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Effect of gender on suicide attempters versus nonattempters in an adolescent inpatient unit
Comprehensive Psychiatry 46 (2005) 90 – 97 www.elsevier.com/locate/comppsych
Effect of gender on suicide attempters versus nonattempters in an adolescent inpatient unit Silvana Fenniga,b,c,*, Keren Gevab, Gil Zalsmana,c,d, Abraham Weizmanc,d, Shmuel Fenniga,c,e, Alan Aptera,b,c b
a The Feinberg Child Study Center, Schneider Children’s Medical Center of Israel, Petach Tikva 49202, Israel Department of Psychological Medicine, Schneider Children’s Medical Center of Israel, Petach Tikva 49202, Israel c Department of Psychiatry, Sackler School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel d Geha Psychiatric Center, Rabin Medical Center, Petach Tikva 4100, Israel e Outpatient Department, Shalvata Mental Health Center, Hod Hasharon 45263, Israel
Abstract Background: Although gender differences have been noted in the risk factors for suicide and attempted suicide, comparative studies to date have used only 2 groups and a limited number of measures. The present study compared the effect of gender on suicide among 4 groups of psychiatrically hospitalized adolescents using a cross-sectional design. Methods: The study sample consisted of 404 patients, aged between 12 and 21, who were divided into 4 groups: 76 male suicide attempters, 103 male nonattempters, 143 female suicide attempters, and 82 female nonattempters. Patients were tested for life events, affective disorders, aggression, impulsivity, ego defense mechanisms, and death perception with the Child Suicide Potential Scale, Beck Depression Inventory, State-Trait Anxiety Inventory, Overt Aggression Scale, Multidimensional Anger Inventory, Impulsivity Control Scale, and Life Style Index. Findings were analyzed by multivariate regression with stepwise logistic models. Results: Depression and anxiety were more prevalent in female nonattempters than in male nonattempters; there were no such gender differences among the attempters. Antisocial behavior was more prevalent in male attempters than in female attempters; there were no gender differences on this aspect among the nonattempters. There were gender differences for defense mechanisms in the attempters. Logistic regression models for men and women separately revealed that antisocial behavior and anxiety were common predictors of suicide attempt, that destructiveness was a predictor in women only, and that depression was associated with suicide attempt in men only. Conclusions: Suicide-prone female and male adolescent inpatients show distinct differences in psychopathology, ego defense mechanisms, and life events compared to psychiatrically hospitalized adolescents without any history of suicide attempt. Any deviation from a genderspecific behavior must raise suspicion of a risk of attempted suicide. D 2005 Elsevier Inc. All rights reserved.
1. Introduction Epidemiologic studies report that the risk of suicide increases with an increase in the number of risk factors present [1]. Several risk factors are known to be associated with suicidal behavior; these include socioeconomic problems [2]; psychiatric disorders, namely, depression [3,4], anxiety disorders [3,5], conduct disorders [5], and borderline personality disorder [7]; alcohol and drug abuse [3];
* Corresponding author. The Feinberg Child Study Center, Schneider Children’s Medical Center of Israel, Beilinson Campus, Petach Tikva 49202, Israel. Tel.: +972 03 9253761; fax: +972 09 7446654. E-mail address: [email protected] (S. Fennig). 0010-440X/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2004.07.037
suicidal thoughts and previous suicide attempt [2]; history of psychiatric disorder in the family [5]; problematic life events such as suicide in the family and separation from parents [5,8] or sexual abuse [8]; and dysfunctional defense mechanisms [9]. Psychopathologic measures that were found to be associated with suicide included mainly depressive mood [1], aggression, aggressive behavior, anger, violence, and impulsivity [7]. Studies of attempted suicide often include heterogenous populations; thus, the literature on the subject needs to be read carefully. On the basis of the World Health Organization/European Study on Parasuicide [10], the terms battempted suicideQ and bparasuicideQ were considered equivalent and were
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defined as follows: bAn act with nonfatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences.Q Attempted suicide in some cases may be conceived as failed suicides. In most cases, this is not true because their dynamics differ. Most of the studies on risk factors of suicidal behaviors in adolescents were done in psychiatric populations. These studies found that low income and residential mobility were highly associated with serious suicide attempts. Other significant findings were childhood sexual abuse, low parental care, and poor parental relationship. Patients had an elevated risk for mood disorder, substance abuse, and conduct disorder [11]. Some authors suggested that the effectiveness of coping mechanisms and defense mechanisms in suicide attempters may also differ from those in nonattempters. Apter et al [9] found that suicide-prone adolescents could be distinguished from non–suicide-prone inpatients by their Life Style Index (LSI) scores on displacement (higher) and compensation (lower). On the Ego Defense Scale, suicide-prone adolescents scored higher on regression, denial, projection, introjection, repression, and total defenses and lower on sublimation. Denial and regression correlated positively with suicidal and violent behavior, whereas sublimation correlated negatively with such behavior. How are these risk factors associated with gender? The development of boys and girls differs in terms of intensity and prevalence of depressive and anxiety symptoms, internalization/externalization, rigid/ambivalent cognitive styles, and pressure of social roles [12,13]. These differences may be of biologic or sociologic origin [12,13]. Large-scale epidemiologic and clinical studies have found that rates of clinical depression are similar in boys and girls during childhood and would then increase markedly during adolescence in girls but less so in boys [11,13]. In general, girls have a greater tendency to internalize their suffering and pain and to manifest their internal pain as anxiety and depression and psychosomatic symptoms. Depression is more severe in girls than in boys [12,13], as are many symptoms associated with depression such as low selfesteem, poor body image, feelings of unattractiveness, pessimism, feelings of failure, guilt, and self-blame, anger, social withdrawal, hesitancy, preoccupation with health, and loss of interest in the opposite sex. By contrast, boys tend to externalize their pain in the form of behavioral problems, problems with the law, and drug abuse. These findings may shed light on the well-recognized bgender paradoxQ in suicide. On one hand, women report suicidal ideation more frequently than men do and attempt to commit suicide more often. On the other hand, men exceed women in the rate of suicidal deaths. Identifying the
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risk factors for suicidal behavior for each gender separately may help us understand why these occur. Accordingly, in an epidemiologic sample from France, Gasquet and Choquet [16] studied suicidal behavior in schoolchildren and found that a deviation from normal behavior was more noticeable in male attempters than in female attempters. They also reported that suicide attempters suffered more from depression than nonattempters did and that this finding was more evident in boys than in girls. Von Knorring et al [17] found that 60% of boys and 44% of girls who had attempted suicide were currently suffering from moderate or severe depression. In the same survey, 2% of all the boys and 5% of all the girls had moderate or severe depression. The authors concluded that although depression is more prevalent in girls, it is an ominous sign predictive of suicidal behavior in boys. Findings from autopsies of subjects who committed suicide are inconclusive with regard to the association of depression, suicide, and gender. Two studies reported that major depression was more prevalent in women who committed suicide than in men [18,19], with respective rates of 56% and 26% [18]. Others found that depression occurred at a similar rate in suicide-prone men and women but was a stronger predictor of completed suicide in men [20]. These discrepancies may be attributable to differences in the samples, methodology, and definition of suicide attempt. The association of antisocial behavior, suicide, and gender is also far from clear. In a psychologic autopsy study of suicide cases, Brent et al [21] found that conduct and antisocial disorder were more prevalent in boys than in girls, whereas Mattunen et al [19] found no such gender difference, although conduct disorder served as a risk factor for completed suicide in men. Wannan and Fambonne [14], in a study of adolescents, found antisocial behavior to be a risk factor for suicide attempts in girls, whereas Andrews and Lewisohn et al. [6] reported that conduct disorder had no predictive value for suicide attempts. In a psychiatric population, aggressive behavior was the only predictor of suicide attempts in girls [4], but in a community study, it was a risk factor for suicide attempts in boys only [3]. One study from Finland showed that male adolescent suicide attempters had more social problems, lower function, and more behaviors with self-destructive potential than female attempters did [22]. Some studies failed to find gender difference in the use of alcohol and drugs between male and female suicide attempters [19,20]. However, Shaffer et al [18] found alcohol and drug use to be a risk factor for suicide attempts in boys, while Brent et al [21] reported that it was a risk factor in both genders. No difference in anxiety was found between male and female suicide attempters [4,18]. Regarding life events and attempted suicide, academic failure was found to be a risk factor in boys only [16]. Kotila and Lonnquist [22] found that among suicide attempters, boys had a poorer attendance record than girls did, and they
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often missed regular daily activities at school or work. In contrast, in a study of completed suicide, the rate of unemployment was higher among the women [18,20], and no differences were noted for other life events [20]. However, the women had more adverse life events and their suicide attempts were often a reaction to these events. Pfeffer et al [4] reported that the specific life events associated with suicidal behavior differed by gender: in girls, major events were separation from a boyfriend, sexual abuse, and problems in school; in boys, major events were aggression in the family and having a sibling with suicidal behavior. However, these findings failed to reach statistical significance in the final analysis. Data on coping styles and defense mechanisms in suicide-prone individuals are scarce. Overall, women are believed to think in a more general way and to take more variables into account before making a decision; this tendency may protect them from performing an irreversible act such as suicide. They change their minds more easily and use social interactions to ventilate and process their feelings [23]. How these sociologic findings are expressed by way of defense mechanisms has not been studied in suicide attempters from different diagnostic groups. In contrast to most of earlier studies that included only 2 study groups and compared either male attempters with female attempters or attempters with nonattempters, we used a cross-sectional design and included a convenience sample of 4 groups of subjects: male attempters, female attempters, male nonattempters, and female nonattempters. The aim of the present study was to further investigate the interactions of gender, risk factors, psychopathologic measures, and suicide attempts using a large scale of instruments. 2. Methods The study sample consisted of 404 consecutive adolescents, aged between 12 and 21 (mean, 16 years), who were hospitalized in 2 psychiatric units in central Israel. All had been evaluated psychiatrically and were diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I and Axis II disorders. They were interviewed within 7 days of their hospitalization with the Hebrew version of the Schedule for Affective Disorders and Schizophrenia for School-age Children, which was validated in earlier studies on our unit’s population [24,25]. The psychiatrists who made the final diagnoses were blinded to the study results. In addition, data were gathered from the families and from clinical observations during hospitalization. Subjects whose mental condition or cognitive abilities prevented them from participating and those with mental retardation were excluded from the study. Subjects with severe gender identity problems were also excluded because the main aim of the study was to investigate the interaction between gender and suicide attempt across different
diagnostic groups. The patients were divided into the following 4 groups: 1. 2. 3. 4.
Boys hospitalized with psychopathology but without any history of suicide attempt (n = 103); Boys after a suicide attempt (n = 76; 42%); Girls with psychopathology but without any history of suicide attempt (n = 82); Girls after a suicide attempt (n = 143; 64%);
In groups 2 and 4, a suicide attempt caused each of the subjects’ hospitalization. For 10 boys (13.2%) and 25 girls (17.5%), it was not their first attempt to commit suicide. The study was approved by the local institutional review board. Each participant received an explanation of the research, and parents and patients signed an informed consent form. All data were kept confidential. 2.1. Instruments Eight instruments were used to measure 6 areas of psychopathology: life events (Child Suicide Potential Scale [CSPS]) [26]; affective disorders (CSPS, Beck Depression Inventory [BDI] [27], and State-Trait Anxiety Inventory [STAI]) [28]; aggression (BDI, CSPS, [26] Overt Aggression Scale [OAS] [29], and Multidimensional Anger Inventory) [30]; impulsivity (CSPS and Impulsive Control Scale [ICS]) [31]; defense mechanisms (CSPS and LSI) [32]; and death perception (CSPS) [33]. 2.2. Psychometric properties of the instruments The CSPS [26] is a structured interview that evaluates behaviors, emotions, family history, life events, and ego functions in suicide-prone children and adolescents. Data are collected from the children, their parents, and school and hospital staff separately; in this study, we used only the children as sources of information. The subjects were asked about their behavior, thoughts, and affective states 6 months before admission and upon admission. The instrument is composed of 9 scales: spectrum of suicidal behavior (j of interrater reliability Hebrew version = 0.93); spectrum of aggressive behavior (j of interrater reliability Hebrew version = 0.91); life events; affect and behavior in the past; affect and recent behavior; family background; perception of death, namely, preoccupation with death (j of interrater reliability Hebrew version = 0.86), perception of death as agreeable (j of interrater reliability Hebrew version = 0.90), and perception of death as final (j of interrater reliability Hebrew version = 0.90); ego functions (intelligence and reality testing); and defense mechanisms of the ego (j of interrater reliability Hebrew version = 0.52-0.96, with a mean of 0.91 for the whole subscale). The Hebrew version of the CSPS was evaluated in hospitalized adolescents, and its internal consistency (Cronbach a = 0.93) and interrater reliability (j = 0.86-0.93 for the different subscales) were found to be high [34]. The BDI [27] evaluates depression in adults and adolescents. It is composed of 21 items dealing with
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psychiatric populations. When regression was excluded as a defense mechanism, the use of all other defense mechanisms in the 5 months before the present investigation proved to be the same. The test-retest reliability in a normal control group was found to range between 0.48 and 0.76.
symptoms and attitudes of depression such as mood, feelings of failure, guilt, despair, low self-esteem, suicidal thoughts, social isolation, loss of interest in sex, sleep problems, loss of appetite, and decrease in weight. Each item is rated from 0 to 3 according to the degree by which it reflects a patient’s state during the previous week. The BDI has a high internal consistency for psychiatric populations ranging from 0.73 to 0.92; its test-retest reliability, from 0.48 to 0.86; and concurrent validity, from 0.55 to 0.96 [26]. The Spielberger et al STAI [28] is a self-report instrument for the evaluation of anxiety as a state or trait. It includes 20 statements rated according to a respondent’s state at the time of the test and another 20 rated according to the respondent’s feelings in general. Internal consistency is between 0.80 and 0.90 for the 2 scales and test-retest reliability is 0.70 for anxiety-trait and from 0.27 to 0.62 for anxiety-state (for an interval of 20-104 days). Construct validity is high [28]. The STAI was translated into Hebrew and adapted for the Israeli population by Teichman and Malinek [35]. The OAS [29] documents and quantifies verbal and physical behaviors of overt aggression directed against property, the self, and others. The interclass correlation was 0.80 and interrater reliability was 0.87. The Multidimensional Anger Inventory [30] evaluates different aspects of anger: frequency, duration, intensity, and presentation, situations that provoke anger, and attitude towards hostility. Factor analysis yielded 3 factors: arousal of anger, hostility, and situations that provoke anger. Internal consistency was found to be high (Cronbach a = 0.84 and 0.89) in 2 different populations and test-retest agreement was 0.75. The ICS [31] is a self-report questionnaire measuring individuals’ tendency to engage in impulsive behaviors. It consists of 15 statements that respondents rate on a scale of 1 to 4 according to their level of agreement with them. The internal consistency of the questionnaire was found to be moderate in the general population (Cronbach a = 0.68) and in high-army Israeli soldiers (Cronbach a = 0.83) [31]. The LSI [32] is a self-report measure of defense mechanisms. It includes 97 yes/no statements (for example: bI have a need to receive compliments from othersQ or bI often lieQ). The Cronbach a varied from 0.54 to 0.86 in
2.3. Statistical analysis The study groups were compared by analysis of variance and the log linear model in uni- and bidirections. To investigate the independent variables that predict suicidal behavior, variables for which an interaction between gender and suicide attempt was found were entered into a stepwise logistic regression model. This analysis was done for the study population collectively using gender as one of the variables and separately for men and women. The odds ratio was calculated with a 95% confidence interval. 3. Results The reasons for admission among the nonattempters were mainly violent behavior and inability to function in the community. No differences were found among the groups for age, socioeconomic status, number of siblings, marital status of the parents, country of birth, or country of birth of the parents. Analysis of ethnic distribution yielded a higher rate of Ashkenazi and Sephardic origin in the non–suicide-prone adolescents (men and women) and a higher rate of botherQ ethnic origins in the suicide-prone adolescents (v 2 = 24.98; df = 2; P b .0001). More patients in the suicide-prone groups were adopted (v 2 = 5.56; df = 1; P b .005). 3.1. Psychiatric diagnosis Men had higher rates of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses of schizophrenia (27.9% [n = 50] vs 16.9% [n = 38]) and conduct disorder (18.4% [n = 33] vs 1.3% [n = 3]), whereas women had higher rates of eating disorder (14.7% [n = 33] vs 2.8% [n = 5]) and borderline disorder (25.3% [n = 57] vs 6.7% [n = 12]). Differences for the presence of other personality disorders were not significant (men: 9.5% [n = 17]; women: 8.4% [n = 19]): affective disorder (men: 8.4% [n = 15]; women: 11.6% [n = 26]), other diagnoses
Table 1 Interaction of anxiety and depression scales, gender, and suicide attempts Variable
Attempters Men
Depression Anxiety (CSPS) Past anxiety (CSPS) Anxiety-state (STAI) Anxiety-trait (STAI)
Nonattempters Women
Men
ANOVA Women
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
62 74 73 52 52
28.40 7.61 8.41 52.67 50.65
122 105 101 114 114
27.22 8.39 9.04 50.02 51.25
87 98 101 73 81
19.53 5.05 6.18 37.58 39.33
63 81 82 59 64
25.22 6.43 6.96 44.19 44.80
ANOVA indicates analysis of variance. * P b .05.
(17.05) (2.41) (3.67) (13.19) (13.46)
(16.47) (3.08) (4.52) (12.91) (13.00)
(15.26) (3.52) (4.27) (12.74) (14.91)
(14.73) (3.96) (4.21) (15.17) (15.22)
F F F F F
= = = = =
5.41*; df = 1, 330 0.72; df = 1, 354 0.03; df =1, 353 8.16*; df = 1, 294 2.14; df = 1, 307
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Table 2 Comparison of impulsivity and aggression between suicide attempters and nonattempters Variable
Attempters Men
Violence (CSPS) Antisocial (CSPS) Past antisocial (CSPS) Aggression Past aggression (CSPS) Impulsive (CSPS) Impulsive (ICS) Anger (MAI)
Nonattempters Women
Men
ANOVA Women
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
75 74 73 74 73 66 62 53
3.19 1.55 1.37 4.72 4.32 13.92 34.89 70.68
141 106 101 106 100 95 121 113
2.53 1.07 1.01 4.58 4.31 14.57 31.50 66.94
103 98 101 99 101 94 89 82
2.55 0.44 0.48 3.62 3.42 13.34 29.33 55.60
80 81 81 80 82 76 64 62
1.69 0.47 0.37 3.10 2.46 14.96 28.31 60.03
(1.94) (1.29) (1.41) (2.72) (2.62) (3.44) (8.07) (18.75)
(1.56) (1.16) (1.16) (2.52) (2.57) (3.33) (6.51) (16.94)
(1.85) (0.81) (0.89) (2.85) (3.01) (3.11) (6.36) (21.41)
(1.44) (0.74) (0.73) (2.49) (2.35) (3.70) (6.67) (21.28)
F F F F F F F F
= = = = = = = =
17.71*; df = 1, 395 60.02*; df = 1, 249 42.76*; df = 1, 229 20.77*; df = 1, 355 23.16*; df = 1, 352 0.06; df = 1, 327 32.20*; df = 1, 332 21.94; df = 1, 226
ANOVA, analysis of variance; MAI, Multidimensional Anger Inventory. * P b .0001.
(adjustment disorder, obsessive compulsive disorder; men: 12.0% [n = 21]; women: 11% [n = 25]), and psychosis not otherwise specified (men: 14.1% [n = 25]; women: 11.1% [n = 24]). There were no differences in diagnoses between attempters and nonattempters. 3.2. Depression and anxiety The suicide-prone adolescents had higher rates of depressive and anxiety symptoms than the non–suicideprone adolescents, as indicated by their higher scores on the CSPS upon admission to the study (F = 28.56; df = 1, 307; P b .0001) and 6 months before that (F = 41.77; df = 1, 300; P b .0001). Both trait and state anxiety were predictive of a suicide attempt (trait: F = 41.63; df = 1, 294; P b .001; state: F = 28.56; df = 1, 307; P b .0001). Within the non–suicide-prone group, depression was more prevalent in women than in men. Table 1 presents the analysis of variance findings for the interaction of gender, depressive and anxiety states, and suicide attempt. An interaction was noted between suicide attempt and both depressive symptoms, as measured by the CSPS, and between suicide attempt and anxiety state, as measured by the STAI. Among the nonattempters, women were more depressed/anxious than men; among the suicide attempters, the opposite was true. 3.3. Impulsivity and aggressiveness (CSPS, ICS) Aggressiveness, anger, destructive behavior, impulsivity (by the ICS but not by the CSPS), and antisocial behavior upon admission and at 6 months before admission were all associated with suicidal behavior (Table 2). An interaction of antisocial behavior in the 6 months before admission, suicidal
behavior, and gender, with male attempters having higher antisocial behavior scores than female attempters, was found. No such difference was noted among the nonattempters. Destructive behavior as measured by the OAS was dichotomized to bdestructive behaviorQ and bnondestructive behaviorQ. Subjects who were rated by the staff as presenting any destructive behavior were regarded as having overt aggression. Destructive behavior was more prevalent among men than women and among suicide attempters than nonattempters. On 3-way analysis, destructive behavior was significantly more prevalent in female attempters than in female nonattempters. No such difference was found for men (Table 3). 3.4. Perception of death Attempters perceived death as more pleasant (F = 68.87; df = 1, 290; P b .05) and less definite (F = 5.66; df = 1, 267; P b .005) than nonattempters did. Men perceived death as less definite than women did (F = 4.05; df = 1, 266; P b .05). 3.5. Life events Life events predicted suicide attempts (F = 27.82; df = 1, 400; P b .0001). Specifically, an association was found between suicide attempts and life events such as separation from the parents in the 6 months preceding admission, suicide attempt by a family member (especially the mother), psychiatric hospitalization, and addiction to drugs and alcohol of a family member. There was no difference between attempters and nonattempters in the prevalence of chronic illness or depression in the family. Among attempters, women had a higher completed suicide rate in
Table 3 Destructive behavior in suicide attempters and nonattempters by gender Behavior Destructive Nondestructive
Attempters
Nonattempters
Men (n = 68)
Women (n = 98)
Total (N = 166)
Men (n = 94)
Women (n = 80)
Total (N = 174)
54.4% 45.6%
45.9% 54.1%
49.4% 50.6%
41.5% 58.5%
15.0% 85.0%
29.3% 70.7%
Destructiveness by gender: v 2 = 11.77; df = 1; P b .001. Destructiveness by suicide attempt: v 2 = 18.35; df = 1; P b .0001. Destructiveness by gender and by suicide attempt: v 2 = 4.69; df = 1; P b .05.
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Table 4 Defense mechanisms, gender, and suicide attempts as measured by the CSPS using analysis of variance Variable
Attempters Men
Regression Denial Projection Introjection Reaction formation Undoing Displacement Intellectualization Compensation Sublimation Repression Total defense mechanisms
Nonattempters Women
Men
ANOVA Women
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
69 69 69 69 68 68 67 67 67 68 67 67
1.70 2.20 1.94 1.83 1.68 1.46 1.46 1.63 1.73 1.68 2.18 19.55
102 102 102 101 102 102 102 101 102 101 101 99
1.82 2.13 2.09 1.88 1.88 1.64 1.78 1.75 1.90 1.81 2.00 20.74
99 99 99 98 99 99 99 99 98 98 98 97
2.03 2.25 2.09 1.72 1.87 1.69 1.72 1.82 1.77 1.48 2.00 20.49
81 81 81 80 81 80 80 81 79 77 78 79
1.99 2.35 2.03 1.91 1.74 1.80 1.78 1.83 1.68 1.81 2.12 20.92
(0.77) (0.74) (0.80) (0.80) (0.66) (0.70) (0.61) (0.76) (0.81) (0.63) (0.65) (3.12)
(0.70) (0.78) (0.77) (0.71) (0.78) (0.73) (0.74) (0.77) (0.80) (0.70) (0.60) (3.42)
(0.65) (0.73) (0.77) (0.72) (0.79) (0.79) (0.72) (0.80) (0.74) (0.56) (0.69) (3.78)
(0.62) (0.71) (0.77) (0.68) (0.79) (0.79) (0.69) (0.82) (0.71) (0.78) (0.68) (2.83)
F F F F F F F F F F F F
= = = = = = = = = = = =
1.34; df = 1, 347 1.10; df = 1, 347 1.59; df = 1, 347 0.72; df = 1, 344 4.10*; df = 1, 346 0.17; df = 1, 345 3.01; df = 1, 344 0.47; df = 1, 344 2.28; df = 1, 342 1.68; df = 1, 340 4.23*; df = 1, 340 1.03; df = 1, 338
ANOVA, analysis of variance. T P b .05.
family members than men did, and men had a higher rate of family members who threatened to kill or hurt someone. Female attempters also had a higher rate of chronic illness in family members. Among the nonattempters, men had a higher suicide rate among family members. (v 2 = 14.32; df = 2; P b .001). Gender interactions with suicide attempt were found for a family member who threatened murder and for chronic illness in the family but not for other pathologic conditions such as depression, drug abuse, and use of tranquilizers or for psychiatric hospitalization. 3.6. Defense mechanisms Differences were found between attempters and nonattempters with regard to the use of defense mechanisms. Analysis for the self-report LSI showed that attempters used more regression (F = 4.78; df = 1, 161; P b .05) and displacement (F = 5.15; df = 1, 161; P b .05). According to the CSPS, attempters used less regression (F = 11.11; df = 1, 280; P b .001) and less undoing (F = 5.78; df = 1, 345; P b .05). We did not find any interaction between gender with defense mechanisms and suicide attempt with the LSI, but, as shown in Table 4, in the CSPS, reaction formation was used more by female attempters than by male attempters and
Table 5 Stepwise logistic regression analysis predicting suicide attempts Variable Women Destructiveness Antisocial behavior Anxiety-state Men Anxiety-state Antisocial behavior Depression
P
Odds ratio
95% confidence interval
b.0001 b.05 .05
3.39 1.55 1.03
1.23; 9.32 0.99; 2.41 1.00; 1.06
b.0001 b.0001 b.05
1.10 3.16 1.38
1.05; 1.15 1.74; 5.73 0.99; 1.92
more by male nonattempters than by female nonattempters. Repression was used more by male attempters than by female nonattempters. On multivariate analysis with stepwise logistic regression, we entered only those variables with a statistically significant difference in the interaction between gender and suicide attempt: suicidal behavior, destructive behavior, antisocial behavior, depression, and anxiety state. The variables noted in very low numbers of participants (homicide by siblings, suicide in the family, and chronic illness in a family member) were not included. To study the independent risk factors by gender, a separate model was formatted for men and women. As shown in Table 5, 2 variables were found to predict suicide attempts: antisocial behavior and anxiety state. The relationship of both antisocial behavior and anxiety with suicide attempt was stronger in men than in women; destructive behavior had the strongest predictive value for suicide attempts in women, whereas it was not specifically associated with suicide attempts in men. In the men, separately, only depression predicted suicide attempts. 4. Discussion The general findings of this study revealed several differences between suicide attempters and nonattempters, showed differences regarding various measures, and concurred with the literature on clinical and nonclinical samples. The scores for depression and anxiety state and trait were higher in attempters than in nonattempters upon admission and at 6 months preceding admission [3-5], as were the scores for aggressiveness, anger, destructive behavior, and impulsivity in some but not all of the instruments [7]. Attempters perceived death as more pleasant and less definite than nonattempters did. Similar to previous studies, separation from parents, suicide attempt by a family member, psychiatric hospitalization of a family
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member, and addiction to drugs and alcohol were all associated with suicide attempt [2,5,8]. Attempters also used defense mechanisms differently from nonattempters. Attempters used more displacement than nonattempters did and less undoing. Regression was used more by attempters according to the self-report instrument and less by the interviewer’s rating. The findings on displacement and regression (higher scores) are in accordance to our previous study [9], although more types of other differences were found in the previous study. On multivariate analysis, antisocial behavior and anxiety predicted suicide. The present study also yielded gender differences in risk factors for suicidal behavior: depression, anxiety, impulsivity, aggression, and life events. There was an interaction of gender, depression, and suicide attempt, with depression being more prevalent in female nonattempters than in male nonattempters; male attempters used more repression than female attempters did and less reaction formation. This differential use of repression has an important implication for the direction that the intervention should take in this population (ie, encouragement of self-disclosure; see also our previous study [9]). On stepwise logistic regression analysis, depression was statistically significant in predicting suicide attempt only in boys. The measure of depression cut across all the diagnostic groups. A similar interaction was found for anxiety: female nonattempters were more anxious than male nonattempters, but among suicide attempters, this difference disappeared. In the final multivariate analysis, the association between state anxiety and suicide attempt was stronger in men than in women. This finding may indicate that depression and anxiety have a stronger association with suicide attempt in hospitalized male adolescents but less specific findings in hospitalized females. Support for our results was provided by earlier community studies [6,15]. Our clinical sample, however, with subjects from different diagnostic groups, suggests that regardless of diagnosis, depressed and anxious moods in boys are an ominous sign and might be associated with suicide attempt. Women who attempted suicide showed more destructive behavior in the unit than women who did not attempt suicide, and there was an interaction of gender, destructive behavior, and suicide attempt. Antisocial behavior was predictive of a suicide attempt in both girls and boys. This finding is similar to an earlier community study [6], although in a more recent study [13], antisocial behavior was found to be predictive of suicide attempt only in girls. These discrepancies may be attributable to differences in the study populations, the measures used, and the specific types of antisocial, destructive, and suicidal behaviors. Like Pfeffer et al [4], we found that life events had a similar association with suicide attempt for men and women. By contrast, Kotila and Lonnquist [22] reported that suicide attempts are usually a reaction to a conflict or a serious life event only in girls. In the study of Pfeffer et al [4], the specific life events associated with suicidal behavior
differed by gender: in girls, major events were separation from a boyfriend, sexual abuse, and problems in school; in boys, major events were aggression in the family and having a sibling with suicidal behavior. In our study, there were gender differences for several life events such as suicide or chronic illness in the family (more in girls who attempted suicide) or threats of homicide by a family member (more in boys who attempted suicide). However, owing to the small number of each of these events, we could not include these variables in the final analyses. 4.1. Limitations of the study 1.
2.
3.
The study population included hospitalized patients only. Therefore, it might be biased with regard to gender because referring psychiatrists tend to consider suicide attempts more serious in men and to send more male than female attempters for hospitalization. Furthermore, female attempters may represent the more severe end of the spectrum and therefore have more severe psychopathology. The sample was unique in composition, and the differences in psychiatric diagnoses represent the population in psychiatric hospitals but not the population in general. The inclusion of all diagnostic groups and the effort to reveal behaviors and correlates that cut across diagnostic groups might have led to some dilution of the findings. The heterogeneity of the sample is both a weakness and a strength of the study, making it possible for us to view suicidal behavior above and beyond diagnostic groups. A cross-sectional design was used, precluding conclusions on directionality and causality.
5. Conclusions 1.
2.
Suicide-prone female and male adolescent inpatients show distinct differences in psychopathology, ego defense mechanisms, and life events compared to psychiatrically hospitalized adolescents without any history of suicide attempt. Any deviation from a gender-specific behavior must raise suspicion of a risk of attempted suicide.
References [1] Lewinsohn PM, Rohde P, Seeley JR. Psychosocial characteristics of adolescents with a history of suicide attempt. J Am Acad Child Adolesc Psychiatry 1993;32:60 - 8. [2] Reinherz HZ, Giaconia RM, Silverman AB, Friedman A, Pakiz B, Frost AK, et al. Early psychosocial risks for adolescents’ suicidal ideation and attempts. J Am Acad Child Adolesc Psychiatry 1995; 34:599 - 611. [3] Gould MS, King R, Greenwald S, Fisher P, Schawab-Stone M, Kramer R, et al. Psychopathology associated with suicidal ideation and attempts among children and adolescents. J Am Acad Child Adolesc Psychiatry 1998;37:915 - 23.
S. Fennig et al. / Comprehensive Psychiatry 46 (2005) 90 –97 [4] Pfeffer CR, Newcorn J, Kaplan G, Misruchi MS, Plutchik R. Suicidal behavior in adolescent psychiatric inpatients. J Am Acad Child Adolesc Psychiatry 1988;27:357 - 61. [5] Carlson GA, Abott SF. Mood disorders and suicide. In: Kaplan HI, Sadock BJ, editors. Comprehensive textbook psychiatry, 6th ed., vol. 2. New York (NY)7 Williams & Wilkins; 1995. p. 2384 - 8. [6] Andrews JA, Lewisohn PM. Suicidal attempts among older adolescents: prevalence and co-occurrence with psychiatric disorders. J Am Acad Child Adolesc Psychiatry 1992;31:655 - 62. [7] Stein D, Apter A, Ratzoni G, Har-Even D, Avidan G. Association between multiple suicide attempts and negative affects in adolescents. J Am Acad Child Adolesc Psychiatry 1998;37:488 - 94. [8] Wild EJ, Kienhorst ICWM, Diekstra RFW, Wolters WHG. The relationship between adolescent suicidal behavior and life events in childhood and adolescents. Am J Psychiatry 1992;149:45 - 51. [9] Apter A, Gothelf D, Offer R, Ratzoni G, Orbach I, Tyano S, et al. Suicidal adolescents and ego defense mechanisms. J Am Acad Child Adolesc Psychiatry 1997;36:1520 - 7. [10] Platt S, Bill-Brahe U, Kerkhof A, Schmidtke A, Berjke T, Crept P, et al. Parasuicide in Europe: The WHO/Euro Multicenter Study on Parasuicide. I: Introduction and preliminary analysis for 1989. Acta Psychiatr Scand 1992;85:97 - 104. [11] Apter A, Freudenstein O. Adolescent suicidal behaviour: psychiatric populations. In: Hawton K, van Heeringeen K, editors. The international handbook of suicide and attempted suicide. New York (NY)7 Wiley; 2000. p. 261 - 73. [12] Rich AR, Kirkpatric-Smith J, Bonner RL, Jans F. Gender differences in the psychosocial correlates of suicidal ideation among adolescents. Suicide Life Threat Behav 1992;22:364 - 73. [13] Olssson G, Von Knorring AL. Beck’s Depression Inventory as a screening instrument for adolescent depression in Sweden: gender differences. Acta Psychiatr Scand 1997;95:277 - 82. [14] Wannan G, Fambonne E. Gender differences in rates and correlates of suicidal behavior amongst child psychiatric outpatients. J Adolesc 1998;21:371 - 81. [15] Lewinsohn PM, Rohde P, Seeley JR, Baldwin CL. Gender differences in suicide attempts from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry 2001;40:427 - 34. [16] Gasquet I, Choquet M. Gender role in adolescent suicidal behavior: observation and therapeutic implications. Acta Psychiatr Scand 1993;87:59 - 65. [17] Von Knorring AL, Kristiansson G. Depression and suicidal behaviour in young people. In: Bskow J, editor. Rvtt till liv lust till liv. Om sjvlvmordsbtende bland barn och ungdomar. Rapport 95, vol. 4. Stockholm: Forskningsruds-nvmnden; 1995. p. 35-43. [18] Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, et al. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry 1996;53:339 - 48.
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[19] Mattunen MJ, Henriksson MM, Aro HM, Heikkinen ME, Isoetsa ET, Lonnqvist JK. Suicide among female adolescents: characteristics and comparison with males in the age group 13 to 22 years. J Am Acad Child Adolesc Psychiatry 1995;34:1297 - 307. [20] Groholt B, Ekeberg O, Wichstrom L, Haldorrsen T. Sex differences in adolescent suicides in Norway, 1990-1992. Suicide Life Threat Behav 1999;29:295 - 308. [21] Brent DS, Baugher M, Bridge J, Chen T, Chiappetta L. Age and sexrelated risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry 1999;38:1497 - 505. [22] Kotila L, Lonnquist J. Adolescent suicide attempts: sex differences predicting suicide. Acta Psychiatr Scand 1988;77:264 - 70. [23] Murphy G. Why women are less likely than men to commit suicide. Compr Psychiatry 1998;39:1 - 12. [24] Apter A, Orvaschel H, Laseg M, Moses T, Tyano S. Psychometric properties of the K-SADS-P in an Israeli adolescent psychiatric population. J Am Acad Child Adolesc Psychiatry 1989;28:61 - 5. [25] Shanee N, Apter A, Weizman A. Psychometric properties of the KSADS-PL in an Israeli adolescent clinical population. Isr J Psychiatry Relat Sci 1997;34:179 - 86. [26] Pfeffer CR, Conte HR, Plutchik R, Jerret J. Suicidal behavior in latency-age children: an empirical study. J Am Acad Child Adolesc Psychiatry 1979;18:679 - 92. [27] Beck AT, Steer RA. Internal consistency of the original and revised Beck Depression Inventory. J Clin Psychol 1984;40:1365 - 7. [28] Spielberger CD, Gorsuch RI, Lushene RD. STAI: manual for the State-Trait Anxiety Inventory. Palo Alto (CA)7 Consulting Psychologists Press; 1970. [29] Yudofsky SC, Silvaer JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry 1986;143:35 - 9. [30] Siegel JM. The Multidimensional Anger Inventory. J Pers Soc Psychol 1986;51:191 - 200. [31] Plutchik R, van Praag HM. The measurement of suicidality, aggressivity and impulsivity. Clin Neuropharmacol 1986;9:380 - 2. [32] Plutchik R, Kellerman H, Conte HR. A structural model of ego defenses and emotions. In: Izard CE, editor. Emotions in personality and psychology. New York (NY)7 Plenum Press; 1979. p. 10 - 46. [33] Gothelf D, Apter A, Brant-Gothelf A, Offer N, Ofek H, Tyano S, et al. Death concepts in suicidal adolescents. J Am Acad Child Adolesc Psychiatry 1998;37:1279 - 86. [34] Ofek H, Weizman T, Apter A. The Child Suicide Potential Scale: inter-rater reliability and validity in Israeli in-patient adolescents. Isr J Psychiatry Relat Sci 1998;35:253 - 61. [35] Teichman Y, Malinek H. STAI: measure for evaluating state and trait anxiety. Hebrew manual for the evaluator. Tel Aviv7 Ramot, Tel Aviv University; 1984.
Effect of gender on suicide attempters versus nonattempters in an adolescent inpatient unit Silvana Fenniga,b,c,*, Keren Gevab, Gil Zalsmana,c,d, Abraham Weizmanc,d, Shmuel Fenniga,c,e, Alan Aptera,b,c b
a The Feinberg Child Study Center, Schneider Children’s Medical Center of Israel, Petach Tikva 49202, Israel Department of Psychological Medicine, Schneider Children’s Medical Center of Israel, Petach Tikva 49202, Israel c Department of Psychiatry, Sackler School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel d Geha Psychiatric Center, Rabin Medical Center, Petach Tikva 4100, Israel e Outpatient Department, Shalvata Mental Health Center, Hod Hasharon 45263, Israel
Abstract Background: Although gender differences have been noted in the risk factors for suicide and attempted suicide, comparative studies to date have used only 2 groups and a limited number of measures. The present study compared the effect of gender on suicide among 4 groups of psychiatrically hospitalized adolescents using a cross-sectional design. Methods: The study sample consisted of 404 patients, aged between 12 and 21, who were divided into 4 groups: 76 male suicide attempters, 103 male nonattempters, 143 female suicide attempters, and 82 female nonattempters. Patients were tested for life events, affective disorders, aggression, impulsivity, ego defense mechanisms, and death perception with the Child Suicide Potential Scale, Beck Depression Inventory, State-Trait Anxiety Inventory, Overt Aggression Scale, Multidimensional Anger Inventory, Impulsivity Control Scale, and Life Style Index. Findings were analyzed by multivariate regression with stepwise logistic models. Results: Depression and anxiety were more prevalent in female nonattempters than in male nonattempters; there were no such gender differences among the attempters. Antisocial behavior was more prevalent in male attempters than in female attempters; there were no gender differences on this aspect among the nonattempters. There were gender differences for defense mechanisms in the attempters. Logistic regression models for men and women separately revealed that antisocial behavior and anxiety were common predictors of suicide attempt, that destructiveness was a predictor in women only, and that depression was associated with suicide attempt in men only. Conclusions: Suicide-prone female and male adolescent inpatients show distinct differences in psychopathology, ego defense mechanisms, and life events compared to psychiatrically hospitalized adolescents without any history of suicide attempt. Any deviation from a genderspecific behavior must raise suspicion of a risk of attempted suicide. D 2005 Elsevier Inc. All rights reserved.
1. Introduction Epidemiologic studies report that the risk of suicide increases with an increase in the number of risk factors present [1]. Several risk factors are known to be associated with suicidal behavior; these include socioeconomic problems [2]; psychiatric disorders, namely, depression [3,4], anxiety disorders [3,5], conduct disorders [5], and borderline personality disorder [7]; alcohol and drug abuse [3];
* Corresponding author. The Feinberg Child Study Center, Schneider Children’s Medical Center of Israel, Beilinson Campus, Petach Tikva 49202, Israel. Tel.: +972 03 9253761; fax: +972 09 7446654. E-mail address: [email protected] (S. Fennig). 0010-440X/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2004.07.037
suicidal thoughts and previous suicide attempt [2]; history of psychiatric disorder in the family [5]; problematic life events such as suicide in the family and separation from parents [5,8] or sexual abuse [8]; and dysfunctional defense mechanisms [9]. Psychopathologic measures that were found to be associated with suicide included mainly depressive mood [1], aggression, aggressive behavior, anger, violence, and impulsivity [7]. Studies of attempted suicide often include heterogenous populations; thus, the literature on the subject needs to be read carefully. On the basis of the World Health Organization/European Study on Parasuicide [10], the terms battempted suicideQ and bparasuicideQ were considered equivalent and were
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defined as follows: bAn act with nonfatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences.Q Attempted suicide in some cases may be conceived as failed suicides. In most cases, this is not true because their dynamics differ. Most of the studies on risk factors of suicidal behaviors in adolescents were done in psychiatric populations. These studies found that low income and residential mobility were highly associated with serious suicide attempts. Other significant findings were childhood sexual abuse, low parental care, and poor parental relationship. Patients had an elevated risk for mood disorder, substance abuse, and conduct disorder [11]. Some authors suggested that the effectiveness of coping mechanisms and defense mechanisms in suicide attempters may also differ from those in nonattempters. Apter et al [9] found that suicide-prone adolescents could be distinguished from non–suicide-prone inpatients by their Life Style Index (LSI) scores on displacement (higher) and compensation (lower). On the Ego Defense Scale, suicide-prone adolescents scored higher on regression, denial, projection, introjection, repression, and total defenses and lower on sublimation. Denial and regression correlated positively with suicidal and violent behavior, whereas sublimation correlated negatively with such behavior. How are these risk factors associated with gender? The development of boys and girls differs in terms of intensity and prevalence of depressive and anxiety symptoms, internalization/externalization, rigid/ambivalent cognitive styles, and pressure of social roles [12,13]. These differences may be of biologic or sociologic origin [12,13]. Large-scale epidemiologic and clinical studies have found that rates of clinical depression are similar in boys and girls during childhood and would then increase markedly during adolescence in girls but less so in boys [11,13]. In general, girls have a greater tendency to internalize their suffering and pain and to manifest their internal pain as anxiety and depression and psychosomatic symptoms. Depression is more severe in girls than in boys [12,13], as are many symptoms associated with depression such as low selfesteem, poor body image, feelings of unattractiveness, pessimism, feelings of failure, guilt, and self-blame, anger, social withdrawal, hesitancy, preoccupation with health, and loss of interest in the opposite sex. By contrast, boys tend to externalize their pain in the form of behavioral problems, problems with the law, and drug abuse. These findings may shed light on the well-recognized bgender paradoxQ in suicide. On one hand, women report suicidal ideation more frequently than men do and attempt to commit suicide more often. On the other hand, men exceed women in the rate of suicidal deaths. Identifying the
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risk factors for suicidal behavior for each gender separately may help us understand why these occur. Accordingly, in an epidemiologic sample from France, Gasquet and Choquet [16] studied suicidal behavior in schoolchildren and found that a deviation from normal behavior was more noticeable in male attempters than in female attempters. They also reported that suicide attempters suffered more from depression than nonattempters did and that this finding was more evident in boys than in girls. Von Knorring et al [17] found that 60% of boys and 44% of girls who had attempted suicide were currently suffering from moderate or severe depression. In the same survey, 2% of all the boys and 5% of all the girls had moderate or severe depression. The authors concluded that although depression is more prevalent in girls, it is an ominous sign predictive of suicidal behavior in boys. Findings from autopsies of subjects who committed suicide are inconclusive with regard to the association of depression, suicide, and gender. Two studies reported that major depression was more prevalent in women who committed suicide than in men [18,19], with respective rates of 56% and 26% [18]. Others found that depression occurred at a similar rate in suicide-prone men and women but was a stronger predictor of completed suicide in men [20]. These discrepancies may be attributable to differences in the samples, methodology, and definition of suicide attempt. The association of antisocial behavior, suicide, and gender is also far from clear. In a psychologic autopsy study of suicide cases, Brent et al [21] found that conduct and antisocial disorder were more prevalent in boys than in girls, whereas Mattunen et al [19] found no such gender difference, although conduct disorder served as a risk factor for completed suicide in men. Wannan and Fambonne [14], in a study of adolescents, found antisocial behavior to be a risk factor for suicide attempts in girls, whereas Andrews and Lewisohn et al. [6] reported that conduct disorder had no predictive value for suicide attempts. In a psychiatric population, aggressive behavior was the only predictor of suicide attempts in girls [4], but in a community study, it was a risk factor for suicide attempts in boys only [3]. One study from Finland showed that male adolescent suicide attempters had more social problems, lower function, and more behaviors with self-destructive potential than female attempters did [22]. Some studies failed to find gender difference in the use of alcohol and drugs between male and female suicide attempters [19,20]. However, Shaffer et al [18] found alcohol and drug use to be a risk factor for suicide attempts in boys, while Brent et al [21] reported that it was a risk factor in both genders. No difference in anxiety was found between male and female suicide attempters [4,18]. Regarding life events and attempted suicide, academic failure was found to be a risk factor in boys only [16]. Kotila and Lonnquist [22] found that among suicide attempters, boys had a poorer attendance record than girls did, and they
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often missed regular daily activities at school or work. In contrast, in a study of completed suicide, the rate of unemployment was higher among the women [18,20], and no differences were noted for other life events [20]. However, the women had more adverse life events and their suicide attempts were often a reaction to these events. Pfeffer et al [4] reported that the specific life events associated with suicidal behavior differed by gender: in girls, major events were separation from a boyfriend, sexual abuse, and problems in school; in boys, major events were aggression in the family and having a sibling with suicidal behavior. However, these findings failed to reach statistical significance in the final analysis. Data on coping styles and defense mechanisms in suicide-prone individuals are scarce. Overall, women are believed to think in a more general way and to take more variables into account before making a decision; this tendency may protect them from performing an irreversible act such as suicide. They change their minds more easily and use social interactions to ventilate and process their feelings [23]. How these sociologic findings are expressed by way of defense mechanisms has not been studied in suicide attempters from different diagnostic groups. In contrast to most of earlier studies that included only 2 study groups and compared either male attempters with female attempters or attempters with nonattempters, we used a cross-sectional design and included a convenience sample of 4 groups of subjects: male attempters, female attempters, male nonattempters, and female nonattempters. The aim of the present study was to further investigate the interactions of gender, risk factors, psychopathologic measures, and suicide attempts using a large scale of instruments. 2. Methods The study sample consisted of 404 consecutive adolescents, aged between 12 and 21 (mean, 16 years), who were hospitalized in 2 psychiatric units in central Israel. All had been evaluated psychiatrically and were diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I and Axis II disorders. They were interviewed within 7 days of their hospitalization with the Hebrew version of the Schedule for Affective Disorders and Schizophrenia for School-age Children, which was validated in earlier studies on our unit’s population [24,25]. The psychiatrists who made the final diagnoses were blinded to the study results. In addition, data were gathered from the families and from clinical observations during hospitalization. Subjects whose mental condition or cognitive abilities prevented them from participating and those with mental retardation were excluded from the study. Subjects with severe gender identity problems were also excluded because the main aim of the study was to investigate the interaction between gender and suicide attempt across different
diagnostic groups. The patients were divided into the following 4 groups: 1. 2. 3. 4.
Boys hospitalized with psychopathology but without any history of suicide attempt (n = 103); Boys after a suicide attempt (n = 76; 42%); Girls with psychopathology but without any history of suicide attempt (n = 82); Girls after a suicide attempt (n = 143; 64%);
In groups 2 and 4, a suicide attempt caused each of the subjects’ hospitalization. For 10 boys (13.2%) and 25 girls (17.5%), it was not their first attempt to commit suicide. The study was approved by the local institutional review board. Each participant received an explanation of the research, and parents and patients signed an informed consent form. All data were kept confidential. 2.1. Instruments Eight instruments were used to measure 6 areas of psychopathology: life events (Child Suicide Potential Scale [CSPS]) [26]; affective disorders (CSPS, Beck Depression Inventory [BDI] [27], and State-Trait Anxiety Inventory [STAI]) [28]; aggression (BDI, CSPS, [26] Overt Aggression Scale [OAS] [29], and Multidimensional Anger Inventory) [30]; impulsivity (CSPS and Impulsive Control Scale [ICS]) [31]; defense mechanisms (CSPS and LSI) [32]; and death perception (CSPS) [33]. 2.2. Psychometric properties of the instruments The CSPS [26] is a structured interview that evaluates behaviors, emotions, family history, life events, and ego functions in suicide-prone children and adolescents. Data are collected from the children, their parents, and school and hospital staff separately; in this study, we used only the children as sources of information. The subjects were asked about their behavior, thoughts, and affective states 6 months before admission and upon admission. The instrument is composed of 9 scales: spectrum of suicidal behavior (j of interrater reliability Hebrew version = 0.93); spectrum of aggressive behavior (j of interrater reliability Hebrew version = 0.91); life events; affect and behavior in the past; affect and recent behavior; family background; perception of death, namely, preoccupation with death (j of interrater reliability Hebrew version = 0.86), perception of death as agreeable (j of interrater reliability Hebrew version = 0.90), and perception of death as final (j of interrater reliability Hebrew version = 0.90); ego functions (intelligence and reality testing); and defense mechanisms of the ego (j of interrater reliability Hebrew version = 0.52-0.96, with a mean of 0.91 for the whole subscale). The Hebrew version of the CSPS was evaluated in hospitalized adolescents, and its internal consistency (Cronbach a = 0.93) and interrater reliability (j = 0.86-0.93 for the different subscales) were found to be high [34]. The BDI [27] evaluates depression in adults and adolescents. It is composed of 21 items dealing with
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psychiatric populations. When regression was excluded as a defense mechanism, the use of all other defense mechanisms in the 5 months before the present investigation proved to be the same. The test-retest reliability in a normal control group was found to range between 0.48 and 0.76.
symptoms and attitudes of depression such as mood, feelings of failure, guilt, despair, low self-esteem, suicidal thoughts, social isolation, loss of interest in sex, sleep problems, loss of appetite, and decrease in weight. Each item is rated from 0 to 3 according to the degree by which it reflects a patient’s state during the previous week. The BDI has a high internal consistency for psychiatric populations ranging from 0.73 to 0.92; its test-retest reliability, from 0.48 to 0.86; and concurrent validity, from 0.55 to 0.96 [26]. The Spielberger et al STAI [28] is a self-report instrument for the evaluation of anxiety as a state or trait. It includes 20 statements rated according to a respondent’s state at the time of the test and another 20 rated according to the respondent’s feelings in general. Internal consistency is between 0.80 and 0.90 for the 2 scales and test-retest reliability is 0.70 for anxiety-trait and from 0.27 to 0.62 for anxiety-state (for an interval of 20-104 days). Construct validity is high [28]. The STAI was translated into Hebrew and adapted for the Israeli population by Teichman and Malinek [35]. The OAS [29] documents and quantifies verbal and physical behaviors of overt aggression directed against property, the self, and others. The interclass correlation was 0.80 and interrater reliability was 0.87. The Multidimensional Anger Inventory [30] evaluates different aspects of anger: frequency, duration, intensity, and presentation, situations that provoke anger, and attitude towards hostility. Factor analysis yielded 3 factors: arousal of anger, hostility, and situations that provoke anger. Internal consistency was found to be high (Cronbach a = 0.84 and 0.89) in 2 different populations and test-retest agreement was 0.75. The ICS [31] is a self-report questionnaire measuring individuals’ tendency to engage in impulsive behaviors. It consists of 15 statements that respondents rate on a scale of 1 to 4 according to their level of agreement with them. The internal consistency of the questionnaire was found to be moderate in the general population (Cronbach a = 0.68) and in high-army Israeli soldiers (Cronbach a = 0.83) [31]. The LSI [32] is a self-report measure of defense mechanisms. It includes 97 yes/no statements (for example: bI have a need to receive compliments from othersQ or bI often lieQ). The Cronbach a varied from 0.54 to 0.86 in
2.3. Statistical analysis The study groups were compared by analysis of variance and the log linear model in uni- and bidirections. To investigate the independent variables that predict suicidal behavior, variables for which an interaction between gender and suicide attempt was found were entered into a stepwise logistic regression model. This analysis was done for the study population collectively using gender as one of the variables and separately for men and women. The odds ratio was calculated with a 95% confidence interval. 3. Results The reasons for admission among the nonattempters were mainly violent behavior and inability to function in the community. No differences were found among the groups for age, socioeconomic status, number of siblings, marital status of the parents, country of birth, or country of birth of the parents. Analysis of ethnic distribution yielded a higher rate of Ashkenazi and Sephardic origin in the non–suicide-prone adolescents (men and women) and a higher rate of botherQ ethnic origins in the suicide-prone adolescents (v 2 = 24.98; df = 2; P b .0001). More patients in the suicide-prone groups were adopted (v 2 = 5.56; df = 1; P b .005). 3.1. Psychiatric diagnosis Men had higher rates of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses of schizophrenia (27.9% [n = 50] vs 16.9% [n = 38]) and conduct disorder (18.4% [n = 33] vs 1.3% [n = 3]), whereas women had higher rates of eating disorder (14.7% [n = 33] vs 2.8% [n = 5]) and borderline disorder (25.3% [n = 57] vs 6.7% [n = 12]). Differences for the presence of other personality disorders were not significant (men: 9.5% [n = 17]; women: 8.4% [n = 19]): affective disorder (men: 8.4% [n = 15]; women: 11.6% [n = 26]), other diagnoses
Table 1 Interaction of anxiety and depression scales, gender, and suicide attempts Variable
Attempters Men
Depression Anxiety (CSPS) Past anxiety (CSPS) Anxiety-state (STAI) Anxiety-trait (STAI)
Nonattempters Women
Men
ANOVA Women
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
62 74 73 52 52
28.40 7.61 8.41 52.67 50.65
122 105 101 114 114
27.22 8.39 9.04 50.02 51.25
87 98 101 73 81
19.53 5.05 6.18 37.58 39.33
63 81 82 59 64
25.22 6.43 6.96 44.19 44.80
ANOVA indicates analysis of variance. * P b .05.
(17.05) (2.41) (3.67) (13.19) (13.46)
(16.47) (3.08) (4.52) (12.91) (13.00)
(15.26) (3.52) (4.27) (12.74) (14.91)
(14.73) (3.96) (4.21) (15.17) (15.22)
F F F F F
= = = = =
5.41*; df = 1, 330 0.72; df = 1, 354 0.03; df =1, 353 8.16*; df = 1, 294 2.14; df = 1, 307
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Table 2 Comparison of impulsivity and aggression between suicide attempters and nonattempters Variable
Attempters Men
Violence (CSPS) Antisocial (CSPS) Past antisocial (CSPS) Aggression Past aggression (CSPS) Impulsive (CSPS) Impulsive (ICS) Anger (MAI)
Nonattempters Women
Men
ANOVA Women
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
75 74 73 74 73 66 62 53
3.19 1.55 1.37 4.72 4.32 13.92 34.89 70.68
141 106 101 106 100 95 121 113
2.53 1.07 1.01 4.58 4.31 14.57 31.50 66.94
103 98 101 99 101 94 89 82
2.55 0.44 0.48 3.62 3.42 13.34 29.33 55.60
80 81 81 80 82 76 64 62
1.69 0.47 0.37 3.10 2.46 14.96 28.31 60.03
(1.94) (1.29) (1.41) (2.72) (2.62) (3.44) (8.07) (18.75)
(1.56) (1.16) (1.16) (2.52) (2.57) (3.33) (6.51) (16.94)
(1.85) (0.81) (0.89) (2.85) (3.01) (3.11) (6.36) (21.41)
(1.44) (0.74) (0.73) (2.49) (2.35) (3.70) (6.67) (21.28)
F F F F F F F F
= = = = = = = =
17.71*; df = 1, 395 60.02*; df = 1, 249 42.76*; df = 1, 229 20.77*; df = 1, 355 23.16*; df = 1, 352 0.06; df = 1, 327 32.20*; df = 1, 332 21.94; df = 1, 226
ANOVA, analysis of variance; MAI, Multidimensional Anger Inventory. * P b .0001.
(adjustment disorder, obsessive compulsive disorder; men: 12.0% [n = 21]; women: 11% [n = 25]), and psychosis not otherwise specified (men: 14.1% [n = 25]; women: 11.1% [n = 24]). There were no differences in diagnoses between attempters and nonattempters. 3.2. Depression and anxiety The suicide-prone adolescents had higher rates of depressive and anxiety symptoms than the non–suicideprone adolescents, as indicated by their higher scores on the CSPS upon admission to the study (F = 28.56; df = 1, 307; P b .0001) and 6 months before that (F = 41.77; df = 1, 300; P b .0001). Both trait and state anxiety were predictive of a suicide attempt (trait: F = 41.63; df = 1, 294; P b .001; state: F = 28.56; df = 1, 307; P b .0001). Within the non–suicide-prone group, depression was more prevalent in women than in men. Table 1 presents the analysis of variance findings for the interaction of gender, depressive and anxiety states, and suicide attempt. An interaction was noted between suicide attempt and both depressive symptoms, as measured by the CSPS, and between suicide attempt and anxiety state, as measured by the STAI. Among the nonattempters, women were more depressed/anxious than men; among the suicide attempters, the opposite was true. 3.3. Impulsivity and aggressiveness (CSPS, ICS) Aggressiveness, anger, destructive behavior, impulsivity (by the ICS but not by the CSPS), and antisocial behavior upon admission and at 6 months before admission were all associated with suicidal behavior (Table 2). An interaction of antisocial behavior in the 6 months before admission, suicidal
behavior, and gender, with male attempters having higher antisocial behavior scores than female attempters, was found. No such difference was noted among the nonattempters. Destructive behavior as measured by the OAS was dichotomized to bdestructive behaviorQ and bnondestructive behaviorQ. Subjects who were rated by the staff as presenting any destructive behavior were regarded as having overt aggression. Destructive behavior was more prevalent among men than women and among suicide attempters than nonattempters. On 3-way analysis, destructive behavior was significantly more prevalent in female attempters than in female nonattempters. No such difference was found for men (Table 3). 3.4. Perception of death Attempters perceived death as more pleasant (F = 68.87; df = 1, 290; P b .05) and less definite (F = 5.66; df = 1, 267; P b .005) than nonattempters did. Men perceived death as less definite than women did (F = 4.05; df = 1, 266; P b .05). 3.5. Life events Life events predicted suicide attempts (F = 27.82; df = 1, 400; P b .0001). Specifically, an association was found between suicide attempts and life events such as separation from the parents in the 6 months preceding admission, suicide attempt by a family member (especially the mother), psychiatric hospitalization, and addiction to drugs and alcohol of a family member. There was no difference between attempters and nonattempters in the prevalence of chronic illness or depression in the family. Among attempters, women had a higher completed suicide rate in
Table 3 Destructive behavior in suicide attempters and nonattempters by gender Behavior Destructive Nondestructive
Attempters
Nonattempters
Men (n = 68)
Women (n = 98)
Total (N = 166)
Men (n = 94)
Women (n = 80)
Total (N = 174)
54.4% 45.6%
45.9% 54.1%
49.4% 50.6%
41.5% 58.5%
15.0% 85.0%
29.3% 70.7%
Destructiveness by gender: v 2 = 11.77; df = 1; P b .001. Destructiveness by suicide attempt: v 2 = 18.35; df = 1; P b .0001. Destructiveness by gender and by suicide attempt: v 2 = 4.69; df = 1; P b .05.
S. Fennig et al. / Comprehensive Psychiatry 46 (2005) 90 –97
95
Table 4 Defense mechanisms, gender, and suicide attempts as measured by the CSPS using analysis of variance Variable
Attempters Men
Regression Denial Projection Introjection Reaction formation Undoing Displacement Intellectualization Compensation Sublimation Repression Total defense mechanisms
Nonattempters Women
Men
ANOVA Women
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
69 69 69 69 68 68 67 67 67 68 67 67
1.70 2.20 1.94 1.83 1.68 1.46 1.46 1.63 1.73 1.68 2.18 19.55
102 102 102 101 102 102 102 101 102 101 101 99
1.82 2.13 2.09 1.88 1.88 1.64 1.78 1.75 1.90 1.81 2.00 20.74
99 99 99 98 99 99 99 99 98 98 98 97
2.03 2.25 2.09 1.72 1.87 1.69 1.72 1.82 1.77 1.48 2.00 20.49
81 81 81 80 81 80 80 81 79 77 78 79
1.99 2.35 2.03 1.91 1.74 1.80 1.78 1.83 1.68 1.81 2.12 20.92
(0.77) (0.74) (0.80) (0.80) (0.66) (0.70) (0.61) (0.76) (0.81) (0.63) (0.65) (3.12)
(0.70) (0.78) (0.77) (0.71) (0.78) (0.73) (0.74) (0.77) (0.80) (0.70) (0.60) (3.42)
(0.65) (0.73) (0.77) (0.72) (0.79) (0.79) (0.72) (0.80) (0.74) (0.56) (0.69) (3.78)
(0.62) (0.71) (0.77) (0.68) (0.79) (0.79) (0.69) (0.82) (0.71) (0.78) (0.68) (2.83)
F F F F F F F F F F F F
= = = = = = = = = = = =
1.34; df = 1, 347 1.10; df = 1, 347 1.59; df = 1, 347 0.72; df = 1, 344 4.10*; df = 1, 346 0.17; df = 1, 345 3.01; df = 1, 344 0.47; df = 1, 344 2.28; df = 1, 342 1.68; df = 1, 340 4.23*; df = 1, 340 1.03; df = 1, 338
ANOVA, analysis of variance. T P b .05.
family members than men did, and men had a higher rate of family members who threatened to kill or hurt someone. Female attempters also had a higher rate of chronic illness in family members. Among the nonattempters, men had a higher suicide rate among family members. (v 2 = 14.32; df = 2; P b .001). Gender interactions with suicide attempt were found for a family member who threatened murder and for chronic illness in the family but not for other pathologic conditions such as depression, drug abuse, and use of tranquilizers or for psychiatric hospitalization. 3.6. Defense mechanisms Differences were found between attempters and nonattempters with regard to the use of defense mechanisms. Analysis for the self-report LSI showed that attempters used more regression (F = 4.78; df = 1, 161; P b .05) and displacement (F = 5.15; df = 1, 161; P b .05). According to the CSPS, attempters used less regression (F = 11.11; df = 1, 280; P b .001) and less undoing (F = 5.78; df = 1, 345; P b .05). We did not find any interaction between gender with defense mechanisms and suicide attempt with the LSI, but, as shown in Table 4, in the CSPS, reaction formation was used more by female attempters than by male attempters and
Table 5 Stepwise logistic regression analysis predicting suicide attempts Variable Women Destructiveness Antisocial behavior Anxiety-state Men Anxiety-state Antisocial behavior Depression
P
Odds ratio
95% confidence interval
b.0001 b.05 .05
3.39 1.55 1.03
1.23; 9.32 0.99; 2.41 1.00; 1.06
b.0001 b.0001 b.05
1.10 3.16 1.38
1.05; 1.15 1.74; 5.73 0.99; 1.92
more by male nonattempters than by female nonattempters. Repression was used more by male attempters than by female nonattempters. On multivariate analysis with stepwise logistic regression, we entered only those variables with a statistically significant difference in the interaction between gender and suicide attempt: suicidal behavior, destructive behavior, antisocial behavior, depression, and anxiety state. The variables noted in very low numbers of participants (homicide by siblings, suicide in the family, and chronic illness in a family member) were not included. To study the independent risk factors by gender, a separate model was formatted for men and women. As shown in Table 5, 2 variables were found to predict suicide attempts: antisocial behavior and anxiety state. The relationship of both antisocial behavior and anxiety with suicide attempt was stronger in men than in women; destructive behavior had the strongest predictive value for suicide attempts in women, whereas it was not specifically associated with suicide attempts in men. In the men, separately, only depression predicted suicide attempts. 4. Discussion The general findings of this study revealed several differences between suicide attempters and nonattempters, showed differences regarding various measures, and concurred with the literature on clinical and nonclinical samples. The scores for depression and anxiety state and trait were higher in attempters than in nonattempters upon admission and at 6 months preceding admission [3-5], as were the scores for aggressiveness, anger, destructive behavior, and impulsivity in some but not all of the instruments [7]. Attempters perceived death as more pleasant and less definite than nonattempters did. Similar to previous studies, separation from parents, suicide attempt by a family member, psychiatric hospitalization of a family
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S. Fennig et al. / Comprehensive Psychiatry 46 (2005) 90–97
member, and addiction to drugs and alcohol were all associated with suicide attempt [2,5,8]. Attempters also used defense mechanisms differently from nonattempters. Attempters used more displacement than nonattempters did and less undoing. Regression was used more by attempters according to the self-report instrument and less by the interviewer’s rating. The findings on displacement and regression (higher scores) are in accordance to our previous study [9], although more types of other differences were found in the previous study. On multivariate analysis, antisocial behavior and anxiety predicted suicide. The present study also yielded gender differences in risk factors for suicidal behavior: depression, anxiety, impulsivity, aggression, and life events. There was an interaction of gender, depression, and suicide attempt, with depression being more prevalent in female nonattempters than in male nonattempters; male attempters used more repression than female attempters did and less reaction formation. This differential use of repression has an important implication for the direction that the intervention should take in this population (ie, encouragement of self-disclosure; see also our previous study [9]). On stepwise logistic regression analysis, depression was statistically significant in predicting suicide attempt only in boys. The measure of depression cut across all the diagnostic groups. A similar interaction was found for anxiety: female nonattempters were more anxious than male nonattempters, but among suicide attempters, this difference disappeared. In the final multivariate analysis, the association between state anxiety and suicide attempt was stronger in men than in women. This finding may indicate that depression and anxiety have a stronger association with suicide attempt in hospitalized male adolescents but less specific findings in hospitalized females. Support for our results was provided by earlier community studies [6,15]. Our clinical sample, however, with subjects from different diagnostic groups, suggests that regardless of diagnosis, depressed and anxious moods in boys are an ominous sign and might be associated with suicide attempt. Women who attempted suicide showed more destructive behavior in the unit than women who did not attempt suicide, and there was an interaction of gender, destructive behavior, and suicide attempt. Antisocial behavior was predictive of a suicide attempt in both girls and boys. This finding is similar to an earlier community study [6], although in a more recent study [13], antisocial behavior was found to be predictive of suicide attempt only in girls. These discrepancies may be attributable to differences in the study populations, the measures used, and the specific types of antisocial, destructive, and suicidal behaviors. Like Pfeffer et al [4], we found that life events had a similar association with suicide attempt for men and women. By contrast, Kotila and Lonnquist [22] reported that suicide attempts are usually a reaction to a conflict or a serious life event only in girls. In the study of Pfeffer et al [4], the specific life events associated with suicidal behavior
differed by gender: in girls, major events were separation from a boyfriend, sexual abuse, and problems in school; in boys, major events were aggression in the family and having a sibling with suicidal behavior. In our study, there were gender differences for several life events such as suicide or chronic illness in the family (more in girls who attempted suicide) or threats of homicide by a family member (more in boys who attempted suicide). However, owing to the small number of each of these events, we could not include these variables in the final analyses. 4.1. Limitations of the study 1.
2.
3.
The study population included hospitalized patients only. Therefore, it might be biased with regard to gender because referring psychiatrists tend to consider suicide attempts more serious in men and to send more male than female attempters for hospitalization. Furthermore, female attempters may represent the more severe end of the spectrum and therefore have more severe psychopathology. The sample was unique in composition, and the differences in psychiatric diagnoses represent the population in psychiatric hospitals but not the population in general. The inclusion of all diagnostic groups and the effort to reveal behaviors and correlates that cut across diagnostic groups might have led to some dilution of the findings. The heterogeneity of the sample is both a weakness and a strength of the study, making it possible for us to view suicidal behavior above and beyond diagnostic groups. A cross-sectional design was used, precluding conclusions on directionality and causality.
5. Conclusions 1.
2.
Suicide-prone female and male adolescent inpatients show distinct differences in psychopathology, ego defense mechanisms, and life events compared to psychiatrically hospitalized adolescents without any history of suicide attempt. Any deviation from a gender-specific behavior must raise suspicion of a risk of attempted suicide.
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