A Multiethnic Examination of Suicidal Ideation, Psychotic Symptoms and Belongingness Among Adults Based On the Collaborative Psychiatric Epidemiological Surveys

Purpose:  Psychotic symptoms are often associated with increased risk of suicidal behavior.  Identification of such behaviors is critical for effective early intervention.  Joiner’s (2005) interpersonal theory of suicide suggests that belongingness – being socially involved and supported – mitigates suicidal ideation.  Joiner’s theory, aimed at suicide prevention, is a relatively new framework that has not been empirically validated for application to ethnically diverse populations or those with psychotic symptoms.  Historical and sociocultural experiences shared within ethnic groups may be associated with risk of suicidal ideation.  This study aims to answer the following research questions: Are psychotic symptoms differentially associated with risk of suicidal ideation across ethnic groups? Based on Joiner’s theory, are family support and religious service involvement associated with a reduction of suicidal ideation?

Method: Using data from the Collaborative Psychiatric Epidemiological Surveys (CPES), 11,937 participants (19.7% Latino, 18.9% Caribbean-Black/African American, 52% European American, 8% Asian, and 1.4% Other [weighted]) were evaluated using the Composite International Diagnostic Interview.  Respondents were classified as positive if they reported any psychotic symptoms in their lifetime.  Demographic and clinical covariates, along with family support and religious involvement, were examined for those reporting any suicidal ideation (lifetime).  We compared group differences in the covariates among those with and without lifetime psychotic symptoms using Rao-Scott X² tests.  Multinomial logistic regression was used, controlling for demographic and clinical covariates to assess for differential effects in suicidal ideation within ethnic groups, stratified by psychotic symptoms.  We then repeated the regression including family support and religious involvement.

Results:  Lifetime experience of psychotic symptoms did not differentially affect risk of suicidal ideation for respondents of any ethnic groups.  Controlling for demographic and clinical factors, Caribbean-Black/African Americans and Latinos were less likely than European Americans to report suicidal ideation in their lifetime regardless of endorsing psychotic symptoms (without psychotic symptoms – Caribbean-Black/African American: OR=0.63 [95% CI 0.49–0.81]; Latino: OR=0.59 [95% CI 0.43–0.80]) (with psychotic symptoms – Caribbean-Black/African American: OR=0.60 [95% CI 0.39–0.92]; Latino: OR=0.58 [95% CI 0.34–0.98]).  Controlling for the aforementioned variables, our final regression model suggests family support (OR=0.70 [95% CI 0.53–0.94]) and religious involvement (OR=0.64 [95% CI 0.49–0.82]) were associated with reduction in suicidal ideation among those not reporting psychotic symptoms.  Caribbean-Black/African Americans (OR=0.66 [95% CI 0.49–0.89]) and Latinos (OR=0.58 [95% CI 0.42–0.79]) also reported less suicidal ideation than European Americans after accounting for these protective factors.  However, these protective factors were not associated with a reduction of suicidal ideation among those reporting psychotic symptoms.  Only among Latinos were lifetime psychotic symptoms associated with reduced suicidal ideation after controlling for the two protective factors (OR=0.55 [95% CI 0.30–0.99]).

Conclusions:  These results suggest that Joiner’s interpersonal theory of suicide may not apply to those with psychotic symptoms. Other protective factors for suicidal ideation should be considered for those living with psychotic symptoms.  Although further research is needed, these findings may inform efforts to modify and adapt preventative and early interventions for consumers reporting psychotic symptoms.