Reasons For Living
Reasons For Living
Abstract & Commentary
Source: Malone KM, et al. Protective factors against suicidal acts in major depression: Reasons for living. Am J Psychiatry 2000;157:1084-1088.
Malone and associates studied patients with current major depression and examined factors that may protect against or modulate the expression of suicidal behaviors. Eighty-four patients, 18-80 years of age, were recruited from two urban university psychiatric hospitals. Patients with severe, unstable medical or neurological disorders were excluded. The research participants did not differ significantly from nonparticipants on key demographic and clinical variables including age, sex, race, severity of depression, and number of previous depressive episodes. However, nonparticipants were more likely to have a history of substance abuse.
Study participants were clinically assessed for depression using the Structured Clinical Interview for DSM-III-R. Severity of depression was measured objectively with the Hamilton Depression Rating Scale and subjectively with the Beck Depression Inventory. Hopelessness was assessed with the Hopelessness Scale, and the Reasons for Living Inventory administered. The latter is a self-report instrument measuring beliefs that may contribute to the inhibition of suicidal behavior including six factors: 1) survival and coping beliefs; 2) responsibility to family; 3) child-related concerns; 4) fear of suicide; 5) fear of social disapproval; and 6) moral objections to suicide. Quantity and severity of life events were measured with the St. Paul Ramsay Life Experience Scale and Recent Life Changes Questionaire. A comprehensive lifetime history of suicidal acts was obtained. The Scale for Suicide Ideation was used to assess current suicidal ideation; intent at the most lethal and most recent suicide attempt was assessed with the Suicide Intent Scale. The Medical Lethality Scale was used to measure medical injury resulting from suicidal acts.
Of the 84 participants, 45 had attempted suicide and 39 had not. Suicide attempters reported significantly greater subjective depression, hopelessness, and suicidal ideation compared to nonattempters. In comparison, depressed patients who had not attempted suicide scored significantly higher on reasons for living including greater survival and coping beliefs, greater fear of social disapproval, and greater moral objections to suicide. When suicide attempts were examined based on degree of lethality of the attempt, moral objection to suicide was the only reason for living found to be significantly stronger in subjects with low-lethality suicide attempts compared to those with high-lethality attempts.
Factors which failed to distinguish between suicide attempters and nonattempters included age, sex, educational experience, and religious persuasion. Caucasians were more likely to attempt suicide than noncaucasians.
Limitations of the study include the small sample size, the limitation to subjects with major depression, and a significantly greater number of nonparticipants with a history of substance abuse.
Comment by Lauren B. Marangell, MD & Christopher D. Martin
Malone et al report that more reasons for living are associated with fewer and less intense suicidal acts during a depressive episode. As Malone et al point out, it has been established that prior attempted suicide and hopelessness are powerful clinical predictors of the risk for future completed suicide. Now, Malone et al have identified clinical features that are protective against suicidal behavior in patients with major depression. These results are relevant to any clinician encountering depressed patients in practice. An assessment of reasons for living should be included in the evaluation of depressed patients. A patient who has a history of prior suicide attempts, hopelessness, and expresses few reasons for living should be considered to be at high risk for future suicidal behavior. It is often helpful to instill hope in these patients with the goal of reducing suicide risk, and the results of the current study suggest that increasing depressed patients’ awareness of reasons for living may be a valid means through which this may be accomplished.
Also of note, in the current study, suicide attempters had a slightly greater number of depressive episodes than nonattempers, though duration of the depressive episode was not a distinguishing factor. This may indicate that exposure to repeated depressive episodes may be a risk factor for suicidal behavior. These data speak to the importance of early and adequate antidepressant treatment, as well as the importance of prophylactic antidepressant treatment against further depressive episodes, even after the patient has experienced improvement in symptoms of depression.
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