Suicidal behavior is a major problem worldwide and, at the same time, has received relatively little empirical attention. This relative lack of empirical attention may be due in part to a relative absence of theory development regarding suicidal behavior. The current article presents the interpersonal theory of suicidal behavior. We propose that the most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs—thwarted belongingness and perceived burdensomeness (and hopelessness about these states)—and further that the capability to engage in suicidal behavior is separate from the desire to engage in suicidal behavior. According to the theory, the capability for suicidal behavior emerges, via habituation and opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences. In the current article, the theory’s hypotheses are more precisely delineated than in previous presentations (Joiner, 2005), with the aim of inviting scientific inquiry and potential falsification of the theory’s hypotheses.

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The Interpersonal Theory of Suicide

At a time when lesbian, gay, bisexual, and transgender individuals—often referred to under the umbrella acronym LGBT—are becoming more visible in society and more socially acknowledged, clinicians and researchers are faced with incomplete information about their health status. While LGBT populations often are combined as a single entity for research and advocacy purposes, each is a distinct population group with its own specific health needs. Furthermore, the experiences of LGBT individuals are not uniform and are shaped by factors of race, ethnicity, socioeconomic status, geographical location, and age, any of which can have an effect on health-related concerns and needs. While some research about the health of LGBT populations has been conducted, researchers still have a great deal to learn. To help assess the state of the science, the National Institutes of Health (NIH) asked the Institute of Medicine (IOM) to assess current knowledge of the health status of lesbian, gay, bisexual, and transgender populations; to identify research gaps and opportunities; and to outline a research agenda to help NIH focus its research in this area. A committee of experts was convened by the IOM to consider this task, and its findings are presented in its report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding

Suicidal thoughts and behaviors (STBs) are major public health problems that have not declined appreciably in several decades. One of the first steps to improving the prevention and treatment of STBs is to establish risk factors (i.e., longitudinal predictors). To provide a summary of current knowledge about risk factors, we conducted a meta-analysis of studies that have attempted to longitudinally predict a specific STB-related outcome. This included 365 studies (3,428 total risk factor effect sizes) from the past 50 years. The present random-effects meta-analysis produced several unexpected findings: across odds ratio, hazard ratio, and diagnostic accuracy analyses, prediction was only slightly better than chance for all outcomes; no broad category or subcategory accurately predicted far above chance levels; predictive ability has not improved across 50 years of research; studies rarely examined the combined effect of multiple risk factors; risk factors have been homogenous over time, with 5 broad categories accounting for nearly 80% of all risk factor tests; and the average study was nearly 10 years long, but longer studies did not produce better prediction. The homogeneity of existing research means that the present meta-analysis could only speak to STB risk factor associations within very narrow methodological limits-limits that have not allowed for tests that approximate most STB theories. The present meta-analysis accordingly highlights several fundamental changes needed in future studies. In particular, these findings suggest the need for a shift in focus from risk factors to machine learning-based risk algorithms. (PsycINFO Database Record

Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research.

Despite a growing body of epidemiological evidence in recent years documenting the health impacts of racism, the cumulative evidence base has yet to be synthesized in a comprehensive meta-analysis focused specifically on racism as a determinant of health. This meta-analysis reviewed the literature focusing on the relationship between reported racism and mental and physical health outcomes. Data from 293 studies reported in 333 articles published between 1983 and 2013, and conducted predominately in the U.S., were analysed using random effects models and mean weighted effect sizes. Racism was associated with poorer mental health (negative mental health: r = -.23, 95% CI [-.24,-.21], k = 227; positive mental health: r = -.13, 95% CI [-.16,-.10], k = 113), including depression, anxiety, psychological stress and various other outcomes. Racism was also associated with poorer general health (r = -.13 (95% CI [-.18,-.09], k = 30), and poorer physical health (r = -.09, 95% CI [-.12,-.06], k = 50). Moderation effects were found for some outcomes with regard to study and exposure characteristics. Effect sizes of racism on mental health were stronger in cross-sectional compared with longitudinal data and in non-representative samples compared with representative samples. Age, sex, birthplace and education level did not moderate the effects of racism on health. Ethnicity significantly moderated the effect of racism on negative mental health and physical health: the association between racism and negative mental health was significantly stronger for Asian American and Latino(a) American participants compared with African American participants, and the association between racism and physical health was significantly stronger for Latino(a) American participants compared with African American participants. Protocol PROSPERO registration number: CRD42013005464.

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Racism as a Determinant of Health: A Systematic Review and Meta-Analysis

A systematic review of risk factors for intimate partner violence was conducted. Inclusion criteria included publication in a peer-reviewed journal, a representative community sample or a clinical sample with a control-group comparison, a response rate of at least 50%, use of a physical or sexual violence outcome measure, and control of confounding factors in the analyses. A total of 228 articles were included (170 articles with adult and 58 with adolescent samples). Organized by levels of a dynamic developmental systems perspective, risk factors included: (a) contextual characteristics of partners (demographic, neighborhood, community and school factors), (b) developmental characteristics and behaviors of the partners (e.g., family, peer, psychological/behavioral, and cognitive factors), and (c) relationship influences and interactional patterns. Comparisons to a prior review highlight developments in the field in the past 10 years. Recommendations for intervention and policy along with future directions for intimate partner violence (IPV) risk factor research are presented.

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A Systematic Review of Risk Factors for Intimate Partner Violence

The authors evaluated emotional distress among 9th-12th grade students, and examined whether the association between being lesbian, gay, bisexual, and/or transgendered (i.e., "LGBT") and emotional distress was mediated by perceptions of having been treated badly or discriminated against because others thought they were gay or lesbian. Data come from a school-based survey in Boston, Massachusetts (n = 1,032); 10% were LGBT, 58% were female, and ages ranged from 13 to 19 years. About 45% were Black, 31% were Hispanic, and 14% were White. LGBT youth scored significantly higher on the scale of depressive symptomatology. They were also more likely than heterosexual, non-transgendered youth to report suicidal ideation (30% vs. 6%, p < 0.0001) and self-harm (21% vs. 6%, p < 0.0001). Mediation analyses showed that perceived discrimination accounted for increased depressive symptomatology among LGBT males and females, and accounted for an elevated risk of self-harm and suicidal ideation among LGBT males. Perceived discrimination is a likely contributor to emotional distress among LGBT youth.

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Emotional Distress Among LGBT Youth: The Influence of Perceived Discrimination Based on Sexual Orientation

BACKGROUND:: The current investigation explores the association between rates of household firearm ownership and suicide across the 50 states. Prior ecologic research on the relationship between firearm prevalence and suicide has been criticized for using problematic proxy-based, rather than survey-based, estimates of firearm prevalence and for failing to control for potential psychological risk factors for suicide. We address these two criticisms by using recently available state-level survey-based estimates of household firearm ownership, serious mental illness, and alcohol/illicit substance use and dependence. METHODS:: Negative binomial regression was used to assess the relationship between household firearm ownership rates and rates of firearm, nonfirearm, and overall suicide for both sexes and for four age groups. Analyses controlled for rates of poverty, urbanization, unemployment, mental illness, and drug and alcohol dependence and abuse. RESULTS:: US residents of all ages and both sexes are more likely to die from suicide when they live in areas where more households contain firearms. A positive and significant association exists between levels of household firearm ownership and rates of firearm and overall suicide; rates of nonfirearm suicide were not associated with levels of household firearm ownership. CONCLUSION:: Household firearm ownership levels are strongly associated with higher rates of suicide, consistent with the hypothesis that the availability of lethal means increases the rate of completed suicide. Language: en

Household firearm ownership and rates of suicide across the 50 United States.

Suicide mortality varies widely across age, sex, race, and geography, far more than does mortality from the leading causes of natural death. Unlike the tight correlation between cancer mortality and the incidence of cancer, suicide mortality is only modestly correlated with the incidence of suicidal acts and other established risk factors for suicidal behavior, such as major psychiatric disorders. An implication of this modest correlation is that the proportion of all suicidal acts that prove fatal (the case fatality ratio) must account for a substantial portion of the (nonrandom) variation observed in suicide mortality. In the United States, the case fatality ratio is strongly related to the availability of household firearms. Findings from ecologic and individual-level studies conducted over the past two decades illustrate the importance of accounting for the availability of highly lethal suicide methods in efforts to understand (and ultimately reduce) disparities in suicide mortality across populations.

https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-031811-124636

Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide.

Background In the United States, only motor vehicle crashes and cancer claim more lives among children than do firearms. This national study attempts to determine whether firearm prevalence is related to rates of unintentional firearm deaths, suicides, and homicides among children.Methods Pooled cro

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Firearm availability and unintentional firearm deaths, suicide, and homicide among 5-14 year olds.

OBJECTIVES: To compare the risk of fracture associated with initiating opioids with that of nonsteroidal anti-inflammatory drugs (NSAIDs) and the variation in risk according to opioid dose, duration of action, and duration of use. DESIGN: Retrospective cohort study. SETTING: Two statewide pharmaceutical benefit programs for persons aged 65 and older. PARTICIPANTS: Twelve thousand four hundred thirty-six initiators of opioids and 4,874 initiators of NSAIDs began treatment between January 1, 1999, and December 31, 2006. Mean age at initiation of analgesia was 81; 85% of participants were female, and all had arthritis. MEASUREMENTS: Cox proportional hazards models, adjusted for several potential confounders, quantified fracture risk. Study outcomes were fractures of the hip, humerus or ulna, or wrist, identified using a combination of diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification) and procedure (Common Procedural Terminology) codes. RESULTS: There were 587 fracture events among the participants initiating opioids (120 fractures per 1,000 person-years) and 38 fracture events among participants initiating NSAIDs (25 fractures per 1,000 person-years) (hazard ratio (HR)=4.9, 95% confidence interval (CI)=3.5-6.9). Fracture risk was greater with higher opioid dose. Risk was greater for short-acting opioids (HR=5.1, 95% CI=3.7-7.1) than for long-acting opioids (HR=2.6, 95% CI=1.5-4.4), even in participants taking equianalgesic doses, with differential fracture risk apparent for the first 2 weeks after starting opioids but not thereafter. CONCLUSION: Older people with arthritis who initiate therapy with opioids are more likely to experience a fracture than those who initiate NSAIDs. For the first 2 weeks after initiating opioid therapy, but not thereafter, short-acting opioids are associated with a greater risk of fracture than are long-acting opioids.© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society. Language: en

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Deborah R. Azrael

Papers

Emotional Distress Among LGBT Youth: The Influence of Perceived Discrimination Based on Sexual Orientation

Household firearm ownership and rates of suicide across the 50 United States.

Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide.

Firearm availability and unintentional firearm deaths, suicide, and homicide among 5-14 year olds.

Opioid Analgesics and the Risk of Fractures in Older Adults with Arthritis