Research reportA qualitative investigation into the relationships between social factors and suicidal thoughts and acts experienced by people with a bipolar disorder diagnosis
Introduction
Suicide accounts for 1.5% of all mortality, making it the 14th leading cause of death worldwide (O׳Connor and Nock, 2014). An extensive body of research suggests that suicidal behaviour occurs as the result of a complex interaction between numerous cumulative factors (e.g., Dieserud et al., 2001, O׳Connor and Sheehy, 2001, Panagioti et al., 2013, Taylor et al., 2010, Wasserman et al., 2007). Therefore, a biopsychosocial conceptualisation of suicidal behaviour is utilised within many clinical settings (e.g., Hoffman, 2000; King & Merchant, 2008; O׳Connor and Nock, 2014, O׳Connor and Sheehy, 2000). The influential role of social or interpersonal factors in the development of suicidality (i.e., suicidal thoughts, feelings and behaviours) has been substantially documented within the research literature, in both clinical and non-clinical populations (e.g., Coker et al., 2002, Hawton et al., 2012, Hinduja and Patchin, 2010, Jakupcak et al., 2010). However, the role of such factors within pathways leading to suicidal behaviour is still not fully understood. Previous research focusing upon the role of social factors in suicidal ideation and behaviour has emphasised the impact of characteristics of family relationships, such as the perceived level of family support (e.g., Diamond et al., 2010, Hoagwood et al., 2010) and family conflict (e.g, Legleye et al., 2010, Xing et al., 2010). Characteristics of wider social networks have also been implicated in the formation of suicidal ideation, such as social isolation (e.g., Bearman and Moody, 2004) and peer integration amongst adolescents (e.g., Connor and Rueter, 2006).
Suicide is a cause of death in which psychological factors are directly involved, as the individual ultimately forms a decisive intention to end their own life (Johnson et al., 2008, O׳Connor and Nock, 2014). It is therefore necessary to consider the individual׳s psychological state and the influence of social factors upon their mental health or wellbeing and level of suicidality. There are four main contemporary psychological models of suicidality, each of which specifies a role for social factors in the development, maintenance and intensification of suicidal thoughts and behaviours. The Integrated Motivational-Volitional model of Suicidal Behaviour (O׳Connor, 2011) implicates social problem solving abilities as a key factor in a person׳s evolution from suicidal ideation to behaviour. The Cry of Pain model (Williams, 1997, Williams et al., 2005) asserts that perceptions of ‘no rescue’ are central to both triggering and worsening suicidal ideation and behaviour. Rescue factors can include social support, a lack of which can lead to feelings of entrapment and suicidal ideation as a means of escape from negative life circumstances (Williams et al., 2005). Joiner׳s (2005) Interpersonal Theory of Suicide hypothesises that a combination of the psychosocial factors of feeling burdensome and perceiving a low level of belongingness within social networks, produce a greater risk of suicidal ideation. Finally, the Schematic Appraisals Model of Suicide (Johnson et al., 2008) posits that negative appraisals of social factors, such as, perceptions of poor social support and social interactions, are involved in pathways leading to the development of suicidality
A mental health diagnosis is a strong predictor of suicidal behaviour and nine out of 10 people who end their life will have experienced clinically significant mental health problems (World Health Organisation, 2012). However, the low specificity of this predictor must be acknowledged, as the great majority of people who experience mental illness do not die by suicide. Individuals who experience bipolar disorder are at a heightened risk of suicide compared to the general population (Clements et al., 2013). There is also clear evidence that social factors, particularly the nature of the family environment, can play a key role in determining the clinical course of bipolar disorder. A prospective follow-up study of participants with a diagnosis of bipolar disorder demonstrated that a critical and hostile family atmosphere, known as high expressed emotion, significantly predicted the rate of relapse into acute mood episodes (Miklowitz et al., 1988). The presence of these family attitudes has been associated with more frequent relapses and worse symptomatic outcomes in a number of studies (Honig et al., 1997, Kim and Miklowitz, 2004, Miklowitz et al., 2000, O׳Connell et al., 1991, Yan et al., 2004). Moreover, psychosocial family interventions which focused upon educating family members about bipolar disorder, facilitating better communication, and optimising problem-solving have been associated with better global functioning (Clarkin et al., 1998) in addition to fewer relapses and greater improvements in depressive symptoms (Miklowitz et al., 2000). However, the influence of the immediate social context upon the development of suicidal thoughts remains under-researched in people with bipolar disorder.
The most recent UK based epidemiological study investigating the prevalence rates of suicide in bipolar disorder reported that 1489 people with bipolar disorder ended their own lives between 1996 and 2009, an average of 114 suicides each year (Clements et al., 2013). Despite these high prevalence rates, there are a limited number of studies investigating the relationship between social factors and suicidal behaviour in bipolar disorder. There are a number of studies which report that bipolar disorder is significantly associated with social dysfunction and can have a profound negative effect on social relationships (e.g., Hirschfeld et al., 2003). However, the role of social factors in the development of suicidality within the context of bipolar disorder remains largely under researched. The few studies which have focused upon social factors and suicidality in bipolar disorder have highlighted the significance of adversities during early life, such as childhood physical and sexual abuse (Alvarez et al., 2011, Carballo et al., 2008, Garno et al., 2005, Leverich et al., 2002), a family history of suicidal behaviour (Galfalvy et al., 2006, Leverich et al., 2002, MacKinnon et al., 2005, Pawlak et al., 2013), a family history of mental health problems (Lopez et al., 2001, Pawlak et al., 2013), problems with social relationships (Leverich et al., 2002, Tsai et al., 1999), and stressful life events (Antypa et al., 2013, Azorin et al., 2009).
However, none of the aforementioned studies involved directly asking individuals with past experiences of suicidality and bipolar disorder to identify the socially relevant processes or factors they feel are involved in pathways leading to suicidal thoughts and behaviours. Indeed, family histories of suicidal behaviour and mental health problems may involve maladaptive-dysfunctional social relationships, but this has not been examined directly. Given the lack of specific research targeting social factors in suicidality in individuals who experience bipolar disorder, a practical first step would be to ask people with bipolar disorder which social factors they feel are implicated in the pathways to suicide, as key processes may not have been recognised within the existing research literature.
The aim of the present study was to identify which social factors people who experience bipolar disorder perceived as having triggered, worsened and protected against suicidal thoughts, feelings and behaviours. Qualitative interviews were used to gain an in-depth understanding of participants׳ subjective experiences of suicidal thoughts, feelings and behaviours.
Section snippets
Design
This study involved conducting one-to-one semi-structured qualitative interviews with individuals with a diagnosis of bipolar disorder.
Inclusion criteria
A total of 20 participants were recruited based upon the following inclusion criteria:
- 1.
A primary diagnosis of bipolar disorder (I or II) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV research criteria (First et al., 1997), confirmed by the Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version (SCID; First et
Participants
The mean age of participants was 45.6 years (range 26–60). All met criteria for bipolar disorder I or II, according to the SCID (see Table 2). One participant attended the SCID interview but was excluded due to not having experienced a manic or hypomanic episode according to the SCID. There was considerable range in terms of patterns of lifetime mood episodes, with 0–200 self-reported depressive episodes (mean=27 depressive episodes), and 2–50 manic or hypomanic episodes (mean=16
Discussion
The aim of the present study was to explore which social factors were perceived to have triggered, worsened and also protected against suicidal thoughts, feelings and behaviours by individuals with a diagnosis of bipolar disorder. The themes were grouped into (a) protective social factors and, (b) social triggers or worsening factors. A realist approach was taken during data analysis and an accurate picture of the data was presented by ensuring that the themes were data driven. This meant that
Role of funding source
Funding for this study was provided by the School of Psychological Sciences at the University of Manchester. The funding was for a PhD studentship award.
Conflict of interest
There are no conflicts of interest.
Acknowledgements
There are no further acknowledgements.
References (71)
- et al.
Clinical, psychological and environmental predictors of prospective suicide events in patients with bipolar disorder
J. Psychiatr. Res.
(2013) - et al.
Risk factors associated with lifetime suicide attempts in bipolar I patients: findings from a french national cohort
Compr. Psychiatry
(2009) Reproductive status, family interactions, and suicidal ideation: Surveys of the general public and high-risk groups
Ethol. Sociobiol.
(1995)- et al.
Family history of suicidal behavior and early traumatic experiences: additive effect on suicidality and course of bipolar illness?
J. Affect. Disord.
(2008) - et al.
Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial
J. Am. Acad. Child Adolesc. Psychiatry
(2010) - et al.
Self-harm and suicide in adolescents
Lancet
(2012) - et al.
Psycho-education in bipolar disorder: effect on expressed emotion
Psychiatry Res.
(1997) - et al.
Resilience to suicidal ideation in psychosis: positive self-appraisals buffer the impact of hopelessness
Behav. Res Ther.
(2010) - et al.
Expressed emotion as a predictor of outcome among bipolar patients undergoing family therapy
J. Affect. Disord.
(2004) - et al.
Suicidal ideation among young French adults: association with occupation, family, sexual activity, personal background and drug use
J. Affect. Disord.
(2010)
Early physical and sexual abuse associated with an adverse course of bipolar illness
Biol. Psychiatry
Family-focused treatment of bipolar disorder: 1-year effects of a psychoeducational program in conjunction with pharmacotherapy
Biol. Psychiatry
The psychology of suicidal behaviour
Lancet Psychiatry
A model of suicidal behaviour in posttraumatic stress disorder (PTSD): the mediating role of defeat and entrapment
Psychiatry Res.
Suicide attempts and clinical risk factors in patients with bipolar and unipolar affective disorders
Gen. Hosp. Psychiatry
Defeat and entrapment in schizophrenia: The relationship with suicidal ideation and positive psychotic symptoms
Psychiatry Res.
Characteristics and psychosocial problems of patients with bipolar disorder at high risk for suicide attempt
J. Affect. Disord.
Daily stressor sensitivity, abuse effects, and cocaine use in cocaine dependence
Addict. Behav.
Nature and nurture in suicidal behaviour, the role of genetics: some novel findings concerning personality traits and neural conduction
Physiol. Behav.
Family factors associated with suicide attempts among Chinese adolescent students: a national cross-sectional survey
J. Adolesc. Health
Expressed emotion versus relationship quality variables in the prediction of recurrence in bipolar patients
J. Affect. Disord.
Prevalence and clinical impact of childhood trauma in patients with severe mental disorders
J. Nerv. Ment. Disord.
Suicide and friendships among American adolescents
Am. J. Public Health
Using thematic analysis in psychology
Qual. Res. Psychol.
Evaluation of an evolutionary model of self‐preservation and self‐destruction
Suicide Life Threat. Behav.
Effects of psychoeducational intervention for married patients with bipolar disorder and their spouses
Psychiatr. Serv.
Suicide in bipolar disorder in a national English sample, 1996–2009: frequency, trends and characteristics
Psychol. Med.
Social support protects against the negative effects of partner violence on mental health
J Womens Health Gend. Based Med.
Parent-child relationships as systems of support or risk for adolescent suicidality
J. Fam. Psychol.
The self and autobiographical memory: correspondence and coherence
Soc. Cognit.
Toward an integrative model of suicide attempt: a cognitive psychological approach
Suicide Life Threat. Behav.
Suicide prevention: a study of patients׳ views
Br. J. Psychiatry
Structured clinical interview for DSM-IV axis I disorders-clinician version (SCID-CV)
Clinical predictors of suicidal acts after major depression in bipolar disorder: a prospective study
Bipolar Disord.
Bipolar disorder with comorbid cluster B personality disorder features: impact on suicidality
J. Clin. Psychiatry
Cited by (33)
Examining the mechanisms by which adverse life events affect having a history of self-harm, and the protective effect of social support
2020, Journal of Affective DisordersCitation Excerpt :Suicide as a cause of death, is clearly influenced by an array of psychological factors since it is the individual who decides to intentionally end their own life (O'Connor and Nock, 2014). Based on a robust literature, contemporary theoretical models which seek to understand the psychological pathways underpinning suicidal thoughts/behaviors highlight the importance of perceptions of negative stressors (e.g., negative life events, such as relationship break-ups) (e.g., Kõlves et al., 2006; Owen et al., 2015; Van Orden et al., 2010; Williams, 1997), and hopelessness (e.g., Klonsky et al., 2012; Klonsky and May 2015) as key psychological antecedents of suicide fatalities and suicidal behaviors. Less research has sought to examine if there is a mediational pathway between negative life events, hopelessness and suicide/suicidal behaviors.
‘What people diagnosed with bipolar disorder experience as distressing’: A meta-synthesis of qualitative research
2019, Journal of Affective DisordersCitation Excerpt :Additional distress resulted from direct poor experiences of professional support (5c), with individuals reporting feeling misunderstood, disrespected, or having a lack of belief and trust in those treating them. For example, this person reflected on the gravity this had on their mood: ‘There have been times in my life where I've not been listened to by professionals and they think they understand my moods but they have not got a clue […] it was a total misunderstanding of someone's thoughts of suicide and that can actually definitely send you over the edge’ (Owen et al., 2015). Many described distressing experiences where they were not being seen as an individual (5d), but instead as ‘just another number, another file’ (Blixen et al., 2016) or as their diagnostic label: ‘I am not manic depressive, I'm me!
Association between completed suicide and bipolar disorder: A systematic review of the literature
2019, Journal of Affective DisordersCitation Excerpt :Exclusive articles about attempted suicide or suicidal behaviour and letters to the editor were excluded. We have included 61 articles that have conducted a study on bipolar disorder cases and/or suicide, but 8 of which (McIntyre et al., 2008; Cipriani et al., 2013; Schaffer et al., 2015; Isometsa, 2014; Owen et al., 2015; McGuffin et al., 2010; Antypa et al., 2016; M Pompili et al., 2013) are review articles or they do only a qualitative description associated with suicide. Information was extracted from each included trial on: {1} author(s) and year of publication; {2} sample size studied; {3} type of study (retrospective, prospective, descriptive or case-control); {4} journal published and its quartile; {5} the study is only with BD patients; {6} the study is only with completed suicide (without suicide attempt or suicide behaviour); {7} the number of suicides and the percentage of BD patients; and {8} the years of follow-up.