General Hospital Psychiatry 36 (2014) 726–731
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Gender differences in the association of agitation and suicide attempts among psychiatric inpatients Craig J. Bryan, Psy.D., A.B.P.P. a,⁎, Mario J. Hitschfeld, M.D. b,c, Brian A. Palmer, M.D. b, Kathryn M. Schak, M.D. b, Erika M. Roberge, B.A. a, Timothy W. Lineberry, M.D. b a b c
National Center for Veterans Studies, The University of Utah, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84112, USA Mayo Clinic, Department of Psychiatry and Psychology, 200 First Street Southwest, Rochester, MN 55905, USA Sotero Del Rio Hospital, Department of Psychiatry, Av. Concha y Toro 3459, Puente Alto, Santiago 8207257, Chile
a r t i c l e
i n f o
Article history: Received 10 June 2014 Revised 3 September 2014 Accepted 22 September 2014 Keywords: Suicide Agitation Inpatient Gender Psychiatric hospitalization
a b s t r a c t Objective: To determine if the relationship of agitation with suicide ideation and suicide attempts differed between men and women. Method: Self-reported severity of agitation and other suicide risk factors was obtained from 7698 consecutive patients during admission for inpatient psychiatric treatment during a 5-year period. Results: Agitation was highest among men with a history of suicide attempts. Agitation was significantly associated with frequency of suicide ideation and history of suicide attempt, but the gender-by-suicide interaction was only significant as a predictor of suicide attempt history. For men, agitation was associated with significantly increased risk for suicide attempt, but for women, agitation was not associated with risk for suicide attempt history. Results were unchanged when analyses were repeated among the subgroup of patients with suicide ideation. Conclusions: Agitation is associated with history of suicide attempt among male but not female psychiatric inpatients. Agitation differentiates between those men who have only thought about suicide and those who have made suicide attempts. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Over 32,000 individuals die by suicide in the United States each year, placing suicide among the leading causes of death [1]. Results of metaanalyses [2] and prospective studies indicate that suicide attempts, defined as self-enacted, potentially injurious behaviors with nonfatal outcomes for which there is evidence of intent to die [3], are among the strongest risk factors for death by suicide [4–7]. Suicide attempts appear to confer persistent vulnerability for death by suicide over time, even many years after an individual's initial suicide attempt [8], which aligns with the fluid vulnerability theory (FVT) of suicide [9]. The FVT posits that overall suicide risk entails the interaction of aggravating variables with an individual's predisposing vulnerability for suicide, such that aggravating variables contribute to acute suicidal episodes and lead to suicide attempts only in the presence of sufficient vulnerability. According to the FVT, the reason why some acutely distressed individuals make suicide attempts but others do not is that the former group has a greater predisposition to suicide. Predispositions to suicide include demographic and historical variables that are relatively static in nature, such as genetic or biological
⁎ Corresponding author. National Center for Veterans Studies, The University of Utah, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84105, USA. Tel.: +1 801 587 7978. E-mail address: [email protected] (C.J. Bryan). http://dx.doi.org/10.1016/j.genhosppsych.2014.09.013 0163-8343/© 2014 Elsevier Inc. All rights reserved.
vulnerabilities, race, gender, psychiatric conditions and previous suicide attempts. Aggravating variables, by contrast, include relatively shortterm or acute risk factors such as depression, hopelessness, agitation and suicide ideation. Of the many aggravating risk factors that have been empirically identified, physiological agitation has received considerable empirical and clinical attention and is considered by experts to be a particularly important short-term indicator or warning sign for suicide attempts [10]. Clinically, agitation has been described as an acute state of psychological and physiological overarousal often characterized by behavioral restlessness emotional unrest [11]. Consistent with this general definition, Koukopoulos and Koukopoulos [11] have proposed that agitated mood states include at least two of the following signs and symptoms: motor agitation, psychic agitation or intense inner tension, or crowded thoughts. Although agitation and aggression are associated with each other [12], the two are conceptually distinct; agitation is an internal psychophysiological state, whereas aggression is an externalized behavior. Studies have found that agitation is observed in over 80% of suicide deaths among psychiatric inpatients [13] and patients admitted to emergency departments immediately following a suicide attempt [14]. Agitation further predicts future suicide deaths and suicide attempts among psychiatric outpatients [7,15]. Our understanding of how agitation differentially confers increased risk for suicide attempts across patient subgroups is limited, however, by the absence of studies examining how agitation interacts with predisposing vulnerabilities for suicide attempts.
C.J. Bryan et al. / General Hospital Psychiatry 36 (2014) 726–731
Gender, for instance, is a well-established predisposing risk factor for suicide and suicide attempts: women are more likely to make nonfatal suicide attempts, whereas men are more likely to die by suicide [16,17]. Preliminary research suggests that agitation may differentially affect the risk for suicide attempt between men and women. Men, for instance, are more likely than women to experience depressive episodes marked by agitation, restlessness and racing thoughts (also referred to as mixed depressive episodes) [17–19].As compared to unipolar depressive episodes, mixed episodes are associated with significantly higher risk for suicide ideation and suicide attempts [20–22]. Agitation may therefore differentially confer increased risk for suicide attempts for men than for women. Although these studies provide important information about agitation, gender and risk for suicide attempts, conclusions related to gender are limited because none of these studies explicitly examined gender as a potential moderator of agitation, and each study's sample was restricted to patients diagnosed with a bipolar-spectrum disorder. Additional research is therefore needed. The aim of the current study was to examine the association of gender and agitation with suicide ideation and suicide attempts among individuals admitted to a psychiatric inpatient unit. We hypothesized that the gender-by-agitation interaction would be associated with significantly increased frequency of suicide ideation and risk for suicide attempts; specifically, that the relationship of agitation with suicide ideation and attempts would be stronger among male patients.
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Demographic, historical and clinical data for this cross-sectional study were collected from patients at the time of admission via self-report questionnaires and clinical interview, and subsequently combined with psychiatric diagnosis codes obtained from billing records. Data were deidentified prior to statistical analyses. Regulatory approval for the current study was obtained from Mayo Clinic's Institutional Review Board. 2.2. Measures 2.2.1. Suicide attempts Suicide attempts were defined as nonfatal, self-directed potentially injurious behaviors with any intent to die as a result of the behavior [3]. History of suicide attempt was obtained at the time of admission during the clinical interview (i.e., “Have you ever attempted suicide?”). 2.2.2. Suicide ideation Frequency of suicide ideation was assessed with the suicide ideation item from the Outcomes Questionnaire-45.2 (OQ-45.2) [23]: “I have thoughts of ending my life.” The OQ-45.2 is a 45-item self-report measure designed to assess patient outcomes during the course of psychiatric treatment and assesses psychiatric symptoms and functioning in three domains: subjective distress, interpersonal relationships and social role performance. All items can be aggregated to create a total score, with higher scores indicating poorer functioning. Patients indicated the frequency of suicide ideation during the past 2 weeks on a scale ranging from 0 (“never”) to 4 (“almost always”).
2. Material and methods 2.1. Participants and procedures Participants included 7698 consecutive patients admitted to the Mayo Clinic's inpatient psychiatric unit during a 5-year period from October 2008 to September 2013. Patients were predominantly Caucasian (91.3%) and female (57.2%), ranging in age from 15 to 99 years [M= 39.0, standard deviation (S.D.)=18.0]. A total of 3056 (39.7%) patients had made at least one suicide attempt during their lives, and 4865 (63.2%) reported current (i.e., during the past 2 weeks) suicide ideation. Psychiatric diagnoses were obtained from the medical record using International Classification of Diseases, Ninth Edition codes. The most common primary psychiatric diagnoses were depressive disorders (n=4034; 52.4%), bipolar disorders (n=1084; 14.1%), psychotic disorders (n=623; 8.1%), adjustment disorders (n=463; 6.0%), mood disorder not otherwise specified (n=283; 3.7%), anxiety disorders (n=219; 2.8%), drug-induced psychiatric disorders (n= 202; 2.6%), delirium or dementia (n= 137; 1.8%), and alcohol use disorders (n= 104; 1.4%). Male participants were significantly more likely to be diagnosed with a psychotic disorder, adjustment disorder, drug-induced psychiatric disorder and alcohol use disorder, but women were significantly more likely to be diagnosed with a depressive disorder (see Table 1). Data for the current study were extracted from the psychiatric inpatient unit's clinical data set, which was created in 2007 in a larger effort to improve the hospital's clinical practice in suicide risk assessment. Table 1 Psychiatric diagnoses by gender Men
Depressive disorder Bipolar disorder Psychotic disorder Adjustment disorder Anxiety disorder Drug-induced mental disorder Delirium or dementia Alcohol use disorder
Women
n
(%)
n
(%)
1506 465 369 229 91 125
(45.7) (14.1) (11.2) (6.9) (2.8) (3.8)
2528 619 254 234 128 77
(57.4) (14.1) (5.8) (5.3) (2.9) (1.7)
66 55
(2.0) (1.7)
71 49
(1.6) (1.1)
χ2
P
Φ
103.61 0.00 74.71 8.92 0.14 30.84
b.001 .947 b.001 .003 .704 b.001
0.12 0.00 −0.10 −0.03 0.00 −0.06
1.64 4.38
.200 .036
−0.02 −0.02
2.2.3. Suicide Status Form-II, Revised The Suicide Status Form-II, Revised (SSF-II-R) [24] is a brief selfreport rating scale that assesses six key constructs central to conceptualizing suicide risk: psychological pain (“hurt, anguish, or misery in your mind, not stress, not physical pain”), stress (“your general feeling of being pressured or overwhelmed”), agitation (“emotional urgency, feeling that you need to take action, not irritation, not annoyance), hopelessness (“your expectation that things will not get better no matter what you do”), self-hatred (“your general feeling of disliking yourself, having no self-esteem, having no self-respect”) and the patient's assessment of overall suicide risk (“rate your overall risk of suicide”). Each item is rated on a 5-point Likert scale ranging from 1 (“low”) to 5 (“high”). The constructs assessed by the SSF-II-R have been influenced by several leading theories of suicide to include Shneidman's [25] cubic model of psychological pain stress, and agitation; Beck et al.'s [26] hopelessness model; and Baumeister's [27] theory of suicide as an escape from unbearable self-hatred and self-loathing. The validity of the SSF-II-R among psychiatric inpatients has been established [28]. In the current study, the SSF-II-R's agitation item was used as the primary independent variable and the remaining items were used as covariates. 2.2.4. Patient Health Questionnaire-9 The nine-item depression scale of the Patient Health Questionnaire (PHQ-9) [29] is a self-report survey that corresponds to the nine diagnostic criteria for major depressive disorder, which respondents rate on a scale ranging from 0 (“not at all”) to 3 (“nearly every day”). A total score is obtained by summing the nine individual items, with higher scores corresponding with mild, moderate, moderately severe and severe depression. 2.3. Data analysis Multivariate linear regression was used to test the associations among predictors with frequency of suicide ideation, and multivariate logistic regression was used to test the associations among predictors with lifetime incidence of suicide ideation. Robust maximum likelihood estimation was used due to skew in predictor and outcome variables. The following variables were selected as predictors: gender, race, age, depression severity, frequency of suicide ideation (for the model with
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suicide attempt as outcome), lifetime history of suicide attempt (for the model with suicide ideation as outcome), psychological pain, stress, hopelessness, self-hatred and self-rated suicide risk. To test gender differences, interaction terms were calculated and added to the regression models concurrent with the main effects.
3. Results 3.1. Descriptive analyses A total of 2861 (37.2%) patients had made at least one suicide attempt, and 5056 (65.7%) reported current suicide ideation. In terms of severity of agitation, there were no differences between men and women [M=2.65, S.D.=1.42, vs. M=2.66, S.D.=1.43; F(1,7295)=.35, P= .555, partial η 2= 0.000], but patients with a history of suicide attempt reported significantly more severe agitation [M=2.68, S.D.= 1.43 vs. M=2.63, S.D.= 1.42; F(1,7295)=3.95, P= .047, partial η 2= 0.001]. A significant interaction of gender and suicide attempt was also found for agitation severity [F(1,7295)=8.01, P=.005, partial η 2= 0.001], with male suicide attempters reporting the most severe agitation (see Fig. 1). Overall, the mean agitation score among male suicide attempters (M=2.76, S.D.=1.44) was significantly higher than female suicide attempters [M=2.64, S.D.= 1.42; P= .034, g= 0.08 (0.01, 0.16)] and men with no suicide attempts [M=2.59, S.D.=1.42; P= .002, g= 0.12 (0.06, 0.28)]. Additionally, male suicide attempters' mean agitation scores were marginally higher than women with no suicide attempts [M=2.67, S.D.= 1.44; P= .090, g= 0.06 (− 0.01, 0.14)]. In all cases, the magnitudes of between-group differences were fairly small, as indicated by the mean difference sizes. To further describe the sample, means, S.D.s and intercorrelations of all variables were calculated and are reported in Table 2. Of note, frequency of suicide ideation was positively correlated with psychological pain, stress, agitation, hopelessness, self-hatred and subjective suicide ideation, whereas history of suicide attempts was significantly correlated with female gender, younger age and more severe depression. Female gender was positively correlated with depression severity but was not associated with any other aggravating suicide risk factor.
3.2. Gender differences in predictors of suicide ideation Results of the multivariate regression model predicting frequency of suicide ideation are summarized in Table 3. In the first step, we considered only the main effects of predictor variables: psychological pain, stress, hopelessness, self-hatred and self-rated suicide risk were associated with significantly increased frequency of suicide ideation, whereas agitation was associated with significantly decreased frequency of suicide ideation (Table 3, Model A). We next calculated the interaction term of gender with agitation and added this term to the model, but the interaction was not statistically significant [adjusted odds ratio (AOR)=0.99 (0.96, 1.02), P=.540; Table 3, Model B]. 3.3. Gender differences in predictors of suicide attempt Results of the multivariate regression model predicting history of suicide attempt are also summarized in Table 3. In the first step, female gender, minority race, younger age and severity of depression were associated with significantly increased risk for a suicide attempt (Table 3, Model C). Severity of agitation was also associated with a nonsignificant trend towards increased risk for suicide attempt [AOR=1.05 (1.00, 1.10), P= .071]. We next calculated the interaction term of gender with agitation, which resulted in a statistically significant relationship [AOR=1.12 (1.05, 1.19), P=.001]. The form of this interaction is plotted in Fig. 2. As can be seen in the figure, there was no relationship of agitation with likelihood of suicide attempt for women [B=−0.01, standard error (S.E.)=0.03, Z=−0.09, P=.926] but a positive association existed for men (B=0.11, S.E.=0.03, Z=3.25, P=.001). At low levels of agitation (i.e., a score of 1, which is approximately 1 S.D. below the mean agitation score for men), 29.9% of men and 40.6% of women had made a suicide attempt, but at high levels of agitation (i.e., a score of 4, which is approximately 1 S.D. above the mean agitation score for men), 37.3% of men and 40.4% of women had made a suicide attempt. To confirm that the gender-by-agitation interaction could significantly differentiate suicide attempts from suicide ideation, we repeated the logistic regression analyses among those 3540 patients with current suicide ideation (i.e., scoreN0 on the suicide ideation item). Results were unchanged in this subpopulation, suggesting agitation differentiated male patients with a history of suicide attempt from male patients who were thinking of suicide but had not yet made an attempt. 3.4. Associations of agitation with depressive symptoms To examine the relationship of agitation with each of the 9 DSM-IVdefined symptoms of major depressive disorder, we next computed the correlation coefficients of agitation with each item of the PHQ-9. Results are indicated that agitation had negligible associations with each symptom of depression, suggesting that agitation did not overlap conceptually with depression symptoms in the current sample (see Table 4). 4. Discussion
Fig. 1. Mean agitation scores with 95% confidence intervals among 7299 psychiatric inpatients, by gender and history of suicide attempt. *Pb.05, **Pb.01.
In the current study, we sought to determine if agitation was differentially related to suicide ideation and suicide attempts according to gender. Results partially confirmed our hypotheses. Specifically, results supported our hypotheses that the gender-by-agitation interaction would be significantly associated history of suicide attempts, and that the relationship of agitation with suicide attempts would be stronger among men. Contrary to our expectations, however, we did not find the gender-by-agitation interaction to be significantly associated with frequency of suicide ideation. Taken together, these results suggest that although agitation is associated with suicide ideation across both genders, agitation may be more strongly associated with suicide attempts among men. Previous studies finding associations of agitation and physiological arousal with suicide ideation and attempts have also reported that
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Table 2 Means, S.D.s, and intercorrelations of study variables and covariates 1. 1. 2. 3. 4. 5. 6. 7. 8. 9.
Gender Race Age Suicide attempt Suicide ideation Depression Psych0. pain Stress Agitation
2.
3.
4.
5.
6.
– −0.01 0.45⁎⁎ 0.38⁎⁎ 0.29⁎⁎ 0.51⁎⁎
– −0.04⁎⁎ −0.02 −0.03⁎ −0.03⁎
7.
8.
9.
10.
– 0.53⁎⁎ 0.55⁎⁎ 0.49⁎⁎
– 0.43⁎⁎ 0.39⁎⁎
–
11.
12.
– – 0.12⁎⁎ −0.04⁎⁎ −0.01 0.04⁎⁎
– −0.15⁎⁎ 0.02 0.07⁎⁎
10. Hopelessness
−.01 −0.01 0.08⁎⁎ 0.12⁎⁎ 0.01 −0.01 −0.01 0.00 −0.01
0.01 0.01 0.00 −0.02
0.00 0.00 0.01 0.01
– 0.01 0.12⁎⁎ 0.01 0.00 0.02 0.00
11. Self−hatred
−0.01
−0.01
0.00
0.00
12. Self-rated risk Mean S.D.
−0.01
0.00
0.02
– –
– –
38.99 18.04
−0.03⁎
0.62⁎⁎
–
0.00
0.50⁎⁎ 0.67⁎⁎
– 0.60⁎⁎ 0.48⁎⁎ 0.62⁎⁎ 0.55⁎⁎
0.00
0.42⁎⁎
0.35⁎⁎
0.32⁎⁎
0.49⁎⁎
0.48⁎⁎
–
– –
2.62 1.37
1.30 1.22
3.15 1.49
3.51 1.39
2.65 1.43
3.04 1.54
2.75 1.52
1.78 1.16
⁎ Pb05. ⁎⁎ Pb.01.
agitated mood states are much more common among men [19–22,30]. Furthermore, a recent study conducted among a nonclinical sample of primarily male military personnel similarly found that agitation was positively associated with suicide ideation [31]. In combination, these studies suggest that agitation may be associated with suicide ideation and attempts among men more so than women. Unfortunately, none of these studies explicitly considered gender differences, and the majority [19–22,30] enrolled only very narrowly defined psychiatric samples; specifically, those diagnosed with either unipolar depression or bipolar disorder. The present findings therefore build upon the existing literature by utilizing a heterogeneous clinical sample and by explicitly testing for gender differences. Of note is our finding that agitation was significantly associated with suicide attempts beyond the effects of suicide ideation. As noted by others [32], the considerable majority of suicide risk factors are actually risk factors for suicide ideation, but they do not necessarily identify which individuals with suicide ideation will progress to suicide attempts. For example, in the National Comorbidity Survey, the strengths of the associations among a wide range of psychiatric disorders with a history of suicide ideation and suicide attempts were
approximately equivalent, but these same disorders were either unable to differentiate between individuals with suicide ideation and suicide attempts or had only very small effect sizes [33]. Furthermore, although all psychiatric disorders were associated with increased risk for suicide ideation, depressive episodes, manic episodes and panic disorder — conditions that are each characterized by agitation and/or physiological arousal — were among the only disorders that differentiated individuals who had made suicide attempts from those with suicide ideation only [33]. The current results mirror these findings: although psychological pain, stress, agitation, hopelessness, self-hatred and self-rated suicide risk were significantly associated with increased frequency of suicide ideation, only agitation and depression severity were associated with significantly increased risk for suicide attempts. The very small correlations of agitation with each of the nine symptoms of depression further suggest that self-reported agitation is distinct from depression symptoms. Similar results have been reported previously by others [34], further suggesting that agitation may be distinct from mood disturbance. Therefore, our findings suggest that agitation may serve as a better marker of risk for suicide attempt among men with suicide ideation as compared to other risk factors. Our results also provide further support
Table 3 Results of multivariate regression models predicting suicide ideation and suicide attempt in a psychiatric inpatient sample Suicide ideationa
Suicide attemptb
Model A
Female Caucasian Age Suicide attempt Suicide ideation Depression Severe Moderate-severe Moderate Mild None Psychological pain Stress Agitation Hopelessness Self-hate Self-rated risk Gender×agitation
Model B
Model C
Model D
AOR [95% CI]
P
AOR [95% CI]
P
AOR [95% CI]
P
AOR [95% CI]
P
1.04 [1.00, 1.09] 0.97 [0.89, 1.05] 1.00 [1.00, 1.00] 1.01 [0.96, 1.06] –
.072 .392 .203 .789 –
1.08 [0.96, 1.21] 0.97 [0.89, 1.05] 1.00 [1.00, 1.00] 1.01 [0.96, 1.05] –
.200 .407 .191 .804 –
1.32 [1.18, 1.48] 0.79 [0.64, 0.96] 0.98 [0.98, 0.99] – 1.01 [0.95, 1.08]
b.001 .016 b.001 – .793
1.57 [1.12, 2.20] 0.79 [0.65, 0.96] 0.98 [0.98, 0.99] – 1.01 [0.95, 1.08]
.009 .019 b.001 – .799
1.01 [0.93, 1.09] 1.00 [0.92, 1.09] 1.00 [0.91, 1.09] 1.02 [0.93, 1.12] – 1.07 [1.05, 1.10] 1.05 [1.03, 1.08] 0.97 [0.95, 0.99] 1.10 [1.07, 1.12] 1.10 [1.08, 1.13] 1.72 [1.67, 1.78] –
.866 .931 .947 .701 – b.001 b.001 .002 b.001 b.001 b.001 –
1.00 [0.93, 1.09] 1.00 [0.92, 1.09] 1.00 [0.91, 1.09] 1.02 [0.93, 1.12] – 1.07 [1.05, 1.10] 1.05 [1.03, 1.08] 0.98 [0.95, 1.00] 1.10 [1.08, 1.13] 1.10 [1.08, 1.13] 1.72 [1.68, 1.77] 0.99 [0.96, 1.02]
.917 .964 .929 .744 – b.001 b.001 .079 b.001 b.001 b.001 .540
2.10 [1.71, 2.59] 1.71 [1.37, 2.13] 1.54 [1.22, 1.94] 1.25 [0.98, 1.59] – 0.99 [0.94, 1.05] 1.01 [0.96, 1.07] 1.05 [1.00, 1.10] 0.99 [0.94, 1.04] 1.00 [0.95, 1.05] 0.99 [0.92, 1.05] –
b.001 b.001 b.001 .077 – .786 .683 .071 .619 .900 .647 –
2.10 [1.71, 2.59] 1.70 [1.36, 2.12] 1.54 [1.23, 1.94] 1.25 [0.98, 1.60] – 1.02 [0.85, 1.22] 0.92 [0.76, 1.11] 1.12 [1.05, 1.19] 1.03 [0.86, 1.23] 1.01 [0.85, 1.19] 0.87 [0.71, 1.06] 0.89 [0.83, 0.97]
b.001 b.001 b.001 .073 – .867 .397 .001 .779 .953 .156 .005
Bold values are statistically significant. a Generalized linear regression with robust maximum likelihood estimation. b Logistic regression. For ease of comparisons of effect sizes across all models, linear regression coefficients for Models A and B were converted to AORs via exponentiation the regression coefficient (i.e., eB).
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Clinicians should therefore include an assessment of agitation severity in their suicide risk interviews, especially with male patients. As demonstrated in the current study, even simple self-report rating scales can be clinically useful and practical from a time management perspective. Furthermore, interventions and treatments that directly reduce agitation, whether behavioral (e.g., relaxation, mindfulness) or pharmacologic (e.g., anxiolytics) in nature, may be useful strategies for managing risk for suicide attempts among male psychiatric inpatients.
Probability of suicide attempt
0.40 0.35 0.30 0.25 0.20 0.15
Acknowledgment
0.10
This publication was supported by Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
0.05 0.00 0
1
2
3
4
5
Agitation score Male
References
Female
Fig. 2. Likelihood of suicide attempt among men and women according to severity of agitation.
for the FVT of suicide [9], which posits that aggravating variables such as agitation will be most strongly associated with suicide attempts among individuals with sufficient predispositions. Stated another way, men may be relatively more vulnerable to the negative effects of agitation than women. Several strengths of the present study include its large sample size and diversity of clinical conditions. Nevertheless, conclusions based on the current study should be made cautiously and with consideration for several limitations, the first of which is the study's cross-sectional design. These results should therefore be considered preliminary until prospective studies can be conducted to determine if agitation confers increased risk for future suicide attempts among men. Studies are also needed to confirm that agitation can prospectively differentiate between individuals who think about suicide from those who subsequently act upon these thoughts. Because our study was conducted at a single inpatient psychiatric clinic, generalization of results to nonclinical and outpatient psychiatric settings should also be made with caution. Finally, the current sample was predominantly (91%) Caucasian; additional studies with more diverse samples are warranted to determine if agitation is differentially associated with risk for suicide attempts among individuals from racial or ethnic minority groups. Despite these limitations, the current study provides useful and clinically relevant information that advances our knowledge of how risk factors for suicide attempts vary across different patient subgroups. 5. Conclusions The current results suggest that agitation may also be an especially important indicator of risk for suicide attempts among male patients. Table 4 Correlation coefficients of agitation with each symptom of major depressive disorder, as measured by the PHQ-9 Symptom
r
Anhedonia Depressed mood Sleep disturbance Fatigue/Low energy Appetite change Worthlessness Concentration impairment Psychomotor retardation or activation Thoughts of death or self-harm
−0.03* −0.03* −0.03* −0.02 −0.03* −0.02 −0.02 −0.02 −0.01
* These values are statistically significant at P b .05.
[1] Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]; 2010 [Available from www.cdc.gov/injury/wisqars/index.html]. [2] Harris EC, Barraclough B. Suicide as an outcome for mental disorders: a metaanalysis. Br J Psychiatry 1997;170:205–28. [3] Silverman MM, Berman AL, Sanddal ND, O'Carroll PW, Joiner TE. Rebuilding the Tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors part 2: suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav 2007;37:264–77. [4] Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol 2000;68:371–7. [5] Goldstein RB, Black DW, Nasrallah A, Winokur G. The prediction of suicide: sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients affective disorders. Arch Gen Psychiatry 1991;48:418–22. [6] Nordstrom P, Asberg M, Aberg-Wistedt A, Nordin C. Attempted suicide predicts suicide risk in mood disorders. Acta Psychiatr Scand 1995;92:345–50. [7] Fawcett J, Schefner WA, Fogg L, et al. Time-related predictors of suicide in major affective disorder. Am J Psychiatry 1990;147:1189–94. [8] Clark DC, Gibbons RD, Fawcett J, Scheftner WA. What is the mechanism by which suicide attempts predispose to later suicide attempts? A mathematical model. J Abnorm Psychol 1989;98:42–9. [9] Rudd MD. Fluid vulnerability theory: a cognitive approach to understanding the process of acute and chronic risk. In: Ellis TE, editor. Cognition and Suicide: Theory, Research, and Therapy. Washington, DC: American Psychological Association; 2006. p. 355–67. [10] Rudd MD, Berman AL, Joiner TE, et al. Warning signs for suicide: theory, research, and clinical applications. Suicide Life Threat Behav 2006;36:255–62. [11] Koukopoulos A, Koukopoulos A. Agitated depression as a mixed state and the problem of melancholia. In: Akiskal HS, editor. Bipolarity: beyond classic mania, 22. , Psychiatr Clin North Am; 1999. p. 547–64. [12] Cohen-Mansfield J. Agitated behavior in persons with dementia: the relationship between type of behavior, its frequency, and its disruptiveness. J Psychiatr Res 2008; 43:64–9. [13] Busch K, Fawcett J, Jacobs D. Clinical correlates of inpatient suicide. J Clin Psychiatry 2003;64:14–9. [14] Hall R, Platt D, Hall R. Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempt. Psychosomatics 1999;50:18–27. [15] Bryan CJ, Johnson LG, Rudd MD, Joiner TE. Hypomanic symptoms among first-time suicide attempters predict future multiple attempt status. J Clin Psychol 2008;64: 519–30. [16] Institute of Medicine. Reducing suicide: a national imperative. Washington, DC: National Academies Press; 2002. [17] Kuo WH, Gallo JJ, Tien AY. Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore. Md Psychol Med 2001;31: 1181–93. [18] Dilsaver SC, Benazzi F, Rihmer Z, Akiskal KK, Akiskal HS. Gender, suicidality and bipolar mixed states in adolescents. J Affect Disord 2005;87:11–6. [19] Benazzi F. Depression with racing thoughts. Psych Res 2003;120:273–82. [20] Akiskal HS, Benazzi F. Psychopathologic correlates of suicidal ideation in major depressive outpatients: is it all due to unrecognized (bipolar) depressive mixed states? Psychopathology 2005;38:273–80. [21] Rihmer Z, Kiss K. Bipolar disorders and suicidal behaviour. Bipolar Disord 2002;4: 21–5. [22] Rihmer Z, Pestality P. Bipolar II disorder and suicidal behavior. Psychiatr Clin North Am 1999;22:667–73. [23] Lambert MJ, Kahler M, Harmon C, Burlingame GM, Shimokawa K. Administration and scoring manual for the Outcome Questionnaire-45.2. Salt Lake City, UT: OQMeasures; 2011. [24] Jobes DA. Managing suicidal risk: a collaborative approach. New York, NY: Guilford; 2006. [25] Shneidman ES. Suicide as psychache: a clinical approach to self-destructive behavior. Northvale, NJ: Jason Aronson, Inc.; 1993.
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Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Gender differences in the association of agitation and suicide attempts among psychiatric inpatients Craig J. Bryan, Psy.D., A.B.P.P. a,⁎, Mario J. Hitschfeld, M.D. b,c, Brian A. Palmer, M.D. b, Kathryn M. Schak, M.D. b, Erika M. Roberge, B.A. a, Timothy W. Lineberry, M.D. b a b c
National Center for Veterans Studies, The University of Utah, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84112, USA Mayo Clinic, Department of Psychiatry and Psychology, 200 First Street Southwest, Rochester, MN 55905, USA Sotero Del Rio Hospital, Department of Psychiatry, Av. Concha y Toro 3459, Puente Alto, Santiago 8207257, Chile
a r t i c l e
i n f o
Article history: Received 10 June 2014 Revised 3 September 2014 Accepted 22 September 2014 Keywords: Suicide Agitation Inpatient Gender Psychiatric hospitalization
a b s t r a c t Objective: To determine if the relationship of agitation with suicide ideation and suicide attempts differed between men and women. Method: Self-reported severity of agitation and other suicide risk factors was obtained from 7698 consecutive patients during admission for inpatient psychiatric treatment during a 5-year period. Results: Agitation was highest among men with a history of suicide attempts. Agitation was significantly associated with frequency of suicide ideation and history of suicide attempt, but the gender-by-suicide interaction was only significant as a predictor of suicide attempt history. For men, agitation was associated with significantly increased risk for suicide attempt, but for women, agitation was not associated with risk for suicide attempt history. Results were unchanged when analyses were repeated among the subgroup of patients with suicide ideation. Conclusions: Agitation is associated with history of suicide attempt among male but not female psychiatric inpatients. Agitation differentiates between those men who have only thought about suicide and those who have made suicide attempts. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Over 32,000 individuals die by suicide in the United States each year, placing suicide among the leading causes of death [1]. Results of metaanalyses [2] and prospective studies indicate that suicide attempts, defined as self-enacted, potentially injurious behaviors with nonfatal outcomes for which there is evidence of intent to die [3], are among the strongest risk factors for death by suicide [4–7]. Suicide attempts appear to confer persistent vulnerability for death by suicide over time, even many years after an individual's initial suicide attempt [8], which aligns with the fluid vulnerability theory (FVT) of suicide [9]. The FVT posits that overall suicide risk entails the interaction of aggravating variables with an individual's predisposing vulnerability for suicide, such that aggravating variables contribute to acute suicidal episodes and lead to suicide attempts only in the presence of sufficient vulnerability. According to the FVT, the reason why some acutely distressed individuals make suicide attempts but others do not is that the former group has a greater predisposition to suicide. Predispositions to suicide include demographic and historical variables that are relatively static in nature, such as genetic or biological
⁎ Corresponding author. National Center for Veterans Studies, The University of Utah, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84105, USA. Tel.: +1 801 587 7978. E-mail address: [email protected] (C.J. Bryan). http://dx.doi.org/10.1016/j.genhosppsych.2014.09.013 0163-8343/© 2014 Elsevier Inc. All rights reserved.
vulnerabilities, race, gender, psychiatric conditions and previous suicide attempts. Aggravating variables, by contrast, include relatively shortterm or acute risk factors such as depression, hopelessness, agitation and suicide ideation. Of the many aggravating risk factors that have been empirically identified, physiological agitation has received considerable empirical and clinical attention and is considered by experts to be a particularly important short-term indicator or warning sign for suicide attempts [10]. Clinically, agitation has been described as an acute state of psychological and physiological overarousal often characterized by behavioral restlessness emotional unrest [11]. Consistent with this general definition, Koukopoulos and Koukopoulos [11] have proposed that agitated mood states include at least two of the following signs and symptoms: motor agitation, psychic agitation or intense inner tension, or crowded thoughts. Although agitation and aggression are associated with each other [12], the two are conceptually distinct; agitation is an internal psychophysiological state, whereas aggression is an externalized behavior. Studies have found that agitation is observed in over 80% of suicide deaths among psychiatric inpatients [13] and patients admitted to emergency departments immediately following a suicide attempt [14]. Agitation further predicts future suicide deaths and suicide attempts among psychiatric outpatients [7,15]. Our understanding of how agitation differentially confers increased risk for suicide attempts across patient subgroups is limited, however, by the absence of studies examining how agitation interacts with predisposing vulnerabilities for suicide attempts.
C.J. Bryan et al. / General Hospital Psychiatry 36 (2014) 726–731
Gender, for instance, is a well-established predisposing risk factor for suicide and suicide attempts: women are more likely to make nonfatal suicide attempts, whereas men are more likely to die by suicide [16,17]. Preliminary research suggests that agitation may differentially affect the risk for suicide attempt between men and women. Men, for instance, are more likely than women to experience depressive episodes marked by agitation, restlessness and racing thoughts (also referred to as mixed depressive episodes) [17–19].As compared to unipolar depressive episodes, mixed episodes are associated with significantly higher risk for suicide ideation and suicide attempts [20–22]. Agitation may therefore differentially confer increased risk for suicide attempts for men than for women. Although these studies provide important information about agitation, gender and risk for suicide attempts, conclusions related to gender are limited because none of these studies explicitly examined gender as a potential moderator of agitation, and each study's sample was restricted to patients diagnosed with a bipolar-spectrum disorder. Additional research is therefore needed. The aim of the current study was to examine the association of gender and agitation with suicide ideation and suicide attempts among individuals admitted to a psychiatric inpatient unit. We hypothesized that the gender-by-agitation interaction would be associated with significantly increased frequency of suicide ideation and risk for suicide attempts; specifically, that the relationship of agitation with suicide ideation and attempts would be stronger among male patients.
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Demographic, historical and clinical data for this cross-sectional study were collected from patients at the time of admission via self-report questionnaires and clinical interview, and subsequently combined with psychiatric diagnosis codes obtained from billing records. Data were deidentified prior to statistical analyses. Regulatory approval for the current study was obtained from Mayo Clinic's Institutional Review Board. 2.2. Measures 2.2.1. Suicide attempts Suicide attempts were defined as nonfatal, self-directed potentially injurious behaviors with any intent to die as a result of the behavior [3]. History of suicide attempt was obtained at the time of admission during the clinical interview (i.e., “Have you ever attempted suicide?”). 2.2.2. Suicide ideation Frequency of suicide ideation was assessed with the suicide ideation item from the Outcomes Questionnaire-45.2 (OQ-45.2) [23]: “I have thoughts of ending my life.” The OQ-45.2 is a 45-item self-report measure designed to assess patient outcomes during the course of psychiatric treatment and assesses psychiatric symptoms and functioning in three domains: subjective distress, interpersonal relationships and social role performance. All items can be aggregated to create a total score, with higher scores indicating poorer functioning. Patients indicated the frequency of suicide ideation during the past 2 weeks on a scale ranging from 0 (“never”) to 4 (“almost always”).
2. Material and methods 2.1. Participants and procedures Participants included 7698 consecutive patients admitted to the Mayo Clinic's inpatient psychiatric unit during a 5-year period from October 2008 to September 2013. Patients were predominantly Caucasian (91.3%) and female (57.2%), ranging in age from 15 to 99 years [M= 39.0, standard deviation (S.D.)=18.0]. A total of 3056 (39.7%) patients had made at least one suicide attempt during their lives, and 4865 (63.2%) reported current (i.e., during the past 2 weeks) suicide ideation. Psychiatric diagnoses were obtained from the medical record using International Classification of Diseases, Ninth Edition codes. The most common primary psychiatric diagnoses were depressive disorders (n=4034; 52.4%), bipolar disorders (n=1084; 14.1%), psychotic disorders (n=623; 8.1%), adjustment disorders (n=463; 6.0%), mood disorder not otherwise specified (n=283; 3.7%), anxiety disorders (n=219; 2.8%), drug-induced psychiatric disorders (n= 202; 2.6%), delirium or dementia (n= 137; 1.8%), and alcohol use disorders (n= 104; 1.4%). Male participants were significantly more likely to be diagnosed with a psychotic disorder, adjustment disorder, drug-induced psychiatric disorder and alcohol use disorder, but women were significantly more likely to be diagnosed with a depressive disorder (see Table 1). Data for the current study were extracted from the psychiatric inpatient unit's clinical data set, which was created in 2007 in a larger effort to improve the hospital's clinical practice in suicide risk assessment. Table 1 Psychiatric diagnoses by gender Men
Depressive disorder Bipolar disorder Psychotic disorder Adjustment disorder Anxiety disorder Drug-induced mental disorder Delirium or dementia Alcohol use disorder
Women
n
(%)
n
(%)
1506 465 369 229 91 125
(45.7) (14.1) (11.2) (6.9) (2.8) (3.8)
2528 619 254 234 128 77
(57.4) (14.1) (5.8) (5.3) (2.9) (1.7)
66 55
(2.0) (1.7)
71 49
(1.6) (1.1)
χ2
P
Φ
103.61 0.00 74.71 8.92 0.14 30.84
b.001 .947 b.001 .003 .704 b.001
0.12 0.00 −0.10 −0.03 0.00 −0.06
1.64 4.38
.200 .036
−0.02 −0.02
2.2.3. Suicide Status Form-II, Revised The Suicide Status Form-II, Revised (SSF-II-R) [24] is a brief selfreport rating scale that assesses six key constructs central to conceptualizing suicide risk: psychological pain (“hurt, anguish, or misery in your mind, not stress, not physical pain”), stress (“your general feeling of being pressured or overwhelmed”), agitation (“emotional urgency, feeling that you need to take action, not irritation, not annoyance), hopelessness (“your expectation that things will not get better no matter what you do”), self-hatred (“your general feeling of disliking yourself, having no self-esteem, having no self-respect”) and the patient's assessment of overall suicide risk (“rate your overall risk of suicide”). Each item is rated on a 5-point Likert scale ranging from 1 (“low”) to 5 (“high”). The constructs assessed by the SSF-II-R have been influenced by several leading theories of suicide to include Shneidman's [25] cubic model of psychological pain stress, and agitation; Beck et al.'s [26] hopelessness model; and Baumeister's [27] theory of suicide as an escape from unbearable self-hatred and self-loathing. The validity of the SSF-II-R among psychiatric inpatients has been established [28]. In the current study, the SSF-II-R's agitation item was used as the primary independent variable and the remaining items were used as covariates. 2.2.4. Patient Health Questionnaire-9 The nine-item depression scale of the Patient Health Questionnaire (PHQ-9) [29] is a self-report survey that corresponds to the nine diagnostic criteria for major depressive disorder, which respondents rate on a scale ranging from 0 (“not at all”) to 3 (“nearly every day”). A total score is obtained by summing the nine individual items, with higher scores corresponding with mild, moderate, moderately severe and severe depression. 2.3. Data analysis Multivariate linear regression was used to test the associations among predictors with frequency of suicide ideation, and multivariate logistic regression was used to test the associations among predictors with lifetime incidence of suicide ideation. Robust maximum likelihood estimation was used due to skew in predictor and outcome variables. The following variables were selected as predictors: gender, race, age, depression severity, frequency of suicide ideation (for the model with
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suicide attempt as outcome), lifetime history of suicide attempt (for the model with suicide ideation as outcome), psychological pain, stress, hopelessness, self-hatred and self-rated suicide risk. To test gender differences, interaction terms were calculated and added to the regression models concurrent with the main effects.
3. Results 3.1. Descriptive analyses A total of 2861 (37.2%) patients had made at least one suicide attempt, and 5056 (65.7%) reported current suicide ideation. In terms of severity of agitation, there were no differences between men and women [M=2.65, S.D.=1.42, vs. M=2.66, S.D.=1.43; F(1,7295)=.35, P= .555, partial η 2= 0.000], but patients with a history of suicide attempt reported significantly more severe agitation [M=2.68, S.D.= 1.43 vs. M=2.63, S.D.= 1.42; F(1,7295)=3.95, P= .047, partial η 2= 0.001]. A significant interaction of gender and suicide attempt was also found for agitation severity [F(1,7295)=8.01, P=.005, partial η 2= 0.001], with male suicide attempters reporting the most severe agitation (see Fig. 1). Overall, the mean agitation score among male suicide attempters (M=2.76, S.D.=1.44) was significantly higher than female suicide attempters [M=2.64, S.D.= 1.42; P= .034, g= 0.08 (0.01, 0.16)] and men with no suicide attempts [M=2.59, S.D.=1.42; P= .002, g= 0.12 (0.06, 0.28)]. Additionally, male suicide attempters' mean agitation scores were marginally higher than women with no suicide attempts [M=2.67, S.D.= 1.44; P= .090, g= 0.06 (− 0.01, 0.14)]. In all cases, the magnitudes of between-group differences were fairly small, as indicated by the mean difference sizes. To further describe the sample, means, S.D.s and intercorrelations of all variables were calculated and are reported in Table 2. Of note, frequency of suicide ideation was positively correlated with psychological pain, stress, agitation, hopelessness, self-hatred and subjective suicide ideation, whereas history of suicide attempts was significantly correlated with female gender, younger age and more severe depression. Female gender was positively correlated with depression severity but was not associated with any other aggravating suicide risk factor.
3.2. Gender differences in predictors of suicide ideation Results of the multivariate regression model predicting frequency of suicide ideation are summarized in Table 3. In the first step, we considered only the main effects of predictor variables: psychological pain, stress, hopelessness, self-hatred and self-rated suicide risk were associated with significantly increased frequency of suicide ideation, whereas agitation was associated with significantly decreased frequency of suicide ideation (Table 3, Model A). We next calculated the interaction term of gender with agitation and added this term to the model, but the interaction was not statistically significant [adjusted odds ratio (AOR)=0.99 (0.96, 1.02), P=.540; Table 3, Model B]. 3.3. Gender differences in predictors of suicide attempt Results of the multivariate regression model predicting history of suicide attempt are also summarized in Table 3. In the first step, female gender, minority race, younger age and severity of depression were associated with significantly increased risk for a suicide attempt (Table 3, Model C). Severity of agitation was also associated with a nonsignificant trend towards increased risk for suicide attempt [AOR=1.05 (1.00, 1.10), P= .071]. We next calculated the interaction term of gender with agitation, which resulted in a statistically significant relationship [AOR=1.12 (1.05, 1.19), P=.001]. The form of this interaction is plotted in Fig. 2. As can be seen in the figure, there was no relationship of agitation with likelihood of suicide attempt for women [B=−0.01, standard error (S.E.)=0.03, Z=−0.09, P=.926] but a positive association existed for men (B=0.11, S.E.=0.03, Z=3.25, P=.001). At low levels of agitation (i.e., a score of 1, which is approximately 1 S.D. below the mean agitation score for men), 29.9% of men and 40.6% of women had made a suicide attempt, but at high levels of agitation (i.e., a score of 4, which is approximately 1 S.D. above the mean agitation score for men), 37.3% of men and 40.4% of women had made a suicide attempt. To confirm that the gender-by-agitation interaction could significantly differentiate suicide attempts from suicide ideation, we repeated the logistic regression analyses among those 3540 patients with current suicide ideation (i.e., scoreN0 on the suicide ideation item). Results were unchanged in this subpopulation, suggesting agitation differentiated male patients with a history of suicide attempt from male patients who were thinking of suicide but had not yet made an attempt. 3.4. Associations of agitation with depressive symptoms To examine the relationship of agitation with each of the 9 DSM-IVdefined symptoms of major depressive disorder, we next computed the correlation coefficients of agitation with each item of the PHQ-9. Results are indicated that agitation had negligible associations with each symptom of depression, suggesting that agitation did not overlap conceptually with depression symptoms in the current sample (see Table 4). 4. Discussion
Fig. 1. Mean agitation scores with 95% confidence intervals among 7299 psychiatric inpatients, by gender and history of suicide attempt. *Pb.05, **Pb.01.
In the current study, we sought to determine if agitation was differentially related to suicide ideation and suicide attempts according to gender. Results partially confirmed our hypotheses. Specifically, results supported our hypotheses that the gender-by-agitation interaction would be significantly associated history of suicide attempts, and that the relationship of agitation with suicide attempts would be stronger among men. Contrary to our expectations, however, we did not find the gender-by-agitation interaction to be significantly associated with frequency of suicide ideation. Taken together, these results suggest that although agitation is associated with suicide ideation across both genders, agitation may be more strongly associated with suicide attempts among men. Previous studies finding associations of agitation and physiological arousal with suicide ideation and attempts have also reported that
C.J. Bryan et al. / General Hospital Psychiatry 36 (2014) 726–731
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Table 2 Means, S.D.s, and intercorrelations of study variables and covariates 1. 1. 2. 3. 4. 5. 6. 7. 8. 9.
Gender Race Age Suicide attempt Suicide ideation Depression Psych0. pain Stress Agitation
2.
3.
4.
5.
6.
– −0.01 0.45⁎⁎ 0.38⁎⁎ 0.29⁎⁎ 0.51⁎⁎
– −0.04⁎⁎ −0.02 −0.03⁎ −0.03⁎
7.
8.
9.
10.
– 0.53⁎⁎ 0.55⁎⁎ 0.49⁎⁎
– 0.43⁎⁎ 0.39⁎⁎
–
11.
12.
– – 0.12⁎⁎ −0.04⁎⁎ −0.01 0.04⁎⁎
– −0.15⁎⁎ 0.02 0.07⁎⁎
10. Hopelessness
−.01 −0.01 0.08⁎⁎ 0.12⁎⁎ 0.01 −0.01 −0.01 0.00 −0.01
0.01 0.01 0.00 −0.02
0.00 0.00 0.01 0.01
– 0.01 0.12⁎⁎ 0.01 0.00 0.02 0.00
11. Self−hatred
−0.01
−0.01
0.00
0.00
12. Self-rated risk Mean S.D.
−0.01
0.00
0.02
– –
– –
38.99 18.04
−0.03⁎
0.62⁎⁎
–
0.00
0.50⁎⁎ 0.67⁎⁎
– 0.60⁎⁎ 0.48⁎⁎ 0.62⁎⁎ 0.55⁎⁎
0.00
0.42⁎⁎
0.35⁎⁎
0.32⁎⁎
0.49⁎⁎
0.48⁎⁎
–
– –
2.62 1.37
1.30 1.22
3.15 1.49
3.51 1.39
2.65 1.43
3.04 1.54
2.75 1.52
1.78 1.16
⁎ Pb05. ⁎⁎ Pb.01.
agitated mood states are much more common among men [19–22,30]. Furthermore, a recent study conducted among a nonclinical sample of primarily male military personnel similarly found that agitation was positively associated with suicide ideation [31]. In combination, these studies suggest that agitation may be associated with suicide ideation and attempts among men more so than women. Unfortunately, none of these studies explicitly considered gender differences, and the majority [19–22,30] enrolled only very narrowly defined psychiatric samples; specifically, those diagnosed with either unipolar depression or bipolar disorder. The present findings therefore build upon the existing literature by utilizing a heterogeneous clinical sample and by explicitly testing for gender differences. Of note is our finding that agitation was significantly associated with suicide attempts beyond the effects of suicide ideation. As noted by others [32], the considerable majority of suicide risk factors are actually risk factors for suicide ideation, but they do not necessarily identify which individuals with suicide ideation will progress to suicide attempts. For example, in the National Comorbidity Survey, the strengths of the associations among a wide range of psychiatric disorders with a history of suicide ideation and suicide attempts were
approximately equivalent, but these same disorders were either unable to differentiate between individuals with suicide ideation and suicide attempts or had only very small effect sizes [33]. Furthermore, although all psychiatric disorders were associated with increased risk for suicide ideation, depressive episodes, manic episodes and panic disorder — conditions that are each characterized by agitation and/or physiological arousal — were among the only disorders that differentiated individuals who had made suicide attempts from those with suicide ideation only [33]. The current results mirror these findings: although psychological pain, stress, agitation, hopelessness, self-hatred and self-rated suicide risk were significantly associated with increased frequency of suicide ideation, only agitation and depression severity were associated with significantly increased risk for suicide attempts. The very small correlations of agitation with each of the nine symptoms of depression further suggest that self-reported agitation is distinct from depression symptoms. Similar results have been reported previously by others [34], further suggesting that agitation may be distinct from mood disturbance. Therefore, our findings suggest that agitation may serve as a better marker of risk for suicide attempt among men with suicide ideation as compared to other risk factors. Our results also provide further support
Table 3 Results of multivariate regression models predicting suicide ideation and suicide attempt in a psychiatric inpatient sample Suicide ideationa
Suicide attemptb
Model A
Female Caucasian Age Suicide attempt Suicide ideation Depression Severe Moderate-severe Moderate Mild None Psychological pain Stress Agitation Hopelessness Self-hate Self-rated risk Gender×agitation
Model B
Model C
Model D
AOR [95% CI]
P
AOR [95% CI]
P
AOR [95% CI]
P
AOR [95% CI]
P
1.04 [1.00, 1.09] 0.97 [0.89, 1.05] 1.00 [1.00, 1.00] 1.01 [0.96, 1.06] –
.072 .392 .203 .789 –
1.08 [0.96, 1.21] 0.97 [0.89, 1.05] 1.00 [1.00, 1.00] 1.01 [0.96, 1.05] –
.200 .407 .191 .804 –
1.32 [1.18, 1.48] 0.79 [0.64, 0.96] 0.98 [0.98, 0.99] – 1.01 [0.95, 1.08]
b.001 .016 b.001 – .793
1.57 [1.12, 2.20] 0.79 [0.65, 0.96] 0.98 [0.98, 0.99] – 1.01 [0.95, 1.08]
.009 .019 b.001 – .799
1.01 [0.93, 1.09] 1.00 [0.92, 1.09] 1.00 [0.91, 1.09] 1.02 [0.93, 1.12] – 1.07 [1.05, 1.10] 1.05 [1.03, 1.08] 0.97 [0.95, 0.99] 1.10 [1.07, 1.12] 1.10 [1.08, 1.13] 1.72 [1.67, 1.78] –
.866 .931 .947 .701 – b.001 b.001 .002 b.001 b.001 b.001 –
1.00 [0.93, 1.09] 1.00 [0.92, 1.09] 1.00 [0.91, 1.09] 1.02 [0.93, 1.12] – 1.07 [1.05, 1.10] 1.05 [1.03, 1.08] 0.98 [0.95, 1.00] 1.10 [1.08, 1.13] 1.10 [1.08, 1.13] 1.72 [1.68, 1.77] 0.99 [0.96, 1.02]
.917 .964 .929 .744 – b.001 b.001 .079 b.001 b.001 b.001 .540
2.10 [1.71, 2.59] 1.71 [1.37, 2.13] 1.54 [1.22, 1.94] 1.25 [0.98, 1.59] – 0.99 [0.94, 1.05] 1.01 [0.96, 1.07] 1.05 [1.00, 1.10] 0.99 [0.94, 1.04] 1.00 [0.95, 1.05] 0.99 [0.92, 1.05] –
b.001 b.001 b.001 .077 – .786 .683 .071 .619 .900 .647 –
2.10 [1.71, 2.59] 1.70 [1.36, 2.12] 1.54 [1.23, 1.94] 1.25 [0.98, 1.60] – 1.02 [0.85, 1.22] 0.92 [0.76, 1.11] 1.12 [1.05, 1.19] 1.03 [0.86, 1.23] 1.01 [0.85, 1.19] 0.87 [0.71, 1.06] 0.89 [0.83, 0.97]
b.001 b.001 b.001 .073 – .867 .397 .001 .779 .953 .156 .005
Bold values are statistically significant. a Generalized linear regression with robust maximum likelihood estimation. b Logistic regression. For ease of comparisons of effect sizes across all models, linear regression coefficients for Models A and B were converted to AORs via exponentiation the regression coefficient (i.e., eB).
730
C.J. Bryan et al. / General Hospital Psychiatry 36 (2014) 726–731 0.45
Clinicians should therefore include an assessment of agitation severity in their suicide risk interviews, especially with male patients. As demonstrated in the current study, even simple self-report rating scales can be clinically useful and practical from a time management perspective. Furthermore, interventions and treatments that directly reduce agitation, whether behavioral (e.g., relaxation, mindfulness) or pharmacologic (e.g., anxiolytics) in nature, may be useful strategies for managing risk for suicide attempts among male psychiatric inpatients.
Probability of suicide attempt
0.40 0.35 0.30 0.25 0.20 0.15
Acknowledgment
0.10
This publication was supported by Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
0.05 0.00 0
1
2
3
4
5
Agitation score Male
References
Female
Fig. 2. Likelihood of suicide attempt among men and women according to severity of agitation.
for the FVT of suicide [9], which posits that aggravating variables such as agitation will be most strongly associated with suicide attempts among individuals with sufficient predispositions. Stated another way, men may be relatively more vulnerable to the negative effects of agitation than women. Several strengths of the present study include its large sample size and diversity of clinical conditions. Nevertheless, conclusions based on the current study should be made cautiously and with consideration for several limitations, the first of which is the study's cross-sectional design. These results should therefore be considered preliminary until prospective studies can be conducted to determine if agitation confers increased risk for future suicide attempts among men. Studies are also needed to confirm that agitation can prospectively differentiate between individuals who think about suicide from those who subsequently act upon these thoughts. Because our study was conducted at a single inpatient psychiatric clinic, generalization of results to nonclinical and outpatient psychiatric settings should also be made with caution. Finally, the current sample was predominantly (91%) Caucasian; additional studies with more diverse samples are warranted to determine if agitation is differentially associated with risk for suicide attempts among individuals from racial or ethnic minority groups. Despite these limitations, the current study provides useful and clinically relevant information that advances our knowledge of how risk factors for suicide attempts vary across different patient subgroups. 5. Conclusions The current results suggest that agitation may also be an especially important indicator of risk for suicide attempts among male patients. Table 4 Correlation coefficients of agitation with each symptom of major depressive disorder, as measured by the PHQ-9 Symptom
r
Anhedonia Depressed mood Sleep disturbance Fatigue/Low energy Appetite change Worthlessness Concentration impairment Psychomotor retardation or activation Thoughts of death or self-harm
−0.03* −0.03* −0.03* −0.02 −0.03* −0.02 −0.02 −0.02 −0.01
* These values are statistically significant at P b .05.
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