Factors Related to the Transition from Suicide Ideation to Suicidal Behavior

Background and Purpose:

There are many known predictors of suicidal ideation including depression, anxiety, substance use, impulsivity, trauma history, and others. However, known predictors are very poor at distinguishing individuals with ideation who do not make attempts from those with ideation who do go on to make attempts. It is, therefore, very difficult to predict who is at greatest need for further intervention among individuals with suicidal ideation, leaving a substantial gap in clinical knowledge that has greatly impeded suicide prevention efforts. Two factors that have been shown to distinguish those who make attempts from those who do not are hopelessness and sub-threshold psychotic experiences (i.e., fleeting perceptual abnormalities or unusual thoughts that do not meet DSM-5 psychosis criteria). The purpose of this study is to test whether hopelessness screens and psychotic experience screens independently distinguish people with ideation with attempts from those without attempts.

Methods:

Participants were drawn from a research pool of undergraduate college students (N=678). Each respondent completed a survey that included measures of psychotic experiences (five dichotomous items indicating presence or absence of hallucination- and delusion-like experiences), hopelessness (two items with 5-point Likert responses), and suicidal behavior (dichotomous variables indicating ideation and attempts). Logistic regression analyses tested for associations between suicide attempts (outcome) and psychotic experiences and hopelessness. Analyses were first run with the entire sample to examine predictors of attempts overall, and then within the subset endorsing suicidal ideation to test whether these factors distinguished isolated ideation from ideation with attempts. All analyses were a priori adjusted for sex and race/ethnicity (but not age due to restricted range of the sample), and were considered significant at two-tailed alpha=0.05.

Results:

Within this sample, 36% of respondents endorsed lifetime suicidal ideation and 2.7% reported suicide attempts. At least one lifetime psychotic experience was endorsed by 27.1% of respondents. Approximately half of the sample endorsed at least some hopelessness. Within the entire sample, psychotic experiences (Wald = 6.13, p=0.013) and hopelessness (Wald =17.17, p<0.001) each independently predicted suicide attempts in the fully adjusted model (χ²_df=4=30.28, p<0.001)). Results were similar when the sample was limited to respondents with a history of suicidal ideation (n=244). Specifically, both psychotic experiences (Wald=4.46, p=0.035) and hopelessness (Wald=10.37, p=0.001) were associated with suicide attempts among respondents with ideation in the fully adjusted model (χ² _df=4=18.46, p=0.001).

Conclusions and Implications:

The main finding is that both psychotic experiences and hopelessness independently distinguish individuals with suicidal ideation alone from those with ideation and attempts. This distinction is highly clinically relevant given the difficulty in predicting which individuals will go on to make suicide attempts among those that report suicidal thoughts. Hopelessness and psychotic experiences can both be assessed through brief screening tools that can be easily incorporated into existing suicide prevention efforts. Future prospective studies may clarify the role of psychotic experiences and hopelessness in predicting suicide attempts over time.