It goes without saying that suicide is a major health problem and a leading cause
of death worldwide (1, 2). Recent reports inform that around a million people die
by suicide annually, representing an annual global age-standardized suicide rate of
11.4 per 100,000 populations (15.0 for males and 8.0 for females). Considering a time
perspective from 2000 through 2016, the age-adjusted suicide rate has grown by 30%
(1).
These rates are only the tip of an iceberg. For every suicide, there are many more
who attempt suicide every year. A cautious estimate suggests that more than 20 million
people engage in suicidal behavior annually. Moreover, it is estimated that in the
future, the suicide rates are expected to rise, given the WHO’s declaration that suicide
rates will pass the 1 million mark in the next 15 years (2).
Behind each suicide and attempt is a long-term struggle of these individuals as well
as experiences of trauma and distress among their relatives and friends. Together,
it is evident that suicide prevention comprises a global priority. As clinicians and
researchers, we must make every effort to enhance suicide prevention in order to improve
our identification, intervention, and, subsequently, prevention of suicide and suicidal
behavior. First and foremost, our mission is to improve our knowledge of mechanisms,
factors, and facilitators of suicidality from interdisciplinary perspectives.
Suicide is a highly complex and multifaceted phenomenon, with many contributing and
facilitating variables. It may be determined by the interaction between various factors,
such as neurobiology, personal and family history, stressful events, and sociocultural
environment (3). Given its being one of the most severe human behaviors, a distinct
focus would be to identify the underlying psychological processes that may lead to
suicidal ideation and behavior.
In the last century, we have recognized the contributions of psychological factors
(both individual and social) to suicide and suicide risk. A number of models have
been proposed, with most emphasizing the interaction between predisposing and precipitating
factors (4, 5).
The key factor leading to suicide is unbearable mental pain (6). Several studies have
emphasized the importance of psychache as the primary facilitator of suicide ideation
and behavior (7, 8). Suicide can be seen as a behavior motivated by the desire to
escape from unbearable psychological pain (9, 10). Other psychological factors like
personality traits, emotional characteristics, and dysregulation also seem to play
a role, with emerging importance to decision-making deficit among suicidal individuals
(11).
Interpersonal factors also play an essential role in suicides. Emile Durkheim’s (12)
seminal work established the foundations of our understanding that suicide is also
a social behavior having some cultural characteristics. Joiner’s interpersonal theory
of suicide (13) highlights two major interpersonal structures—perceived burdensomeness
and thwarted belongingness—as critical features that may lead to suicidal ideation
and eventually to suicide.
Approximately 45% of individuals who die by suicide consult a primary care physician
within 1 month of death, without declaring their suicide desires and ideation (14).
This finding highlights the fact that communication difficulties comprise a major
focus of our understanding of suicidal behavior. In the Israeli MSSA (Medically Serious
Suicide Attempters) project, Levi-Belz and colleagues showed that poor self-disclosure,
together with several related factors, may facilitate more lethal suicide behavior
(15–18).
These examples of studies are representative of numerous endeavors to deepen our understanding
of the psychology of suicide phenomenon. In order to continue this course of action
and thought, we dedicate a special issue of Frontiers in Psychiatry to the effort
to explore various approaches to the psychology of suicidal behavior. The purpose
of the current issue is to shed light on in-depth knowledge and empirical data regarding
models, theories, and specific dimensions and variables that may help us increase
the psychological understanding of suicidal phenomena as well as non-suicidal self-injury
(NSSI).
Five stimulating reviews are presented in this issue. Gvion and Levi-Belz examined
specific risk factors for serious suicide attempts (SSAs). SSAs are epidemiologically
very similar to those who died by suicide and thus may serve as valid proxies for
studying suicides. The authors conclude that the interaction of mental pain, interpersonal
factors, and impaired decision making is crucial for suicide risk assessment and research.
Szücs et al. focus on personality and suicidal behavior in old age in their systematic
review. Their review of 31 scientific papers emphasized that maladaptive personality
manifests in milder, subthreshold, and more heterogeneous forms in late-life vs. early-life
suicide. Moreover, the inability to adapt to changes occurring in late life may explain
the relationship between suicide in old age and higher conscientiousness. Obsessive–compulsive
and avoidant personality traits were particularly associated with elderly suicide.
Cipriano et al. conducted an up-to-date systematic review on NSSI, focusing on epidemiological,
etiologic, and diagnostic criteria. NSSI was found to be most common among adolescents
and young adults. Borderline personality disorder and eating disorders are reported
as comorbid antecedents for NSSI. Prevalence rates are 7.5–46.5% for adolescents,
38.9% for university students, and 4–23% for adults. In a mini-review article, Geraldo
da Silva et al. group the main cognitive difficulties among individuals who attempt
suicide. These include attentional bias, impulsivity, and problem-solving and decision-making
deficits. They suggest that in addition to anxiety and depressive symptoms, cognitive
deficits in psychiatric patients comprise important therapeutic goals. Finally, in
Conti et al.’s review, the authors systematically review the relations between binge
eating disorder (BED) and suicidal ideation and suicide attempts. They found that
BED is significantly associated with a marked increase in suicidal behaviors and ideation.
Three papers focus on identifying risk factors in childhood. Schmidt et al. used structural
equation modeling to test theory-driven models in clinical high risk (CHR) for psychosis.
CHR patients were particularly prone to suicidality if adversity/trauma was followed
by the development of depressiveness. In addition, adversity/trauma led to suicidality
through an increased risk for psychosis as indicated by cognitive symptoms.
Bar-Zomer and Brunstein-Klomek examined associations between sibling bullying, attachment
to mother and father, depression, and suicidal ideation among students. Bullying among
siblings was associated with school bullying, depression, and suicide ideation. A
secure attachment to one’s father moderated the association between sibling bullying
and depression/suicide ideation.
In a third article, Falgares et al. assessed the role of self-criticism and dependency
as potential mediators of the link between different types of childhood maltreatment
and suicide among university students. Lack of care and psychological abuse were significantly
associated with suicide risk, and this association was partially mediated by the maladaptive
personality dimension of self-criticism.
Several studies examined risk factors of suicidal behavior in specific populations.
Stein et al. observed a sequential model in their longitudinal study among former
prisoners of war (ex-POWs) in Israel. They found that PTSD symptoms facilitated experiencing
loneliness, and these worked in tandem to implicate suicidal ideation, even years
following their captivity. They conclude that both PTSD symptoms and loneliness are
important factors in ex-POWs’ long-term suicidal ideation and risk. Mérida-López et
al. examined the role of emotional intelligence (EI) as a protective factor of suicide
ideation and behavior among students and the general population. They found EI to
be related to suicide risk, with psychological distress as a mediator. They concluded
that the underlying process by which self-reported EI may act as a protective factor
against suicidal ideation and behaviors is through the reduction of distress among
those with high EI.
Balazs et al. examined quality of life (QoL) as a factor that may serve as a link
between psychopathology and suicide risk among a clinical population of adolescents.
QoL significantly mediated the relationships between emotional difficulties and peer
problems, as both were associated with lower QoL, which, in turn, was related to higher
suicidal risk. Hofstra et al. focus on time trends of suicide among the Dutch population.
They observed 33,224 suicide events that occurred from 1995 to 2015. Results indicated
that suicide incidence peaked at springtime and on Christmas, which highlights the
importance of accessibility of health care services during these high-risk moments.
Several studies in this issue suggested other important risk factors. Tavakoli et
al. examined the association between attentional control and suicidal behavior among
a cohort of inpatient adolescents presenting acute suicidal behavior compared to healthy
controls. A passively presented auditory optimal paradigm was used. The extent of
processing these “to-be-ignored” auditory stimuli was measured by recording event-related
potentials (ERPs), which are thought to reflect processes linked with capturing attention.
The study found a relatively low threshold for the triggering of the involuntary switch
of attention among suicidal patients, a factor that may play a role in their reported
distractibility. Thompson and Chen Ong investigated the association of suicidal behavior
with neurological and behavioral markers, measuring attentional bias and inhibition
in two Stroop tasks, as well as recorded activity in frontal areas by EEG (Electroencephalogram)
during each task. High-risk participants showed slower response times in the color
Stroop (as well as to the word “suicide”) and reduced accuracy in incongruent trials,
but faster response times in the emotional Stroop task (with reduced activity in leftward
frontal areas). Results confirmed that suicide attempters have deficits in attentional
control that may be related to particular conditions of frontal asymmetry. In another
important study, Hadlaczky et al. examined the relationship between loss aversion
and suicidal behavior among adolescents recruited in 30 schools in seven European
countries. Loss aversion predicted attempted suicide in both cross-sectional and 4-month
prospective analyses after controlling for depression, anxiety, stress, and gender.
Interestingly, loss aversion did not predict suicide ideation in this group.
Several innovative papers examine the essential topic of therapeutic interventions
for suicidal patients, with a particular focus on reducing suicide rates. First, Iyengar
et al. conducted a systematic review of randomized controlled trials, reporting therapeutic
interventions as being effective in reducing self-harm, including suicide attempts
(SA). Also reported was a reduction of suicidal ideation and depressive symptoms following
therapeutic interventions. While most of the studies were unable to determine the
efficacy of therapeutic interventions for both primary and secondary outcomes, individual
self-driven and socially driven processes seemed to display the greatest prospect
of reducing suicide attempts.
Another contribution on prevention is that of Pickering et al., who studied an intervention
program in which students underwent a yearlong training as peer leaders, and 3,730
9th−12th graders completed baseline surveys assessing friendships and adults at school
as well as recording suicidal thoughts and behaviors. In general, training more peer
leaders increased school-wide exposure for all modalities. Exposure was higher for
students closer to peer leaders in the friendship network and for students who named
more trusted adults. Relatedly, Barzilay et al. validated the Therapist Response Questionnaire-Suicide
Form (TRQ-SF) in a general outpatient clinic setting in a cohort of adult psychiatric
outpatients and their therapists. TRQ-SF correlated positively with concurrent and
predictive evaluations of patient suicidal outcomes, depression severity, and clinicians’
judgment of patient suicide risk. However, the TRQ-SF was not predictive of global
symptom severity, thus indicating specifically suicide-related responses. In a seminal
work, Brodsky, et al. present the assess, intervene, and monitor for suicide prevention
model as a guide for implementation of the Zero Suicide model, a framework to coordinate
a multilevel approach for applying evidence-based practices in clinical settings.
The paper describes 10 basic steps for clinical management and illustrates how to
implement them through a clinical vignette. Finally, Sakashita and Oyama present an
integration of psycho-behavioral components associated with suicide, existing guidelines
for identifying critical points of intervention, and the preventive strategies framework
into a theoretical model for elderly suicide.
Two more papers examine different issues regarding suicide. Moreno-Küstner et al.
focus on demographic factors in their analysis of the characteristics of 181,824 calls
made to the Málaga Prehospital Emergency Service for suicidal behavior. Of the total
calls (N = 181,824), 1,728 (0.9%) were made due to suicidal behavior. The mean age
was 43.21 ( ± 18) years, and 57.4% were women. Zhao and Shai’s study reveals that
the students’ attitudes toward suicidal behavior and the attitude toward suicide-loss
survivors played as a mediator between self-efficacy in managing happiness and self-evaluations
among college students. Thus, for this population, the attitudes toward suicide may
be understood as one of the factors that shape self-evaluation and satisfaction with
life.
In conclusion, in this special issue, we seek to advance the knowledge on suicide
by identifying particular psychological characteristics that may facilitate targeted
prevention, intervention methods, and programs. Improving our understanding of these
topics may help clinicians and researchers establish specific prevention strategies
and methods that will ultimately help diminish suicide rates around the globe as well
as find psychological remedy for all of those struggling with suicide ideation and
behavior.
Author Contributions
We state that 1) all authors have read the paper and approved the data and the conclusions
presented therein; 2) each author believes that the paper represents honest work;
3) all authors have contributed to the present paper with equal effort; and 4) no
financial support was given for this editorial.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.