and Prevention (AISRAP), Brisbane, Australia, 4University of Tartu, Tartu, Estonia, ... Keywords: suicide attempt, Pierce Suicidal Intent Scale, components of ...
M. Sisask et al.: Attempted Crisis Suicide ©2009; 2009and Vol. Hogrefe Suicidal 30(3):136–143 Publishing Intent
Research Trends
Severity of Attempted Suicide as Measured by the Pierce Suicidal Intent Scale Merike Sisask1,2, Kairi Kõlves1,3, and Airi Värnik1,2,4,5 1
Estonian-Swedish Mental Health and Suicidology Institute, Estonian Centre of Behavioral and Health Sciences, Tallinn, Estonia, 2Tallinn University, Tallinn, Estonia, 3Australian Institute for Suicide Research and Prevention (AISRAP), Brisbane, Australia, 4University of Tartu, Tartu, Estonia, 5National Prevention of Suicide and Mental Ill-Health (NASP) at Karolinska Institute and Stockholm County Council’s Centre for Suicide Research and Prevention, WHO Lead Collaborating Centre of Mental Health Problems and Suicide Across Europe, Stockholm, Sweden Abstract. Background: Suicidal intent is an essential feature of suicidal behavior. Previous research has been controversial and the need for further evidence has been pointed out. Aims: The aim of the present study was to characterize the severity of attempted suicide by extracting components of suicidal intent and analyzing levels of suicidal intent by gender, age, and variables indicating the severity of attempted suicide. Methods: Data on suicide attempters (N = 469) were collected in Estonia using WHO SUPRE-MISS methodology. To measure suicidal intent, a revised version of the Pierce Suicidal Intent Scale (PSIS) was used. Results: The level of suicidal intent was not gender-dependent, but rose with age. Males and females were also similar in terms of discrete components. Classified in age groups, their unequivocally expressed “wish to die” was similar, but equivocal communication (components termed “arrangements” and “circumstances”) increased with age. Middle-aged groups scored higher for the “alcohol/drugs” component. Psychiatric diagnosis, method of attempting suicide, and duration of hospitalization were linked to suicidal intent, but danger to life as assessed by interviewers was not. Conclusions: In suicide-risk assessment, results from a Suicidal Intent Scale contribute to clinical observation and add valuable information about a suicidal person’s real intention. Keywords: suicide attempt, Pierce Suicidal Intent Scale, components of suicidal intent, gender and age differences
Introduction Suicidal intent is an essential component of any definition of suicide and suicidal behavior. This is primarily because it permits a distinction to be drawn between accidental and suicidal behavior (Andriessen, 2006). Suicidal intent has been defined as the seriousness or intensity of a person’s wish to terminate his or her life (Beck, Schuyler, & Herman, 1974). The term level of suicidal intent is used to describe the intensity of a death wish (Hjelmeland & Hawton, 2004). The development of suicidal behavior has been characterized by the model of suicidal process, and suicidality has been described as a continuum from the lowest (weariness of life, suicidal ideation) to the highest (serious suicide attempt and completed suicide) level of suicidality (Maris, Berman, Silverman, & Bongar, 2000; Wasserman, 2001). Suicidal intent evolves during the suicidal process and levels of suicidal intent at different stages of the suicidal proCrisis 2009; Vol. 30(3):136–143 DOI 10.1027/0227-5910.30.3.136
cess may vary. Suicidal intent consists in a consciously expressed wish to be dead, but there are also nonsuicidal conscious or unconscious purposes, such as trying to manipulate others or escape from an intolerable situation (Andriessen, 2006; Hjelmeland, 1995; Hjelmeland & Hawton, 2004; Hjelmeland & Knizek, 1999; Michel, Valach, & Waeber, 1994). Moreover, suicidal behavior has clear verbal communication aspects, but nonverbal suicidal communication also expresses suicidal intent, one example being the particular way in which a suicidal act is carried out, especially in the presence of others (Lester, 2001; Wasserman, 2001). Psychometric scales are available to measure levels and various aspects of suicidal intent. One of the best-known scales, the Beck Suicide Intent Scale (BSIS), is not a suicide-risk scale as such, but rather a scale designed for use in research studies to classify suicide attempters (Bech, Raabaek Olsen, & Nimeus, 2001; Beck, Kovacs, & Weissman, 1979; Beck et al., 1974). A comparable scale, the © 2009 Hogrefe Publishing
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Table 1. Description of suicide attempters by gender and by age groups Males Age group 15–24
N
Females %
60
N
37.3
118
Total %
N
38.3
178
% 38.0
25–34
50
31.1
64
20.8
114
24.3
35–44
26
16.1
57
18.5
83
17.7
45–54
18
11.2
44
14.3
62
13.2
7
4.3
25
8.1
32
6.8
161
100.0
308
100.0
469
100.0
55+ Total
Pierce Suicidal Intent Scale (PSIS), was devised to measure the severity of suicidal intent among suicide attempters (Pierce, 1977). Pierce’s intention was to design and test a more objective scale for measuring suicidal intent than the BSIS, but the outcome was merely a modification. Although some aspects and meanings of suicidal intent have been studied, the results of various studies have been controversial and the need for further evidence on this issue, focusing particularly on nonfatal suicidal behavior and gender-age differences, has been pointed out (Andriessen, 2006; Hjelmeland & Hawton, 2004; Hjelmeland et al., 2000). The aim of the present study was to characterize the severity of attempted suicide by extracting the components of suicidal intent and analyzing levels of suicidal intent by gender, age, and variables indicating the severity of attempted suicide.
Material and Methods In 2000 the World Health Organization (WHO) launched the worldwide intervention study on suicidal behavior SUPRE-MISS (Suicide Prevention – Multisite Intervention Study on Suicidal Behaviors). Its main objective was to reduce the mortality and morbidity associated with suicidal behavior. The study was conducted on five continents, and one of the participating centers was Estonia (Tallinn). The methodology of SUPRE-MISS was elaborated by a WHO expert group and adapted to local conditions (Fleischmann et al., 2005; WHO, 2002). In Estonia, the study was conducted by the EstonianSwedish Mental Health and Suicidology Institute (ERSI). The Tallinn Medical Research Ethics Committee approved the Estonian study. All suicide attempters identified by medical staff in the emergency-care settings of the Northern Estonian Regional Hospital between December 2001 and January 2004 were invited to participate in the study. Those who agreed filled in a consent form, and structured in-depth interviews were conducted as soon as their medical condition had stabilized. The interviewers were clinically experienced specialists (psychiatrists and psychologists). The research subjects were 469 suicide attempters, 161 © 2009 Hogrefe Publishing
(34.3%) males and 308 (65.7%) females. The suicide attempters’ mean age was 32.6 years (SD ± 14.1), 31.5 (SD ± 11.8) for males and 33.2 (SD ± 15.1) for females. The difference in mean age between males and females was statistically nonsignificant, t = –1.2, p = .222. The suicide attempters enrolled constituted 53% of all suicide attempters seen at the emergency department during the study period. Among the suicide attempters enrolled, females were slightly overrepresented, χ² = 9.7, df = 1, p = .002. The difference in mean ages of the enrolled and nonenrolled suicide-attempter groups was not statistically significant, t = 0.7, p = .480. For analysis, suicide attempters were divided into five age groups (Table 1). For measuring suicidal intent, a revised version of the original Pierce Suicidal Intent Scale (PSIS) was used (Pierce, 1977; WHO, 2002). The scale consisted of 12 questions and the possible total score ranged from 0 to 24: the higher the score, the more severe the suicide attempt. The internal consistency of PSIS was good (Cronbach’s α = 0.77). Three research subjects with three or more missing PSIS responses were excluded from the final analysis. Two subjects with two missing responses and 16 subjects with one missing response were included in the analysis. To characterize the severity of attempted suicide, the following variables were chosen for analysis: psychiatric disorders, method of attempting suicide, duration of hospitalization after the suicide attempt, and interviewers’ assessment regarding the physical consequences of and danger to life entailed by the suicide attempt. Interviewers coded psychiatric disorders and method of attempting suicide according to the ICD-10. Psychiatric diagnoses of 54 suicide attempters interviewed by psychologists were missing. The group with missing diagnoses did not differ from the other subjects in terms of gender, χ² = 2.8, df = 1, p = .092, or mean age, t = 0.4, p = .698. Psychiatric diagnoses and method of attempting suicide were divided into categories for analysis. Psychiatric diagnoses were categorized as: None, affective disorders (F30–F39), acute stress reaction (F43.0), schizophrenia (F20–F29), or other. Method of attempting suicide was categorized as: poisoning (X60– X69), sharp objects (X78), and other (hard) methods. Duration of hospitalization after the suicide attempt was calculated according to the date and time of admission and discharge from the hospital. For analysis, the following time periods were Crisis 2009; Vol. 30(3):136–143
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Table 2. Factor analysis (principal component analysis with varimax rotation) of Pierce Suicidal Intent Scale (PSIS) filled in after suicide attempt Components (factors)
Variables
Wish to die (F1)
Stated intent
.886
.087
Factor loadings .160
.053
Purpose of the act
.876
.073
.112
–.002 .060
Predictable outcome Arrangements (F2)
.762
.267
.251
–.045
.756
.057
.042
Preparations
.167
.649
.231
–.123
Suicide note
.145
.694
.110
.152
Communication
.268
.519
–.320
.136
Isolation
.065
.129
.740
.165
Timing
.264
.052
.714
–.241
Precautions against rescue
.156
.409
.461
–.290
Acting to gain help
.200
.021
.613
.289
Relation with alcohol and drugs
.075
.105
.095
.884
Final acts in anticipation
Circumstances (F3)
Alcohol/drugs (F4)
Table 3. Mean scores on Pierce Suicidal Intent Scale (PSIS) and its components (factors), suicide attempters, by gender and age group Total (SD)
Gender Males (SD)
Females t-test (SD)
p value
Age Group 15–24 (SD)
25–34 (SD)
35–44 (SD)
45–54 (SD)
55+ (SD)
F
Total score of PSIS
8.2 (± 4.4)
8.0 (± 4.5)
8.4 (± 4.4)
–0.8
.402
7.5 (± 4.2)
8.0 (± 4.3)
8.3 (± 4.3)
10.0 (± 4.7)
9.7 (± 4.7)
4.7
.001
Wish to die (F1)
1.1 (± 1.6)
1.1 (± 1.6)
1.1 (± 1.5)
–0.2
.853
1.0 (± 1.5)
1.1 (± 1.5)
1.0 (± 1.6)
1.3 (± 1.8)
1.2 (± 1.5)
0.6
.701
Arrangements (F2)
3.5 (± 2.0)
3.4 (± 2.0)
3.5 (± 2.1)
–0.5
.631
3.2 (± 1.9)
3.3 (± 2.0)
3.5 (± 2.1)
4.0 (± 2.2)
4.2 (± 2.2)
2.9
.021
Circumstances (F3)
3.4 (± 2.1)
3.2 (± 2.0)
3.5 (± 2.1)
–1.5
.145
3.0 (± 2.1)
3.2 (± 1.9)
3.4 (± 2.0)
4.2 (± 1.9)
4.2 (± 2.0)
5.5
