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ScienceDirect Comprehensive Psychiatry 56 (2015) 103 – 111 www.elsevier.com/locate/comppsych

Resilience moderates the risk of depression and anxiety symptoms on suicidal ideation in patients with depression and/or anxiety disorders Jung-Ah Min a , Chang-Uk Lee b , Jeong-Ho Chae b,⁎ a b

Health Promotion Center, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea Department of Psychiatry, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea

Abstract Background: Few studies have investigated the role of protective factors for suicidal ideation, which include resilience and social support among psychiatric patients with depression and/or anxiety disorders who are at increased risk of suicide. Methods: Demographic data, history of childhood maltreatment, and levels of depression, anxiety, problematic alcohol use, resilience, perceived social support, and current suicidal ideation were collected from a total of 436 patients diagnosed with depression and/or anxiety disorders. Hierarchical multiple logistic regression analyses were used to identify the independent and interaction effects of potentially influencing factors. Results: Moderate-severe suicidal ideation was reported in 24.5% of our sample. After controlling for relevant covariates, history of emotional neglect and sexual abuse, low resilience, and high depression and anxiety symptoms were sequentially included in the model. In the final model, high depression (adjusted odds ratio (OR) = 9.33, confidence interval (CI) 3.99–21.77) and anxiety (adjusted OR = 2.62, CI = 1.24–5.53) were independently associated with moderate-severe suicidal ideation among risk factors whereas resilience was not. In the multiple logistic regression model that examined interaction effects between risk and protective factors, the interactions between resilience and depression (p b .001) and between resilience and anxiety were significant (p = .021). A higher level of resilience was protective against moderate-severe suicide ideation among those with higher levels of depression or anxiety symptoms. Conclusions: Our results indicate that resilience potentially moderates the risk of depression and anxiety symptoms on suicidal ideation in patients with depression and/or anxiety disorders. Assessment of resilience and intervention focused on resilience enhancement is suggested for suicide prevention. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Although suicide is a weighty problem in public health worldwide, issues related to developing effective screening and preventive interventions are still unresolved [1]. Researchers have sought to identify the risk factors associated with suicide that could provide targets for effective prevention program. Psychiatric and physical disorders, which are most commonly affective disorders, contribute to suicide risk [2,3]. Additionally, demographic factors, such as a lower household income, lower educational attainment, unemployment, and living alone [4,5] as well as childhood maltreatment [6] have been reported to be ⁎ Corresponding author at: Department of Psychiatry, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, 222 Banpo-Daero, Seocho-Gu, Seoul, 137–701, Republic of Korea. Tel.: +82 2 2258 6083. E-mail address: [email protected] (J.-H. Chae). http://dx.doi.org/10.1016/j.comppsych.2014.07.022 0010-440X/© 2014 Elsevier Inc. All rights reserved.

associated with increased suicide risk. However, these suggested risk factors may be insufficient to predict and prevent suicide because individual risk factors account for a small proportion of the variance in risk and lack sufficient specificity [7]. Indeed, no significant decreases in suicidal ideation and attempts have been reported despite an increase in treatment for suicidal behaviors to date [8]. As an alternative to these limitations, interest has expanded into investigating protective factors of suicidal behaviors. Protective factors are broadly divided into two concepts: the internal psychological construct of resilience and the external factor of social support. Resilience refers to a set of both state and a trait characteristics that protect from stress and foster adaptation [9]. Extant research suggests that resilience and related psychological characteristics, such as positive attributional style, coping strategies, hope, and optimism, are associated with reduced suicide risk [10]. It has been reported that resilience is negatively associated with

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suicidal ideation [11–15] and suicide attempts [13,16,17]. This negative association remained after controlling for traumatic life events of combat exposure [18] and history of childhood trauma [19]. In addition, greater social support, perceived social support in particular, has been shown to be related to low levels of suicidal ideation [20–22] and attempts [23]. Therefore, resilience and perceived social support may constitute potential protective factors of suicidal behaviors. However, there are some caveats from previous studies that examined protective factors for suicide that need to be duly considered. Since protective factors are regarded as more than just the absence of risk factors [9], independent effects of protective factors need to be examined after controlling for risk factors. Moreover, risk factors often cannot be eliminated by intervention, and the moderation effect of protective factors on suicide risk, which is an interaction effect, should be also investigated in addition to negative association [10]. Few previous studies have demonstrated the moderating roles of resilience [17] and social support [24,25] on suicide risk factors to date. In addition, preventive effects of protective factors might vary between different samples. Earlier studies investigating the roles of resilience and social support on suicidal behaviors have been performed mainly in non-clinical samples comprising students or community-dwelling individuals [10]. In studies among clinical populations, subjects have been limited to abstinent substance abusers [16,19], those with schizophrenia-spectrum disorders [26], and patients in primary care service [12,20]. Although depression and anxiety disorders have been proposed as the most common psychiatric disorders that are associated with suicidal behaviors [2], studies regarding the protective factors of suicide in patients with these disorders are few, except for studies with inpatients older than 50 years of age with a mood disorder [23] and in adolescents with depression [17]. Therefore, further studies are required in various populations. Based on this background, we attempted to examine the roles of resilience and social support in predicting moderatesevere suicidal ideation among outpatients with depression and/or anxiety disorders. As an outcome variable, suicidal ideation was chosen because it has been shown to be a key indicator of future suicide attempts in a continuum model of suicide and thus, suicide prevention has been focused on this stage [27]. To identify the independent and interaction effects of resilience and social support, multivariate logistic regression models were used after controlling for suggested risk factors for suicide including demographic and clinical variables, childhood maltreatment, and various psychiatric symptoms. 2. Methods 2.1. Participants and procedures During the period between February 2011 and May 2013, patients who first visited the Anxiety and Mood Disorder Clinic at Seoul St. Mary's Hospital, The Catholic University

of Korea and met the DSM-IV criteria for depressive and/or anxiety disorders were recruited consecutively. Diagnosis was conducted by a psychiatrist using semi-structured interviews of the Mini-International Neuropsychiatric Interview (M.I.N.I.) [28]. Eligibility criteria included being 18– 65 years of age and literate in Korean. Exclusion criteria included a lifetime diagnosis of psychotic disorder, bipolar disorder, mental retardation, any mental disorder due to general medical condition, and significant personality disorders and/or medical problems likely to interfere with study participation. A total of 449 psychiatric outpatients who met the inclusion and exclusion criteria consented to participate and filled in a battery of self-report questionnaires. Restricting analyses to those who had completed all measures, the final sample included 436 (of 449) patients. The study procedure was approved by the Institutional Review Boards of the ethical committee of the Seoul St. Mary's Hospital at the Catholic University of Korea (IRB no. KC09FZZZ0211). 2.2. Measures 2.2.1. Demographic, clinical information, and suicide ideation Demographic and medical data were collected from participants and hospital charts. Current suicidal ideation was assessed by measuring responses of Beck Depression Inventory (BDI) item 9. Responses were grouped into two categories: with none-mild suicidal ideation (0–1) and with moderate-severe suicidal ideation (2–3) [29]. 2.2.2. Childhood maltreatment Childhood or adolescent maltreatment experiences were assessed using the short form of Childhood Trauma Questionnaire (CTQ) [30]. The CTQ is a self-report questionnaire consisting of 28 items (25 clinical and three validity items). It measures five categories of childhood maltreatment including emotional and physical neglect as well as emotional, physical, and sexual abuse. Each subscale has 5 items with a 5-point frequency of occurrence and scores of each subscale range from 5 to 25. Based on the manual of CTQ specifying cutoff points for the levels of none, low, moderate, and severe, we used the moderate to severe cutoff scores for each subscales in determining an exposure to childhood trauma in that category [31]. The reliability and validity of the Korean version of CTQ were demonstrated [32]. 2.2.3. Resilience The Korean version of Connor–Davidson Resilience Scale (CD-RISC) [33] was used to measure resilience. The CD-RISC was developed for clinical practice as a measurement of coping ability in the face of adversity [34]. It consists of 25 items, each on a 5-point Likert scale, ranging from 0 (not true at all) to 4 (true nearly all the time). Higher total scores indicate greater resilience. The CDRISC is regarded as one of the best resilience measures in

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terms of psychometric properties and an ability to evaluate changes [35]. 2.2.4. Social support The Duke-University of North Carolina Functional Social Support Questionnaire (FSSQ) was used to assess the perceived social support [36]. It consisted of 14 items rated on a 5-point Likert scale, ranging from 1 (much less than I would like) to 5 (as much as I would like). Higher scores reflect higher perceived social support. Korean version of the FSSQ showed sound reliability and validity [37]. 2.2.5. Psychiatric symptoms Depression and anxiety symptoms were measured by the BDI [38] and the state anxiety subscale of the State-Trait Anxiety Inventory (STAI) [39], respectively. The BDI consists of 21 items with a 0–3 scale and total score ranges from 0 to 63. The STAI consists of two separate 20-item subscales measuring state and trait anxiety. State anxiety items ask people to describe how they feel at a particular moment, whereas trait anxiety items inquire about how they generally feel. Each item is rated on a 4-point (1–4) Likert scale and the total score of state anxiety subscale of STAI (SAI) ranges from 20 to 80. A higher total score of BDI and SAI means more severe depressive and anxiety symptoms, respectively. In the present study, the BDI total scores that omitted the suicidality item 9 were used to avoid circularity in univariate and multivariate analyses. Korean versions of BDI [40] and STAI [41] were validated. The Alcohol Use Disorder Identification Test (AUDIT) was used to assess hazardous drinking behavior in the past year [42]. It is a 10-item scale with a total score ranging from 0 to 40. Higher total scores on the AUDIT are associated with greater level of alcohol problems. Korean version of AUDIT was validated [43]. 2.3. Statistics Characteristics between patients with none-mild and moderate-severe suicidal ideation were compared using χ 2 tests (for categorical variables) and independent-sample t-tests (for continuous variables). Demographic and clinical variables that were significantly different between groups in univariate analyses (p b .05) were entered into multiple regression analyses as covariates. Cohen's d values were also computed to estimate effect sizes of group differences in continuous variables regarding protective (resilience and social support) and risk (psychiatric symptoms) factors [44]. To reduce the number of independent variables that were entered into the multiple regression analyses, only those variables associated with suicidal ideation at the p b .05 level and with a Cohen's d values ≥0.5 (moderate to large effect) were selected. Among selected independent variables, continuous variables were transformed into dichotomous variables (low versus high), using receiver operating characteristic (ROC) curves to choose the cut-off point with the best discrimination capability. A test of the null

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hypothesis that the area under the curve (AUC) is 50% was performed using the Wilcoxon rank sum test and cutoff points were calculated based on the Youden index (J ) [45]. The point with the largest J was defined as the optimal operating point (OOP). Hierarchical multiple regression analyses were used to predict suicidal behavior from protective and risk factors. This model accounted for the causal structure of the predictor variables, which may be a useful analytic tool for suicide research [46]. In a four-block model, demographic and clinical covariates were entered into the first block with an entrance method to adjust for their effects. Blocks 2, 3, and 4 were determined using guidelines that “no factor coming later in the series can causally affect one coming earlier” [46]. Accordingly, history of childhood maltreatment, which is one of the distal risk factors of suicide [3], was entered in block 2. Although protective factors and clinical symptoms seem to influence each other reciprocally [47], it has been theoretically conceptualized that resilience allows individuals to cope well with and overcome adversity [48]. Moreover, prospective studies have revealed that the constructs of resilience and social support predispose as protective factors for depression and/or anxiety disorders after various traumatic experiences [49,50]. Hence, protective factors and psychiatric symptoms were entered into blocks 3 and 4, respectively. Because substantial intercorrelations between variables in each category were expected, a forward selection method was used in blocks 2, 3, and 4. As a secondary analysis, interaction effects were also examined between protective and risk factors that were included in the final regression model. All tests were considered significant at p = .05, 2-tailed. Data were analyzed using Statistical Analysis System (SAS), version 9.1 (SAS Institute Inc., Cary, NC). 3. Results The mean (±SD) age of the sample was 37.3 (±13.3) years and 56.1% of the participants were female. Of 436 patients, 232 (53.2%) and 135 (31.0%) were primarily diagnosed with depressive disorder and anxiety disorder, respectively. Sixty-nine (15.8%) patients had comorbid depression and anxiety disorders. Overall, 107 (24.5%) patients with depression and/or anxiety disorders reported moderatesevere suicidal ideation. 3.1. Associated risk and protective factors with suicidal ideation: univariate analyses Table 1 summarizes demographic and clinical characteristics, prevalence of childhood maltreatment, and scores on measures of protective factors and psychiatric symptoms by suicidal ideation status. In univariate analyses, younger age, lower education levels, lower family income, and higher rates of living alone, emotional neglect, emotional abuse, physical abuse, and sexual abuse were associated with

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Table 1 Demographic and clinical characteristics, childhood maltreatment, and positive factors by suicidal ideation status. Variable

None-mild Moderate-severe P a suicidal ideation suicidal ideation (n = 329) (n = 107)

Demographic and clinical variables Age, y, mean ± SD 38.5 ± 13.3 Gender (females), no. (%) 179 (55.6) Education, y, mean ± SD 14.0 ± 2.9 Marital status (living 164 (52.7) alone), no. (%) Employment status 147 (49.5) (no), no. (%) Family income 95 (33.8) (b$2000/month), no. (%) Having religion (no), no. (%) 96 (30.4) Physical illness (yes), 151 (50.2) no. (%) Primary diagnosis, no. (%) Depressive disorder 163 (70.3) Anxiety disorder 118 (87.4) Comorbidity b 48 (69.6) Childhood maltreatments (CTQ) Emotional neglect (yes), 127 (39.3) no. (%) Emotional abuse (yes), 56 (17.2) no. (%) Physical neglect (yes), 98 (30.1) no. (%) Physical abuse (yes), 101 (31.2) no. (%) Sexual abuse (yes), 48 (15.0) no. (%) Positive factors Resilience (CD-RISC), 51.3 ± 18.2 mean ± SD Social support (FSSQ), 40.7 ± 11.9 mean ± SD Psychiatric symptoms Depression (BDI except 20.1 ± 9.4 item 9), mean ± SD State anxiety (SAI), 55.2 ± 12.0 mean ± SD Problematic alcohol use 5.9 ± 6.4 (AUDIT). mean ± SD

34.0 ± 12.8 61 (57.5) 13.2 ± 2.7 69 (70.4)

0.003 0.725 0.010 0.002

55 (53.9)

0.440

52 (56.5)

b0.001

39 (37.5) 50 (48.1)

0.177 0.713 0.001

69 (29.7) 17 (12.6) 21 (30.4) 65 (60.7)

b0.001

37 (35.9)

b0.001

29 (27.4)

0.596

55 (52.4)

b0.001

30 (28.3)

0.002

38.1 ± 18.2

b0.001

34.6 ± 11.5

b0.001

34.5 ± 9.5

b0.001

66.4 ± 9.9

b0.001

6.4 ± 7.3

0.527

K-CTQ, childhood trauma questionnaire; CD-RISC, Connor–Davidson Resilience Scale; FSSQ, functional social support questionnaire; BDI, Beck depression inventory; SAI, state anxiety inventory; AUDIT, alcohol use disorder identification test. a Statistical significance from independent t-tests or chi-square tests. b Having both depressive and anxiety disorders.

moderate-severe suicidal ideation. Prevalence of moderatesevere suicidal ideation was significantly lower in patients with an anxiety disorder than those with depression or a comorbidity ( p b .001, χ 2 = 13.988 and p = .002, χ 2 = 9.590) whereas prevalence in patients with depression and those with a comorbidity did not differ significantly ( p = .912, χ 2 = 0.012). Thus, psychiatric diagnosis was transformed into a dichotomous variable (anxiety disorder versus

depression or comorbidity). Additionally, a higher degree of depression and anxiety symptoms as well as lower resilience and social support were related to moderate-severe suicidal ideation. There was no difference in the prevalence of gender, employment status, religion, physical illness, and physical neglect, as well as degree of alcohol use problems by suicidal ideation status. 3.2. Independent effects of risk and protective factors on suicidal ideation: multivariate analyses Among variables of protective factors and psychiatric symptoms that significantly differed by suicidal ideation status in univariate analyses, moderate to large effect size (d ≥ 0.5) group differences were demonstrated in resilience, depression, and anxiety severity (data not shown). These three variables were transformed into dichotomous variables (low versus high) using ROC curves before entering them into the next multivariate regression models. The ROC curves for resilience, depression, and anxiety were significant with AUCs of 0.696, 0.855, and 0.774, respectively (Fig. 1). The cutoffs for CD-RISC, BDI except item 9, and SAI were 39.5 (39/40) with 75.4% sensitivity and 58.1% specificity, 25.5 (25/26) with 86.7% sensitivity and 72.2% specificity, and 63.5 (63/64) with 70.1% sensitivity and 74.3% specificity, respectively. Table 2 shows the results of a hierarchical multivariate logistic regression analysis examining the predictors of moderate-severe suicidal ideation. After controlling for demographic and clinical covariates, a history of emotional neglect and sexual abuse, low resilience, and high depression and anxiety symptoms were sequentially included in the model. In the final model, high depression (adjusted [adj.] OR = 9.33) and anxiety symptoms (adj. OR = 2.62) were independently associated with moderate-severe suicidal ideation whereas sexual abuse showed a trend-level association. The overall model fit the data well (Hosmer and Lemeshow test of goodness-of-fit χ 2 = 9.92, p = .270). 3.3. Interaction effects of risk and protective factors on suicidal ideation The interaction effects of resilience with risk factors included in the final model (emotional neglect, sexual abuse, depression, and anxiety) were investigated in the multivariate logistic regression model after controlling for relevant covariates. The interactions of resilience with depression ( p b .001) and with anxiety ( p = .021) were significant, whereas the interactions of resilience with each childhood maltreatment experience (emotional neglect and sexual abuse) were not significant ( p = .092 and p = .628, respectively). The model fits the data well (Hosmer and Lemeshow test of goodness-of-fit χ 2 = 6.25, p = .618). The pattern of interaction between resilience and depression is depicted in Fig. 2. Among patients with low resilience, 61.6% with high depression reported moderate-severe suicidal ideation. On the other hand, among patients with

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4. Discussion

Fig. 1. The ROC curves for resilience (CD-RISC), depression (BDI except for item 9), and state anxiety (SAI). a) The ROC curve of CD-RISC for nomild suicidal ideation. Area under the curve (AUC) is 0.696 (95% CI 0.636– 0.755) and asymptotic significance is p b .001. b) The ROC curve of BDI except for item 9 for moderate-severe suicidal ideation. Area under the curve (AUC) is 0.855 (95% CI 0.814–0.896) and asymptotic significance is p b .001. c) The ROC curve of SAI for moderate-severe suicidal ideation. Area under the curve (AUC) is 0.774 (95% CI 0.723–0.825) and asymptotic significance is p b .001.CD-RISC, Connor–Davidson Resilience Scale; BDI, Beck depression inventory; SAI, state anxiety inventory.

high resilience, only 38.8% with high depression reported moderate-severe suicidal ideation. A similar pattern of interaction was demonstrated in the interaction between resilience and anxiety (Fig. 3).

In the present study of outpatients with depression and/or anxiety disorders, resilience and perceived social support were not significant independent predictors for increased suicidal ideation after controlling for demographic and clinical factors, childhood maltreatment, and psychiatric symptoms. However, resilience moderated the risk of depressive and anxiety symptoms on suicide ideation after accounting for relevant covariates. In particular, a higher level of resilience was protective against moderate-severe suicide ideation among those with higher levels of depression or anxiety. These results corroborate the proposed concept of suicide resilience, which acts as a buffer against risk factors [10]. Moreover, in line with a previous study that reported that resilience is a moderator of lifetime violent events on attempted suicide among adolescents [17], results from the current study extend the moderating role of resilience against suicidal behaviors into a clinical population with depression and/or anxiety disorders. Since many unplanned and planned first suicide attempts may occur within a year of the onset of suicidal ideation [27], detection and management of suicidal behavior at this stage are important. In the present study, significant suicidal ideation was reported in 24.5% of outpatients with depression and/or anxiety disorders. This prevalence converges with previous reports ranging from suicidal ideation in 16%–43% in patients with anxiety disorders [20,51], but is lower than that of other reports that range from 58% to 69% in patients with major depressive disorder [51–53]. Given that the diagnosis of major depressive disorder and an inpatient setting are usually associated with a higher suicide risk than other depressive disorders and outpatient setting, respectively [2], the prevalence rate in the current study might stem from the inclusion of psychiatric outpatients with dysthymia, depressive disorder not otherwise specified (NOS), and various anxiety disorders. Nevertheless, it should be noted that in our sample, one out of every four outpatients with depression and/or anxiety disorders has significant suicidal ideation. Our results of resilience buffering against suicidal ideation imply some clinical implications. To begin with, assessment of resilience level in conjunction with clinical risk factors, such as depression and anxiety symptoms, may be recommended to increase accuracy in screening patients at risk of suicide. In addition, since resilience appears to be modifiable by pharmacological [54] and psychological interventions [55], resilience enhancement interventions that boost the buffering effect can be applied to manage suicidal ideation. The protective effect of high resilience was prominent in patients with high depression and anxiety symptoms in the present study. However, dealing with issues on resilience in acutely ill patients can be quite difficult due to their overwhelming negative emotions and thoughts [55]. Since depression and anxiety symptoms were the two independent predictors of suicidal ideation in our study and the treatment

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Table 2 Results of hierarchical logistic regression model predicting moderate-severe suicide ideation. Block no., variable

Each step results using forward stepwise method in block 2–4 OR (95%CI)

Constant 1. Covariates Age, y Education, y Living alone Monthly family income b$2000 Depression or comorbidity 2. Childhood maltreatment Emotional neglect, yes Sexual abuse, yes 3. Positive factors Resilience, low 4. Psychiatric symptoms Depression, high Anxiety, high Model fit Hosmer and Lemeshow test

Last step results

P

OR (95%CI)

P

OR (95%CI)

P

OR (95%CI)

P

0.97(0.95–1.00) 0.91(0.82–1.01) 1.27 (0.62–2.60) 2.06 (1.14–3.71)

0.109 0.081 0.500 0.016

0.97 (0.94–1.00) 0.90 (0.81–1.01) 1.18 (0.57–2.46) 1.90 (1.04–3.46)

0.081 0.076 0.644 0.034

0.99 (0.96–1.02) 0.90 (0.81–1.01) 1.06 (0.49–2.28) 1.97 (1.05–3.69)

0.513 0.075 0.881 0.034

0.97 (0.94–1.00) 0.91 (0.80–1.04) 1.10 (0.46–2.64) 1.71 (0.84–3.48)

0.150 0.173 0.819 0.138

3.81 (1.76–8.22)

0.001 3.14 (1.43–6.88)

0.004 2.73 (1.21–6.17)

0.015 1.75 (0.68–4.49)

0.240

1.90 (1.06–3.41) 2.01 (1.02–3.98)

0.031 1.32 (0.70–2.48) 0.043 2.34 (1.13–4.85)

0.386 1.40 (0.67–2.93) 0.021 2.20 (0.95–5.11)

0.367 0.066

4.05 (2.07–7.93)

b0.001 1.55 (0.69–3.48)

0.281

9.33 (3.99–21.77) 2.62 (1.24–5.53) χ 2 = 7.63, P = 0.470

χ 2 = 6.49, P = 0.592

of psychiatric disorders has long been considered to be the central component of suicide prevention [1], one would be able to speculate the priority of treating psychiatric symptoms over resilience-enhancement. Indeed, Fava and Tomba [55] suggested that positive intervention of well-being therapy might be helpful in patients with residual phase of depression and anxiety disorders with the emphasis of individualized approach. To test our speculation, the specificity of each treatment and a suitable time to start resilience-enhancement approach, such as residual phase, should preferentially be determined. Investigations on the efficacy of sequential versus simultaneous approaches targeting psychiatric symptoms and resilience are also recommended. Although there is mounting evidence that social support is associated with lower suicide risk in patients with depression

χ 2 = 4.34, P = 0.825

b0.001 0.011

χ 2 = 9.92, P = 0.270

[23,56] and anxiety disorders [20,57], we did not find significant independent or interaction effects of social support on suicidal ideation. This may be partly due to inconsistent measures that assess different aspects and sources of social support across studies. Some studies suggest that the relationship between psychosocial protective factors and suicidal ideation is mediated by depressive symptoms [22,58] as well as resilience [59]. Indeed, the weakened protective effect of social support on suicidal ideation has been shown in the presence of depression [12]. The effects of these mediating factors may also confound the relationships between social support and suicidal ideation. Further studies on the protective effect of social support will be needed. Among types of childhood maltreatment, sexual abuse had a trend-level association with suicidal ideation in the

Fig. 2. Interaction effect of depression and resilience on suicidal ideation. A significant interaction was present between depressive symptoms and resilience in predicting suicidal ideation after controlling for demographic covariates of age, education year, marital status, and monthly family income (p b .001). In patients with high levels of depressive symptoms, the proportion of moderate-severe suicidal ideation was 61.1% (a) and 38.8% (b) when they had low and high resilience, respectively.

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Fig. 3. Interaction effect of anxiety and resilience on suicidal ideation. A significant interaction was present between anxiety symptoms and resilience in predicting suicidal ideation after controlling for demographic covariates of age, education year, marital status, and monthly family income (p = .021). In patients with high levels of anxiety symptoms, the proportion of moderate-severe suicidal ideation was 60.8% (a) and 32.9% (b) when they had low and high resilience, respectively.

final model. Childhood sexual abuse has been reported to increase suicide risk in the general population [60,61]. However, some researchers propose that there might be confounding factors for the relationship between sexual abuse and suicide risk such as a gender difference [62] and psychopathologies, such as mood disorders and hopelessness, which are associated with childhood sexual abuse [62,63]. These confounders may partly contribute to a weaker association between sexual abuse and suicidal ideation in the current study. Additionally, there was no significant interaction between emotional neglect and sexual abuse with resilience. Considering that resilience interacted with depression and anxiety symptoms, but not with childhood maltreatment, it may be presumed that resilience can moderate or buffer certain risk factors but not others [10]. Studies on the specificity in the moderating role of resilience are encouraged. The data and conclusions described here are tempered by methodological limitations. First, causality cannot be inferred due to the cross-sectional design. Future studies with a prospective design as well as intervention study of resilienceenhancement programs may be required in order to ascertain the contribution of high resilience in mitigating the effects of risk factors on suicidal ideation. The second limitation is the reliance on self-rated measures used in this study. Although BDI item 9 is a meaningful measure of current suicidal ideation, it cannot assess all the aspect of suicidal ideation including a hatched plan or preparedness with limited sensitivity and specificity [64]. In addition, self-rated measures of protective factors (resilience and social support) may be influenced by psychiatric symptoms and social desirability. Third, patients with depression and anxiety disorders were considered as a group in the present study. In clinical practice, these two disorders are highly comorbid and sometimes considered to be merely different expressions of an emotional disorder that shares common genetic vulnerability [65]. Common psychotherapeutic approaches are effacious in

broad-spectrum patients with depression and anxiety disorders [66]. However, regarding the different prevalence of suicidal ideation according to diagnosis, studies in separate diagnostic population will identify the specificity of each diagnosis. Furthermore, patients with bipolar or personality disorder were excluded in the present study. Future study targeted these patients who are at particularly high risk for suicide would be valuable. Fourth, we transformed the variables of resilience, depression, and anxiety into dichotomous ones. Although this transformation might be helpful for clinical applications of our results, it entails a loss of original information and arbitrary cut-offs. In conclusion, resilience potentially moderates the risk of depression and anxiety symptoms on suicidal ideation in patients with depression and/or anxiety disorders who are at increased risk of suicide. On the basis of these findings, an assessment of resilience and strategic interventions to enhance resilience might be helpful for suicide prevention in this population. Acknowledgment This research was supported by a grant from the Korea Research Foundation, Basic Research Project (2012– 001314). The authors thank Yong-Gyu Park for his statistical advice. References [1] Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA 2005;294 (16):2064-74. [2] Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry 1997;170:205-28. [3] Hawton K, van Heeringen K. Suicide. Lancet 2009;373(9672):1372-81. [4] Lee HY, Hahm MI, Park EC. Differential association of socioeconomic status with gender- and age-defined suicidal ideation among

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or anxiety disorders.

Few studies have investigated the role of protective factors for suicidal ideation, which include resilience and social support among psychiatric pati...
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