Psychology and Suicidal Behaviour

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1 Psychology and Suicidal Behaviour Professor Rory O Connor PhD CPsychol AFBPsS FAcSS Past President, International Academy of Suicide Research Institute of Health & Wellbeing University of Glasgow Follow us on

2 Psychological markers of suicide risk Integrated Motivational-Volitional Model of Suicidal Behaviour (IMV; O Connor, 2011) Defeat and entrapment Social perfectionism From suicidal thoughts to suicidal attempts Fearlessness about death, impulsivity Stress response and wellbeing Brief intervention to reduce repeat self-harm Volitional helpsheet (VHS) Safety Planning Conclusions Outline

3 @suicideresearch

4 Iceberg model of suicide and self-harm (Hawton, Saunders, & O Connor, 2012)

Rates reported (%) 30 25 20 15 10 5 0 Scottish Wellbeing Study:

5 Rates reported (%) Scottish Wellbeing Study: Baseline rates: Self-harm Self-harm All Age Group Men Women

6 Scottish Wellbeing Study Baseline rates: Suicide attempts Suicide attempts Rates reported (%) All Age Group Men Women

7 Behind every suicide death is a tragedy I am terribly sorry for having chosen to take my own life, but I have just reached the point where I feel that I have no alternative The feeling of being helpless and incapable is something that I am unable to cope with. I can t see any future other than a continual decline into a situation of helplessness and even worse unhappiness which is not something that I think I can bear It is the unrelenting nature of the depression and the way that it robs me of everything that I need to deal with such things, and which despite my best efforts seems to be impossible for me to overcome that gives me no hope for the future

8 Key risk factors for self-harm and suicide

9 Is there too much focus on diagnosis? Smith, Bouch, Bradstreet, Lakey, Nightingale, & O Connor (2015). Lancet Psychiatry

10 O Connor & Nock Lancet Psychiatry (2014) Lancet Psychiatry

11 Integrated Motivational Volitional Model (IMV) O Connor (2011). In O Connor, Platt & Gordon (Eds.). International Handbook of Suicide Prevention: Research, Policy & Practice Wiley-Blackwell

Predicting Suicide Attempts/Suicide over 4 Years 60 50

No Repeat Attempt Repeat Attempt 0 O Connor, Smyth, Ryan,

12 Predicting Suicide Attempts/Suicide over 4 Years All factors significant univariate predictors No Repeat Attempt Repeat Attempt 0 O Connor, Smyth, Ryan, Williams (2013) Journal of Consulting & Clinical Psychology

13 Social Perfectionism (Pre-motivational phase)

14 Social perfectionism (SPP) (socially prescribed perfectionism) taps beliefs about excessive (often unrealistic) expectations we perceive significant others have of us (e.g., I find it difficult to meet others expectations of me ) Hewitt et al. (1991) JPSP

15 Social Perfectionism (SPP) Stress-Threshold Lowering Effect Six month follow-up of 500 adolescents (15-16 yrs) O Connor (2007) Suicide and Life-Threatening Behavior O Connor, Rasmussen & Hawton (2010) Behaviour Research & Therapy O Connor, Dixon, & Rasmussen (2009). Psychological Assessment

16 From suicidal ideation to suicide attempts q Acting on suicidal thoughts? q Theoretical models can help inform understanding of transition q Suicidal ideators versus suicide attempters q Study 1. Impulsivity, exposure to suicide, fearlessness about death (volitional moderators) q Study 2. Stress and wellbeing study

17 Distinguishing suicidal ideation from suicide attempts Suicide Ideators (N=583) Suicide Attempters (N=230) Controls (N=475) Motivational Phase Factors (ideation) o Defeat o Entrapment o Goal Regulation o Burdensomeness o Belongingness According to IMV model, volitional phase factors most important in differentiating IDEATION from ATTEMPTS Volitional Phase Factors (attempts) o Impulsivity o Exposure to suicidal behaviour of friend o Exposure to suicidal behaviour of family o Fearlessness about death o Discomfort tolerance Dhingra, Boduszek, & O Connor Journal of Affective Disorders (2016)

18 What did we find? Motivational Phase Factors (ideation) Defeat Entrapment Goal Regulation Burdensomeness Belongingness Volitional Phase Factors (attempts) Impulsivity Exposure to suicidal behaviour of friend Exposure to suicidal behaviour of family Fearlessness about death Discomfort tolerance Hierarchical multinomial logistic regression No difference between IDEATION vs ATTEMPTS No difference between IDEATION vs ATTEMPTS No difference between IDEATION vs ATTEMPTS No difference between IDEATION vs ATTEMPTS No difference between IDEATION vs ATTEMPTS Sig difference between IDEATION vs ATTEMPTS Sig difference between IDEATION vs ATTEMPTS Sig difference between IDEATION vs ATTEMPTS Sig difference between IDEATION vs ATTEMPTS No difference between IDEATION vs ATTEMPTS Dhingra, Boduszek, & O Connor Journal of Affective Disorders (2016)

19 Cortisol and the Stress Response

20 Cortisol & suicidal behaviour Cortisol is the primary effector hormone of the HPA axis stress response system HPA axis regulated by a negative feedback system (i.e., hypothalamus & pituitary gland have receptors that detect changes in cortisol levels) Excessive, repetitive activation may lead to tissue damage & future ill health (cf., allostatic load, McEwen, 1998) Cortisol linked to impairments in cognitive control, decisionmaking & emotional processing

21 O Connor et al. (2016). Cortisol and suicidal behavior: A meta-analysis. Psychoneuroendocrinology, 63,

22 My twin brother and I Never too early to plan your research

23 Stress & Wellbeing Study: Cortisol reactivity 160 participants Controls 45 Ideators 53 Attempters 47 8 unclear 6 withdrew 1 high C values Attempt within 1 year (n=14) Mean age yrs (16-62 yrs) 100 females (62.5%) Historical attempt (n=33) O Connor, D., Green, J., Ferguson, E., O Carroll, O Connor, R. (2017) PNEC

24 Study Design Informed Consent Suicide History Interview and Questionnaire Packet Rest Period (10 Minutes) Post-Stress Assessments (Cortisol, Blood Pressure, Heart Rate & STAI-6) MAST (15 Minutes) Baseline Assessments (Cortisol, IL-1/IL-6, Blood pressure, Heart Rate, STAI-6) Recovery Period Assessments at +5, +10, +20, +30 and + 40 minutes Debrief 1 & 6 month FU O Connor, D., Green, J., Ferguson, E., O Carroll, O Connor, R. (i2017) PNEC

(mental arithmetic) v Participants led to believe they are being video

25 v Physiologically & psychologically challenging v Combines an uncontrollable physical stressor (cold pressor task) with a social-evaluative component (mental arithmetic) v Participants led to believe they are being video recorded and that the duration of the trials is random Maastricht Acute Stress Task (MAST)

26 12 Effects of group on cortisol during the MAST (n=145) 10 Cortisol (nmol/l) Control Ideator Attempter Time (mins) Main effect of group for cortisol levels, p=0.02; AUCg, p=0.02, AUCi, p=0.04 Note: All analyses controlled for age, BMI, medication usage, time of day, smoking, & gender

27 10 9 Those who had attempted suicide only and cortisol reactivity (n=47) n = 14, < 1 year n = 33, > 1 year 8 7 Cortisol (nmol/l) < 1 year ago > 1 year ago Time (mins) Attempt history x time for cortisol levels, p=0.03 Main effect of group for cortisol levels, ns; AUCg, ns, AUCi, p=0.03

28 Effects of family history of suicide on cortisol reactivity nfh = no family history FH = family history Cortisol (nmol/l) Ideator-nFH Ideator-FH Attempter-nFH Attempter-FH Time (mins) Family history x Group x Time for cortisol levels, p=0.01 Family history x time, p=0.001 [attempters only]

31 From Motivation to Action Volitional Help Sheet to Reduce Suicidal

32 Implementation Intentions and SH Ø In the present context Ø an 'if' situation may be: 'If I want to get relief from a terrible state of mind' and Ø the 'then' behavioural response would be an alternative to SH (e.g., then I will think about the impact of my self-harming on the people around me'). Ø Volitional Help Sheet (modified from Armitage, 2008) Ø 11 critical situations and 11 alternative solutions Ø In other words, they form the alternative actions participants should try to take when they are tempted to

33 Volitional Help Sheet Processes of Change Implementation Intentions Not for reproduction without permission

34 Full RCT of VHS with a 2 month booster v v v v v 6 month follow-up (hospital-treated self-harm as outcome) 518 participants v 259 received VHS +treatment as usual TAU (intervention group) v 259 received TAU (control group) Main Inclusion Criteria v Admission to acute ward after self-harm where there was evidence of suicidal intent (i.e., a suicide attempt) v A self-reported past history of self-harm (i.e., at least one previous self reported episode of self-harm) ITT and PP analyses Past history of self-harm hospitalisation as moderator O Connor, Ferguson, Scott, Smyth, McDaid, Park, Beautrais, Armitage (2017) Lancet

35 80 What did we find? Number of people who self-harmed Intervention Control ED Presentations Overnight Presentations Total Presentations No effect on the number of people admitted to hospital with self-harm in following 6

36 Percentage of participants who self-harmed (overall) as a function of past history of hospital-treated self-harm (PP analyses) p=.17 p= VHS + TAU TAU No History of self-harm History of self-harm Needs replication as post-hoc analyses History: 8.6%, 95%CI , p=.087; NNT = 1 in 12 No History: -8.3%, 95%CI , p=.17; NNH = 1 in 13

37 Repeat hospital-treated self-harm as function of self-harm history and treatment allocation (ITT) Control group: those with past history, higher levels of repeat self-harm For those with self-harm history, trend that intervention associated with reduced self-harm Mean A&E Admissions 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 p =.001 No p =.10 Yes Control Interevntion

38 Repeat A&E hospital treated self-harm as function of self-harm history and treatment allocation (Per Protocol Analysis) Self-harm history associated with increased repeat self-harm incidence Those in intervention arm with self-harm history have significantly lower repeat self-harm incidence Mean A&E Admissions 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 No p =.001 p =.005 Yes O Connor et al. (2017). Lancet Psychiatry Control Interevntion

39 Repeat hospital treated (total) self-harm as function of self-harm history and treatment allocation (Per Protocol Analysis) Same pattern of findings as for A&E presentations Those in intervention arm with self-harm history have significantly lower repeat self-harm incidence Mean Total 1,4 1,2 1 0,8 0,6 0,4 0,2 0 No p =.001 p =.004 Yes Control Interevntion Intervention O Connor et al. (2017). Lancet

Cost effectiveness analyses (ITT analyses): Costs to the NHS 148.000 146.000 144.000 142.000 140.000 138.000 136.000 134.000 132.000 130.000 128.000 126.

40 Cost effectiveness analyses (ITT analyses): Costs to the NHS Although VHS saves money, difference not significant p= ,979 VHS + TAU Group 145,381 TAU Group Mean costs: 513 (VHS) and 561 (TAU) Study not powered on cost

41 Figure: Cost effectiveness plane per protocol past self-harm history subgroup: VHS and treatment as usual versus treatment as usual only Incremental cost Incremental effect Observations in the south west quadrant indicates that it is both less costly and more effective. Nearly all of the bootstrapped values fall in the south west quadrant where the VHS group is less costly than TAU. 90% probability of the VHS being cost effective regardless of willingness to pay threshold O Connor et al. (2017). Lancet

42 New Project Safety Planning and Suicidal Behaviour

43 O Connor & Nock (2014) Lancet Psychiatry

44 Conclusions Promising evidence for utility of VHS Theoretical models important to guide research Differentiate between ideators vs enactors Understanding how, why, when factors increase/decrease risk Do they explain male suicide? Brief (adjunct) interventions offer promise: Widening the intention behaviour gap (volitional phase) Do they work for men?

Rory C. O Connor, Eamonn Ferguson, Fiona Scott, Roger Smyth, David McDaid, A-La Park,

Rory C. O Connor, Eamonn Ferguson, Fiona Scott, Roger Smyth, David McDaid, A-La Park, Annette Beautrais, Christopher J Armitage A brief psychological intervention to reduce repetition of self-harm in patients