Anestis et al. 371 relationshin with suicidal behavior than the abo erlethality The in relationshin be risk factors does not render the relationship between trait siveness of attempt and lethality of attempt has also been replicated in a sample of adolesc ents (Witte et al,2008). tainly calls into que tudies exa ning the ass ation ort th distal variety of samples.more impulsive attempts were associated with lower depre ssion scores (e.g,Brown,Overholse Critical Review of Studies Examining irito,&Frit 19009,si ner et a 2014 Impulsivity of Attempts Kellv Malone, Mann,2000:Suomine In this sectionwe vide a critical review of findings fro Henriksson,Ostamo,&Lonnqvist,1997;Wojnar et al. studics examining the impulsiveness of specific suicide al.,2007an attempts.We opted against using a meta-analysis in this null cause mea the a reno ion of the article was on the mea and o childhood sexual abuse,and Conner et al.(2006)reporte alization of the impulsivity of attempts.In this sense.there that impulsive attempte were less likely to me was no second va ted that this e s note Sher.2008).and a history of childhood sexual abus of impulsivity of attemnts problematic measuremer )re associated with severe suicidal behav approa are evi with the notion ive plan ning attemnts Wher considered within the context o these find out e. ings,models claiming suicidal behavior frequently occurs Study Selection impulsively are particularly problematic,as such perspec large por and fewer risk factors for severe.repeated.and lethal suicida extent to which participants engaged in suicidal behavi behavior. that involved little to no planning.In some studies,the ed the us sure desigr Conceptual Issues With Studies Examining the siven case Impulsiveness of Specific Suicide Attempts distance of attempt from home)or involved one or m Studies that examine impulsiveness of attempts differ in many ways,including the method of measurement and the attempts considered impulsive.Inst Summary of Results of Studies Examining the d ir %(Houston.Hawton.Sheppard.2001)to(Razin Impulsiveness of Specific Suicide Attempts et al.,1991).As such,there does not appear to be a co nsus In studies that examined the impulsivity of specific suicide as to whether impul a rare phe the gene eral tren appears to argue in greater detail below.we believe the actual p uicideemBac-rd olu20) tion of attempts that can accurately be described as impulsive to be at or very close to 0 omihetisirencofahemgtasmeyamciate on s likel ty ny. ed with which an individual must report having thoughts abou at least once Nakagawa and colleagues (2000)found that attempting suicide.In some studies,participants are asked i less planning was associated with lower lethality.In additior they contemplated eir att mpt for longer tha min pric ner and colleagues( of planning were s from
Anestis et al. 371 relationship with suicidal behavior than the above-mentioned risk factors does not render the relationship between trait impulsivity and suicidal behavior meaningless, but it certainly calls into question its centrality. Indeed, our central thesis is not that trait impulsivity is irrelevant to suicidal behavior but rather that the relationship is indirect and distal. Critical Review of Studies Examining Impulsivity of Attempts In this section, we provide a critical review of findings from studies examining the impulsiveness of specific suicide attempts. We opted against using a meta-analysis in this section because such analyses measure the average strength of the relationship between two variables and the focus of this portion of the article was on the measurement and conceptualization of the impulsivity of attempts. In this sense, there was no second variable to which impulsivity of attempts was being compared. As noted earlier in the article, we anticipated that this review would yield an inconsistent definition of impulsivity of attempts, problematic measurement approaches, and a pattern of results that does not align well with the notion that suicidal behavior frequently occurs without extensive planning. Study Selection Inclusion criteria for studies examined in our critical review involved reporting of any results intended to measure the extent to which participants engaged in suicidal behavior that involved little to no planning. In some studies, the assessment approach involved the use of a measure designed to assess impulsiveness of attempts. In other cases, this included the interpretation of objective circumstances (e.g., distance of attempt from home) or involved one or more questions from within a broader measure. These criteria yielded 49 studies (see Table 2). Summary of Results of Studies Examining the Impulsiveness of Specific Suicide Attempts In studies that examined the impulsivity of specific suicide attempts, the general trend appears to indicate that attempts that involve less planning are associated with less severe outcomes. For instance, in a sample of individuals hospitalized for a suicide attempt, Baca-Garcia and colleagues (2001) found that impulsiveness of attempt was inversely associated with lethality of attempt. Similarly, in a sample of adult inpatients diagnosed with depression who had attempted suicide at least once, Nakagawa and colleagues (2009) found that less planning was associated with lower lethality. In addition, in a sample of 673 attempters, Conner and colleagues (2006) found that greater levels of planning were associated with greater lethality. The inverse relationship between impulsiveness of attempt and lethality of attempt has also been replicated in a sample of adolescents (Witte et al., 2008). Studies examining the association between impulsiveness of attempts and psychopathology also fail to support the view that suicidal behavior is frequently impulsive. Across a variety of samples, more impulsive attempts were associated with lower depression scores (e.g., Brown, Overholser, Spirito, & Fritz, 1991; Conner et al., 2006; Jeon et al., 2010; Nakagawa et al., 2009; Simon et al., 2001; Soloff, Lynch, Kelly, Malone, & Mann, 2000; Suominen, Isometsa, Henriksson, Ostamo, & Lonnqvist, 1997; Wojnar et al., 2009; Wyder & de Leo, 2007; see Conner et al., 2007 and Giegling et al., 2009 for null findings). Similarly, Wojnar et al. (2009) found that impulsive attempters were less likely to report a family history of suicide or having experienced childhood sexual abuse, and Conner et al. (2006) reported that impulsive attempters were less likely to meet diagnostic criteria for substance dependence. Given that depression (e.g., Bostwick & Pankratz, 2000), substance use (Bagge & Sher, 2008), and a history of childhood sexual abuse (e.g., Joiner et al., 2007) are associated with severe suicidal behavior, these findings are evidence that individuals in particularly high-risk groups are less likely to engage in impulsive attempts. When considered within the context of these findings, models claiming suicidal behavior frequently occurs impulsively are particularly problematic, as such perspectives seem to suggest that a large proportion of attempts involve individuals with lower levels of psychopathology and fewer risk factors for severe, repeated, and lethal suicidal behavior. Conceptual Issues With Studies Examining the Impulsiveness of Specific Suicide Attempts Studies that examine impulsiveness of attempts differ in many ways, including the method of measurement and the proportion of attempts considered impulsive. In studies that dichotomized attempts as impulsive or non-impulsive, the proportion of attempts considered impulsive has ranged from 13% (Houston, Hawton, & Sheppard, 2001) to 97% (Razin et al., 1991). As such, there does not appear to be a consensus as to whether impulsive suicidal behavior is a rare phenomenon or representative of the vast majority of attempts. As we argue in greater detail below, we believe the actual proportion of attempts that can accurately be described as impulsive to be at or very close to 0%. One explanation for this large discrepancy is likely the inconsistent operationalization of the time frame during which an individual must report having thoughts about attempting suicide. In some studies, participants are asked if they contemplated their attempt for longer than 15 min prior to attempting (e.g., Hawton, Kingsbury, Steinhardt, James, & Fagg, 1999). In others, the time frame ranges from “none; Downloaded from psr.sagepub.com at Remen University of China on September 6, 2015
372 Personality and Social Psychology Review 18(4) Table 2.Results From Studies Examining Impulsivity of Attempts rL2o00 8 L(200 anley (2010 vell et al (2002 and Burgi d Pass (201 tr0od60 591 tal.(2007 er of SIS Getlao090 ed inte ardt.James.and 833mppe704 Sheppard (2001) 0 gepon d Lamis (2008 O:CIDI .017ta n( ont ofa He.and li (2002) had in ent atte B 114 attempters 40 二 n,and v ar eta 298 260 mpulsive;SIS has been utlized using I item on).2 iton ns (ako 0
372 Personality and Social Psychology Review 18(4) Table 2. Results From Studies Examining Impulsivity of Attempts. Authors Measure of impulsivity Attempt sample % Impulsive Baca-Garcia et al. (2001) 2-item SIS 478 attempters 55.0 Baca-Garcia et al. (2005) 8-item SIS 242 attempters 76.0 Bagge, Glenn, and Lee (2013) 2-item SIS 110 attempters 46.0 Brown, Overholser, Spirito, and Fritz (1991) 2-item SIS 86 adolescent attempters 66.3 Chen et al. (2007) 8-item SIS 148 suicide decedents — Chesin, Jeglic, and Stanley (2010) 8-item SIS 40 BPD attempters — Conner et al. (2005) 7-item SIS 505 suicide decedents 32.0 Conner et al. (2006) Unpublished interview 673 attempters 51.0 Conner et al. (2007) 7-item SIS 117 depressed attempters aged 50+ — Conwell et al. (2002) Presence of loaded and/or unlocked guns in home 50 suicide decedents aged 50+ — de Leo, Cerin, Spathonis, and Burgis (2005) Method unspecified 399 attempters — Deisenhammer et al. (2009) Unnamed number of SIS items 82 attempters 47.6 Dombrovski et al. (2011) 7-item SIS 29 depressed attempters aged 60+ — Fazaa and Page (2011) 2-item SIS 96 undergraduate attempters — Giegling, Hartmann, Moller, and Rujescu (2006) Unnamed number of SIS items 203 attempters 59.1 Giegling et al. (2007) Unnamed number of SIS items 167 attempters + 92 decedents 61.0 Giegling et al. (2008) Unnamed number of SIS items 144 attempters 60.5 Giegling et al. (2009) Unnamed number of SIS items 111 attempters 58.6 Hall, Platt, and Hall (1999) Unstructured interview 100 “severe” attempters — Hawton, Kingsbury, Steinhardt, James, and Fagg (1999) 1 item SIS 45 adolescents hospitalized for intentional overdose 83.3 multiple attempters; 70.4 first time attempters Houston, Hawton, and Sheppard (2001) Inquest notes 27 suicide decedents 13.0 Huan et al. (2004) 2-item SIS 100 attempters 26.0 Jeon et al. (2010) Unpublished interview 208 attempters 36.0 Langhinrichsen-Rohling and Lamis (2008) “Suicide interview” 39 youth attempters 83.0 Mann and Malone (1997) 8-item SIS 22 depressed attempters — Mann et al. (1992) “First part” of SIS 53 attempters 66.7 Mann et al. (1996) 8-item SIS 49 attempters — Miranda et al. (2008) Adolescent suicide interview 79 attempters — Nakagawa et al. (2009) 8-item SIS 151 depressed attempters — Nock et al. (2008) WHO: CIDI 5,017 attempters — O’Donnell, Farmer, and Catalan (1996) Unnamed number of SIS items; proximity to home 20 attempters who had jumped in front of a train — Pearson, Phillips, He, and Ji (2002) Unpublished interview 147 female attempters — Raja and Azzoni (2004) Unpublished questionnaire 80 attempters 48.8 Razin et al. (1991) Unstructured interview 33 female adolescent attempters 97.0 Serretti et al. (2007) Unnamed number of SIS items 167 attempters 61.0 Simon et al. (2001) Unpublished interview 153 “nearly lethal” attempters 24.0 Soloff, Lynch, Kelly, Malone, and Mann (2000) 8-item SIS 92 attempters — Spokas, Wenzel, Brown, and Beck (2012) 1-item SIS 143 attempters 43.3 Stanley, Gameroff, Michalsen, and Mann (2001) Unnamed number of SIS items 53 attempters — Suominen, Isometsa, Henriksson, Ostamo, and Lonnqvist (1997) 2-item SIS 114 attempters 44.0 Verkes et al. (1998) 8-item SIS 144 attempters — Westheide et al. (2008) 8-item SIS 29 depressed attempters — Weyrauch, Roy-Byrne, Katon, and Wilson (2001) 3-item SIS 99 attempters — Williams, Davidson, and Montgomery (1980) Unpublished interview 350 attempters 40.4 Witte et al. (2008) Unpublished interview 5,979 attempters 20.0 Wojnar et al. (2008) and Wojnar et al. (2009) Unpublished interview 154 alcohol dependent attempters 62.0 Wong and Phillips (2009) Unpublished interview 353 female attempters — Wyder and de Leo (2007) Unpublished interview 112 attempters 26.0 Note. — = Author(s) did not dichotomize suicide attempts as impulsive/non-impulsive; SIS has been utilized using 1 item (premeditation), 2 items (also includes active preparation), 3 items (also includes suicide note), 7 items (also includes, isolation, timing, precautions against discovery, final acts in anticipation of death), and 8 items (also includes discussions of thoughts/plans with others). SIS = Suicide Intent Scale; BPD = borderline personality disorder; WHO: CIDI = World Health Organization Composite International Diagnostic Interview. Downloaded from psr.sagepub.com at Remen University of China on September 6, 2015