suicidal ideation (Marty et al., 2010). This in turn could indicate that maladaptive coping, including avoidant coping strategies may be a more important predictor of suicidal ideation than emotion-focused coping. In addition, there are two previous longitudinal population based studies that have investigated the association between subsequent completed suicide (Svensson et al., 2014), subsequent suicidal ideation (Woodhead et al., 2014) and coping strategies simultaneously (i.e. in the same regression analyses). These studies, similar to each other and to cross-sectional studies mentioned above, found that avoidant coping was the only predictor of future suicidal ideation and completed suicide (Svensson et al., 2014; Woodhead et al., 2014). These findings taken together with our results suggest that avoidant coping, but not other coping strategies, may be a risk factor for suicidal behaviour.
Avoidant coping including coping strategies are aimed at avoiding dealing with a stressor or feelings related with the stressor. Examples of avoidant coping include ignoring, psychological or behavioural distancing oneself from the stressor or denial. Interestingly, the increased use of avoidant coping strategies has been linked not only to suicide risk or suicidal behaviour but clinical risk factors for suicide such as affective disorders (Bjørkløf et al., 2013; Christensen & Kessing, 2005). There is even evidence from non-psychiatric cohorts for the relationship between the increased use of avoidant coping strategies and psychological suicide risk factors such as lower self-control or higher levels of impulsivity (Boals et al., 2011; Connor-Smith & Flachsbart, 2007; Brezo et al., 2006). In addition, according to a previous study, lower self-control was found to be associated with the increased use of avoidant coping strategies but not emotion-or problem-focused coping strategies (Boals et al., 2011). Furthermore, according to a previous study the increased use of avoidant coping strategies has been found to be associated with reduced autobiographical memory specificity which is a known risk factor for suicidal behaviour (Hermans et al., 2005; Richard-Devantoy et al., 2015). However, because of the absence of previous studies from patients with suicidal behaviour, it is unclear if there may be an association between avoidant coping and the mentioned psychological risk factors in psychiatric patients with suicidal behaviour.
Our study may have some important indications for both researchers and clinical use. Firstly, our findings raise the question whether the assessment of avoidant coping strategies itself, or together with other risk factors for suicide, could be used in order to predict subsequent attempted
or completed suicide among psychiatric patients. Therefore, it would be of interest to perform prospective studies to test this research question. In addition, our findings may raise the issue whether psychotherapy, with focus on improving avoidant focused coping, could reduce the risk of suicide in psychiatric patients.
Conclusion
The results of the present study suggest the involvement of avoidant focused coping, but not other coping strategies in the psychological mechanisms underlying suicidal behaviour among psychiatric patients, independently of history of attempted suicide. We propose that investigation of avoidant focused coping is of further interest for both suicide research and clinical practice.
Acknowledgements
None of these organizations had any further role in the study or in the decision to submit the work for publication.
Declaration of interest
No conflicts of interests to declare for any of the co-authors. This study was supported by the Sjo¨bring Foundation, Province of Scania State Grants (ALF), Foundation for Skane County (REGSKANE-285421).
ORCID
Livia Ambrus http://orcid.org/0000-0001-8962-5960
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