Suicidal ideation and temperament: An investigation among college ...

Journal of Affective Disorders 141 (2012) 399–405

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Suicidal ideation and temperament: An investigation among college students K. Skala a, N.D. Kapusta b,⁎, G. Schlaff c, M. Unseld d, A. Erfurth e, O.M. Lesch c, H. Walter c, K.K. Akiskal f, H.S. Akiskal f a

Medical University of Vienna, Department of Child- and Adolescent Psychiatry, Waehringer Guertel 18–20, 1090 Vienna, Austria Medical University of Vienna, Department of Psychoanalysis and Psychotherapy, Waehringer Guertel 18–20, 1090 Vienna, Austria c Medical University of Vienna, Department of Psychiatry, Waehringer Guertel 18–20, 1090 Vienna, Austria d Medical University of Vienna, Department of Internal Medicine I, Waehringer Guertel 18–20, 1090 Vienna, Austria e Otto Wagner Psychiatric Hospital of Vienna, Head of Department VI, Waehringer Guertel 18–20, 1090 Vienna, Austria f University of California at San Diego, International Mood Center, University of California at San Diego, La Jolla, CA, USA b

a r t i c l e

i n f o

Article history: Received 22 December 2011 Received in revised form 6 February 2012 Accepted 3 March 2012 Available online 2 April 2012 Keywords: Suicidal iIdeation Young Adults Public Health Temperament

a b s t r a c t Background: Suicide is a major health problem accounting for up to 1.5 percent of all deaths worldwide and represents one of the most common causes of death in adolescents and young adults. A number of studies has been performed to establish risk factors for suicide in patients with psychiatric disorders including temperamental features. This study set out to assess the relationship between suicidal ideation and temperament in young adults. Methods: A cross-sectional sample of healthy college students (n = 1381) was examined using a self-rating questionnaire. Suicidal ideation, social background, educational status, substance abuse, and affective temperament according to TEMPS-M were assessed. Predictors of lifetime suicidal ideation were examined in multivariate logistic regression analyses. Results: Suicidal ideation was reported by 12.5% of all subjects at some point in their life and was higher in nicotine dependents, youth with alcohol related problems and users of illicit substances as well as in youth with lower educational status. Lifetime suicidal ideation was associated with the anxious, depressive and cyclothymic temperament in both sexes and the irritable temperament in males. These results remained significant after adjustment for smoking status, frequency of alcohol consumption, drug experience and educational status in a multivariate logistic regression analysis. Limitations: The use of self-rating instruments always reduces objectivity and introduces the possibility of misreporting. Conclusions: Considering the fact that many subjects completing suicide have never been diagnosed with mental disorders it might be reasonable to include an investigation of temperament in screenings for risk of suicide. This might be especially useful for health care professionals without mental health care background. © 2012 Elsevier B.V. All rights reserved.

1. Introduction Suicide is a tremendous health problem accounting for up to 1,5 percent of all deaths worldwide (WHO, 2007). Many countries have established different suicide prevention programmes in order to decrease the number of persons dying ⁎ Corresponding author. Tel.: + 43 1404003071. E-mail address: [email protected] (N.D. Kapusta). 0165-0327/$ – see front matter © 2012 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2012.03.010

by their own hands and research on factors contributing to suicidal behaviour has been extensive for many decades. Although public health care has taken this problem seriously at least in most developed countries suicide still remains the 14th leading cause of death (WHO, 2007). Lifetime suicidal ideation can be expected in as many as 13,5% of the general population (Kessler et al, 1999). Regarding the life span, suicidal behaviour has been reported in children as young as 4 years (Bridge et al., 2006; Tishler et

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al., 2007), although on the other hand children younger than 10 years of age not believed to be capable to understand the finality of death. Children in this age group therefore are not considered to be able to perform suicide as an act of deliberately ending one´s life (Pfeffer, 1997). An increase in suicidality is observed in adolescents and young adults with a peak at 16 years, the risk remaining elevated until the midtwenties (Kessler et al., 1999). After a decline in middle adulthood suicide rates are rising again in persons aged 60 years and older. Although suicide rates have been and still are highest in elderly people an increase has been observed in younger people in some countries (Wasserman et al., 2005). Suicidal behaviour among adolescents seems to be similar in different countries as shown by an international comparison of suicide attempts (Plener et al., 2009), suicidal ideation as such have been found to be very common in youth and occur in up to 44% of high school students (Dervic et al., 2007; Liu et al., 2005; Payci et al., 2005). At large, apart from a history of mental illness and a family history of mental illness or suicide, a personal history of sexual, physical or verbal abuse, social isolation, low self esteem, confusion about sexual orientation and a history of recent loss (ranging from parent's divorce to the experience of suicide of someone close) are considered the most important risk factors for suicidal behaviour in youth. In college students, alienation, the new and unfamiliar environment, academic and social pressure and feelings of failure or decreased performance are reasons attributed to the appearance of suicidal ideations (Suicide Prevention Resource Centre, 2004). Adolescence and early adulthood can thus be considered times of great risk for the development of suicidality especially during psychosocial stress (Bolger et al., 1989; Kessler et al., 1999). In Vienna, Austria, where we performed our study, an investigation of completed suicide in children and adolescents between 1946 and 2002 showed a mean suicide rate of 6.2 per 100.000 (Dervic et al, 2006b) with as much as 1.4 per 100.000 suicides in the group of 10 to 14-year-olds (Dervic et al., 2006a). A study investigating suicidal behaviour of Viennese high school students found suicidal ideation at some point in their lives in as many as 37.9% of all subjects investigated, a value matching data of other studies performed on suicidality in youth (Dervic et al., 2007; Liu et al., 2005; Payci et al., 2005). This study depicted female gender, cigarette smoking, substance abuse and a broken home situation as risk factors for the development of suicidal ideation (Dervic et al., 2007). Personality is commonly considered as consisting of a particular combination of emotional, attitudinal, and behavioral response pattern of an individual, and a person's temperament is considered an enduring aspect of personality innate rather than learned (Kagan, 1994). Based on the temperamental traits (manic, depressive, cyclothymic and irritable) first described by Kraepelin (Kreapelin, 1909–1915) Akiskal et al. developed the dimensions of hyperthymic, depressive, cyclothymic, irritable and generalised anxious temperament (Akiskal, 1996; Akiskal and Akiskal, 1991; Akiskal et al., 1998). The operational instrument developed to determine the different traits of temperament is TEMPS (Temperament Evaluation of Memphis, Pisa, Paris and San Diego, CA).

Furthermore, a self- rating questionnaire (TEMPS-A) and a brief version (brief TEMPS-M) have been developed (Akiskal et al., 1998; Akiskal et al., 2005; Erfurth et al., 2005). Research on the contribution of temperament on the development and course of psychiatric diseases is extensive (Karam et al., 2010; Perugi et al., 2010; Rihmer et al., 2010; Tamás et al., 2007; Tondo et al., 2007) and the influence of features of temperament on suicidal behaviour has also become a matter of interest to researchers (Akiskal et al., 2003; Azorin et al., 2010; Kochman et al., 2005; Serafini et al., 2011; Vázquez et al., 2010). Those studies however also focused on suicidality in persons diagnosed with mental illness. They were describing cyclothymic temperament as a risk factor for suicidality in subjects with mental illness (Akiskal et al., 2003; Azorin et al., 2010; Kochman et al., 2005) whereas hyperthymic temperament has been identified as a possible protective factor (Pompili et al., 2008; Vázquez et al., 2010). Impulsivity, harm avoidance and self- directedness as temperament dimensions defined by Cloninger´s unified biosocial theory of personality (Cloninger, 1986) have also been described to be associated with self-aggressive tendencies (Giegling et al., 2009). Finally, impulsivity in connection with suicidal behaviour is considered more prevalent in adolescents and young adults than in older subjects (McGirr et al., 2008). In examining whether certain traits of temperament are associated with suicidal behaviour in a non-clinical sample of adolescents and young adults, we investigate the contribution of features of temperament to suicidality. In accordance with prior findings in patients with psychiatric disordes (Akiskal et al., 2003; Azorin et al., 2010; Kochman et al., 2005) we expected cyclothymic temperament to be a predictor of suicidal ideation. To evaluate whether the temperamental traits are independent contributors to suicidal ideation we adjust the results in a multivariate model for other significant contributing factors. We then discuss the results in the context of previous results.

2. Methods 2.1. Overview, sample, procedure We asked inhabitants of 20 Viennese residential homes for students and youth to complete an anonymous self-rating questionnaire. 3000 questionnaires were handed out to the residents at the move-in after the holiday at the beginning of the academic year in October 2009. The residential homes for students are operated by an Austrian non-profit and nongovernmental organisation. A total of 1.381 questionnaires were returned into the prepared closed boxes in each residential home at the end of the study in November 2009. Subjects were females (59,8%) and males (38,4%) with an age range of 18 to 25 years. The questionnaires were anonymous and the study was approved by the Ethics Committee at the Medical University of Vienna.

2.2. Measures Sociodemographic characteristics are presented in Table 1.

K. Skala et al. / Journal of Affective Disorders 141 (2012) 399–405 Table 1 Sample characteristics (N = 1381).

Sex Females Males Age ≤ 18 19-20 21-25 ≥ 26 Educational status No high-school diploma High-school diploma University diploma Daily hours spent at PC ≤1 2-3 4-5 6-7 ≥8 Financial status of family Excellent Good Sufficient Poor Lifetime suicidal ideation Ever Never Smoking Non-smoker Smoker HSI score 0-3 04.Jun Alcohol consumption At least once a week Less than once a week CAGE 0 1 ≥2 Drug experience No Yes

n

%

809 520

58,6 37,7

134 424 594 198

9,7 30,7 43,0 14,3

88 905 318

6,4 65,5 23,0

296 592 293 108 50

21,4 42,9 21,2 7,8 3,6

249 555 469 71

18,0 40,2 34,0 5,1

172 1153

1,7 83,5

1084 297

78,5 21,5

278 19

20,1 1,3

803 429

58,1 31,1

744 336 301

53,9 24,3 21,8

765 421

55,4 30,5

2.2.1. Temperament To assess the temperament of the subjects, the brief TEMPS‐M, a short version oft the TEMPS‐A, was used. TEMPS‐A (Temperament Evaluation of Memphis, Pisa, Paris and San Diego‐ Auto questionnaire) was developed by Akiskal et al. (2005) and the brief 35-item TEMPS‐M version with a five‐point anchored likert‐type scale had previously been validated in a German sample of students (Erfurth et al., 2005). 2.2.2. Suicidal ideation Suicidal ideation was assessed by the question “Have you ever considered to commit suicide?” with the response options: (0) never, (1) at some earlier point in life, (2) last month, (3) last week. A positive answer (being any answer from 1 to 3) was considered as lifetime suicidal ideation in further analyses. 2.2.3. Alcohol use The frequency of alcohol consumption was reported according to the question: “Do you drink alcohol?” (0) I

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do not drink, (1) less than once a week, (2) once a week, (3) several times a week, (4) every day. In addition, the CAGE questionnaire (Cutting down, Annoyance by criticism, Guilty feeling and Eye‐openers) was used to rate alcohol related behaviour. The CAGE questionnaire (Ewing, 1984) has good sensitivity and specificity for alcohol dependence (Bradley et al., 2001). Both alcohol consumption measures were correlated with r = 0.41, p b 0.001. 2.2.4. Nicotine use Smoking was assessed with the question: “Are you smoking?” (“yes” or “no”) followed by the Heavy Smoking Index (HSI) which consists of two questions: “How many cigarettes do you smoke per day?” (“non-smoker,” “10 or less,” “11–20,” “21–30,” and “31 or more”) and “When do you smoke your first cigarette in the morning?” (“within 5 minutes,” “6–30 minutes,” “31–60 minutes,” and “after more than 60 minutes”). Both questions were scored between 0 and 3 and a HSI-sum score ranging between 0 and 6 was built. The HSI has been previously validated by plasma and saliva cotinine, as well as carbon monoxide levels (Heatherton et al., 1989; 1991; Kapusta et al., 2010). 2.2.5. Illicit drug use To assess experiences with illicit drugs, the subjects were asked “Have you ever consumed one of the following drugs?” The response options for each substance (THC, Benzodiazepines, Cocaine, Opiates, Ecstasy, other drugs) were: (0) never, (1) once, (2) several times (3) regularly. Based on these reports, a dummy variable “drug experience” was build, representing at least one drug experience during lifetime. 2.2.5.1. Statistics. Due to incomplete data in some parts of the questionnaire, percentages in Table 1 do not sum up to 100% (n= 1381). Therefore subsequent analyses were based on slightly different cell counts. Differences in characteristics between lifetime suicidal ideators and non-ideators were assessed by T-tests and Mann–Whitney-U tests for nonparametric variables. In a second step, significant variables were entered into the multivariate logistic regression analysis to examine predictors of suicidal ideation. P-values at the level b .05 were considered significant. The data were analysed with the IBM SPSS Statistics 19.0 software. 3. Results The sample characteristics are shown in Table 1. Lifetime suicidal ideation was present in 12.5% of the total sample. There was no gender difference as to the prevalence of suicidal ideation with 12.3% of males and 12.9% of females reporting suicidal thoughts at some point in their life (χ² = .073, p = .787). 3.1. Predictors of lifetime suicidal ideation Among socioeconomic variables, lifetime suicidal ideation was only associated with the educational status (χ² = 10.730, p = .005). Students with lowest educational status, namely without high-school diploma, reported 23.9%, persons who completed high-school diploma 11.6% and persons with a university degree 12.3% of lifetime suicidal ideation.

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Suicidal ideation was not associated with age (χ² = 3.841, p = .279), the average time per day spent at a personal computer (χ² = 3.696, p = .449) nor with the self-rated financial situation of the family (χ² = 6.748, p = .080). Concerning substance use, smokers showed a higher prevalence of lifetime suicidal ideation than non-smokers (19.5% vs. 10.9%, χ² = 15.589, p b .001) and the frequency of alcohol consumption (χ² = 6.503, p = .039) as well as the CAGE score (Z = −2.56; p = .010) were associated with lifetime suicidal ideation. Similarly, self reported lifetime experiences with illicit drugs were associated with a higher prevalence of lifetime suicidal ideation (16.6% vs. 11.0%, χ² = 7.43, p = .006). 3.2. Associations of temperament subscales and suicidal ideation Table 2 shows the associations of each separate temperament subscale with lifetime suicidal ideation. The hyperthymic temperament scores significantly higher in persons who recall no suicidal ideation during lifetime, while all other temperament subscales (depressive, cyclothymic, irritable and anxious) are significantly higher in students reporting suicidal ideation at some point during their life. The results were confirmed in logistic regression analysis, with OddsRatios of the temperament scales for the total sample reported in Table 3. In separate analyses for sex, the protective effect of the hyperthymic temperament was nominally significant. To adjust for the influence of multiple predictors on suicide ideation which were associated in our study, all significant variables were entered simultaneously into a predictive model of suicidal ideation for each temperament (Table 3, adjusted model). In the adjusted model, the anxious temperament was most predictive in males with an increase of one point on the temperament scale corresponding to a 48% increase in risk for lifetime suicidal ideation. The depressive, cyclothymic and irritable temperament also remained predictive for suicidal ideation in males with a risk increase by 8-10% with an increment of 1 point on the scales. In females, the depressive, cyclothymic and anxious temperament remained predictors of lifetime suicidal ideation after adjustment for substance use and educational status, with a 1 point increase on the scales resulting in a risk increase of 6-13%. 4. Discussion Suicide is among the leading causes of death worldwide but the need for diagnosis and treatment of suicidal behaviour Table 2 Temperament as a predictor of lifetime suicidal ideation. Temperament

depressive cyclothymic hyperthymic irritable anxious

no suicidal ideation (n = 1145)

suicidal ideation (n = 172)

Mean

SD

Mean

SD

13.5 13.5 22.6 15.1 14.2

5.3 5.3 5.3 5.4 5.3

18.4 18.4 21.4 17.5 17.0

6.5 6.8 5.2 6.0 6.1

T

df

p

− 10.87 −10.805 2.935 −5.258 − 6.284

1314 1312 1317 1308 1309

b.0001 b.0001 0.0034 b.0001 b.0001

Table 3 Temperament as a predictor of lifetime suicidal ideation. Crude model

Total sample depressive cyclothymic hyperthymic irritable anxious Males (n = 520) depressive cyclothymic hyperthymic irritable anxious Females (n = 809) depressive cyclothymic hyperthymic irritable anxious

Adjusted model

a

OR

p

OR

p

1,138 1,135 0,956 1,075 1,089

b 0,001 b 0,001 0,004 b 0,001 b 0,001

1,122 1,111 0,963 1,056 1,083

b0,001 b0,001 0,026 0,001 b0,001

1,131 1,119 0,953 1,085 1,130

b 0,001 b 0,001 0,050 b 0,001 b 0,001

1,104 1,093 0,969 1,081 1,483

b0,001 b0,001 0,243 0,003 b0,001

1,147 1,151 0,960 1,069 1,082

0,000 0,000 0,050 b 0,001 b 0,001

1,134 1,125 0,962 1,037 1,064

b0,001 b0,001 0,085 0,082 0,003

a adjusted for smoking status, frequency of alcohol consumption, drug experience and educational status

is still unmet (Hawton and van Heeringen, 2009; Nock et al., 2008). Completed suicide, especially in young people is one of the most tragic events to be encountered by a person's environment. The question of whether or how such a deed could have been prevented arises but very often remains unanswered. While investigations on suicidal behaviour so far focused on persons with psychiatric disorders, the influence of temperamental features as an independent risk factor in a non-clinical sample has, to our knowledge, not been examined yet. In our study we interviewed 1381 students living in 20 different Viennese residential homes exploring a possible connection between suicidality and temperament traits. The prevalence of lifetime suicidal ideation in the total sample was reported among 12,5% but varied in dependence of educational status and was with 23.9% highest in the group of persons who had not completed or were still attending high-school. This result is lower in comparison with prior findings of an investigation performed in high school students in the same city (Dervic et al., 2007) and findings of other studies performed in youth in Europe showing rates of suicidality between 31% and 44% (Dervic et al., 2005; Gmitrowicz et al., 2003; Tomori et al., 2001). All investigations mentioned above were using selfadministered interviews completed anonymously so these differences cannot be explained by different levels of openness. One possible explanation is that subjects in our sample were older than in the above mentioned studies and probably approaching lower values which are usually found in adults (Kessler et al, 1999). This generally observable decline of lifetime suicidal ideation with age can probably be explained by a recall bias or a neglect of suicidal thoughts that might have occurred earlier in life. Although generally older than in previous studies, there was no significant difference in age between suicide-ideators and non-ideators within our sample, thus reducing the probability of a distortion of further group comparison results.


Concerning substance abuse we were not surprised to find an association between smoking, alcohol consumption and the consumption of illicit drugs with suicidal ideation as these findings are consistent with other studies depicting smoking and the consumption of alcohol and drugs as risk factors for the development of suicidal behaviour (Dervic et al., 2007; Yoshimasu et al., 2008). However, substance abuse might on one hand worsen the proneness to suicide ideation but could on the other hand select a cluster of subjects already prone to suicide. Neither the family's financial situation nor the hours spent at the computer every day had any influence on the occurrence of suicidal thoughts. The latter was a little startling as we expected heavy users to be more socially isolated and thus to be more prone to the development of suicidal ideation as recently shown in high-school students (Messias et al., 2001). However, the use of personal computers among university students might have different purposes and spending up to 3 hours per day in front of a computer as shown seems to have become common (over 60%) in everyday life. Similar to prior findings in a sample of depressive patients (Vázquez et al., 2010) we found a protective effect of the hyperthymic temperament in our non-clinical sample, which, however, was lost after adjustment for substance use and education. In contrary, the depressive, cyclothymic, irritable and anxious temperaments have been shown to be positively associated with lifetime suicidal ideation. There is sparse literature concerning the associations of temperament and suicidal ideation in healthy persons. Our study is the first to replicate previous associations of temperament with suicidal behaviour in clinical samples (Kochman et al., 2005; Rihmer et al., 2009) in a psychopathologically non-selected population. This underscores the validity of the concept of temperament in healthy individuals and at the same time highlights the double nature of temperament from normality to pathology as discussed before (Perugi et al., 2006). Psychiatric disorders are present at the time of death in up to 90% of individuals who completed suicide (Hawton et al., 1998; Harris and Barraclough 1994; 1997) and half of the 10% without any Axis I disorder have at least one subthreshold Axis I diagnosis (Balázs et al., 2000). Nevertheless, psychiatric disorders are often not recognised or taken seriously even though almost half of individuals who die by suicide have visited a family doctor within weeks before death (Pirkis and Burgess, 1998). Furthermore only 39% of people who had engaged in suicidal behaviour worldwide had received some form of treatment in the following year and in only 23% of them help was provided by mental healthcare (Bruffaerts et al., 2011). On the other hand, suicidal ideation is often found in subjects who do not fulfil the diagnosis of any psychiatric disorder (Eisenberg and Resnick, 2006; Fishbain et al., 2011; Goldney et al., 2009). Knowing that suicide is commonly preceded by adverse life events, especially interpersonal conflicts (Foster, 2011), the role of temperament in suicidal behaviour should be further investigated. Models like the diathesis-stress model are taking biological, psychological and social factors into account and consider the impact of stressful life events as being dependent on a person's attributes in this regard. A

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person could thus be regarded as rather stable or rather instable facing stressful life events or experiencing loss (Morley, 1983). Whether suicide might be considered an option in difficult times of life might be, amongst other factors, dependent on personality traits. In this sense, loading high on cyclothymic or depressive temperament scales and especially on the anxious temperament scale among men might represent an important marker of vulnerability to suicidality. 5. Conclusion Our findings of the association between temperamental traits and suicidal ideation in a sample of healthy students might help to understand suicidal behaviour in terms of a non-pathological continuum of vulnerability. Understanding temperament as a vulnerability marker and predictor of suicidal tendencies may be also important for suicide prevention efforts. The knowledge that suicidality can be evoked in healthy persons with specific temperamental traits could be integrated into suicidality screenings and into preventive interventions focussing on general education about suicidal precursors and in indicated prevention programmes. Further studies investigating temperament in conjunction with other comorbid factors in a larger and more representative sample of the general population would be desirable to replicate the findings. 6. Limitations The main limitation of this study is the use of self-rating instruments which reduce objectivity and introduce the possibility of misreporting. The sample consisting of students from Vienna cannot be considered as a representative sample of the general population. Subjects were, although they had no current or former history of psychiatric disorder not investigated for Axis I diagnoses. Also life time history of suicidality was only the history as being reported by the subjects and not investigated using a validated instrument for the measurement of suicidality. Role of funding source No funds have been raised for this project. Conﬂict of interest We declare we have no conflict of interest. Acknowledgement No acknowledgement is being made.

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