Study maps risk and protective factors associated with suicidal behavior

The study involved 2,788 participants with impulse control disorder treated at the University of São Paulo’s general and teaching hospital in Brazil. According to the authors, in these cases, health workers should assess not only explicit suicide attempts but also other kinds of life-threatening behavior.

By Thais Szegö  |  Agência FAPESP – Impulse control disorder (ICD) is a class of psychiatric conditions characterized by potentially inadequate or harmful behavior that reflects a failure to resist urges or desires with potentially negative consequences. 

A study conducted at the Psychiatry Institute of Hospital das Clínicas (HC), the hospital complex run by the University of São Paulo’s Medical School (FM-USP) in São Paulo city, Brazil, shows that people with ICD are more likely to exhibit suicidal behavior.

The study involved 2,788 subjects treated at the HC’s Integrated Outpatient Clinic for Impulse Control Disorder (AMITI) between 1998 and 2019. They were submitted to psychiatric interviews (both structured, comprising set questions for all interviewees, and semi-structured, permitting more flexibility).

Analysis of the data thus collected was based on statistical methods designed to identify risk and protective factors associated with overt and covert suicidal behavior. Suicidal behavior was considered overt if it involved attempted suicide, and covert if there was no explicit intent but the person was objectively at risk of suicide. The researchers also investigated the links between overt and covert suicidal behavior with the aim of finding out whether they coexist and share risk factors. 

“We decided to research these issues because of the need for a better understanding of suicidal behavior in patients with ICD, a group that hasn’t been studied very much but exhibits high rates of suicidality,” said psychiatrist Rodolfo Furlan Damiano, who co-led the study.

“Furthermore, the existing literature focuses on overt suicidal behavior, and few studies are concerned with covert behavior.” 

Suicidality is defined by the American Psychological Association (APA) as “the risk of suicide, usually indicated by suicidal ideation or intent, especially as evident in the presence of a well-elaborated suicidal plan”. 

An article on the study, which was supported by FAPESP, is published in the International Journal of Mental Health and Addiction. 

Specific risk factors

The findings showed that people with ICD are more prone to overt and covert suicidal behavior, pointed to correlations between the two kinds of behavior, and identified shared as well as specific risk factors for each kind.

“ICD patients who exhibited covert suicidal behavior were 3.5 times more likely to report suicide attempts than non-ICD patients,” Damiano said. The risk factors shared by both kinds of suicidal behavior were depressive symptoms, indirect hostility (passive aggression), and low self-direction, a condition that reflects lack of autonomy and self-control, leading to difficulty in addressing challenges and regulating emotions.

The specific risk factors for overt suicidal behavior were being female (compatible with the literature in suggesting that women attempt suicide more often, although men more often succeed), self-transcendence (patients who feel part of something greater than themselves and have spiritual or philosophical inclinations), non-suicidal self-harm (such as cutting or burning), and a history of psychiatric hospitalization to treat conditions such as depression or bipolar disorder.

The specific risk factors for covert suicidal behavior were being young (which may be linked to an inability to assess risks and the impulsiveness typical of this age group), having several children (possibly due to stress and the burden of parental responsibilities in ICD patients), tobacco use or a history of treatment for tobacco dependency (suggesting that substance abuse may be linked to self-destructive behavior), and intermittent explosive disorder (repeated bouts of anger or violent behavior out of proportion to the situation, reflecting the link between impulsiveness and self-destructive behavior). 

Finally, the protective factors were participation in religious communities – considered important to protect against covert suicidal behavior, in line with other studies that point to a positive role for religion in mitigating the risk of suicide – and a diagnosis of skin-picking disorder.

“Interestingly, patients with skin-picking disorder were less likely to engage in covert suicidal behavior, suggesting that this may be a less lethal way of expressing impulsiveness than other disorders,” Damiano said.

According to the researchers, the study underscores the importance of diagnosing both covert and overt suicidal behavior, and of considering individual, social and clinical factors when assessing suicidality in patients with ICD. The findings can be applied immediately in clinical practice, in their view.

“Mental health professionals should take into account not only explicit suicide attempts but also covert behavior that heightens the risk of death, such as dangerous driving or exposure to risky situations,” Damiano said, adding that this kind of behavior is often underestimated and that mental health workers can intervene more effectively to prevent attempted suicide if they identify it. “Moreover, the risk factors highlighted in the study should be investigated in all cases of suicide risk for patients with elevated impulsivity.”

Clinical factors and personality should be considered when diagnosing ICD, according to Damiano, for whom the study shows that traits such as elevated indirect hostility and low self-direction correlate closely with suicidal behavior. Furthermore, the data suggests that factors linked to social vulnerability, such as low educational attainment and lack of family support, also play a significant role in suicidality, pointing to a need for interventions focusing on social support.

Suicide is recognized by the World Health Organization (WHO) as a global public health problem. Some 700,000 people are estimated to die by suicide annually – 80% in low- and middle-income countries. In Brazil, the total was 15,000 in 2021 (one every 34 minutes), and suicide was the third most frequent cause of death in the 15-29 age group.

The article “Unveiling overt and covert suicidal behavior in a sample of Brazilian impulsive outpatients” is at: link.springer.com/article/10.1007/s11469-024-01388-9.