Exploring risk-taking behaviours as potential warning signs for suicide in adults

Scope: The present study investigated a broad range of risk-taking behaviours as risk factors and potential warning signs for suicidality in adult populations. Risky or reckless behaviours are warning signs for suicide in adolescents. However, risk-taking behaviours have not been well researched in adult populations to-date. In addition, investigating a broader scope of risk behaviours could reveal additional suicide risk factors and warning signs that are presently unknown. Purpose: The purpose of the study was to contribute to early suicide intervention efforts by increasing knowledge of risk-taking behaviours as suicide risk factors and potential warning signs in adult populations. Gatekeepers, clinicians and the general public could be made aware of a new group of risk behaviours as warning signs for suicide. Valid warning signs should also be incorporated into clinical screening methods. Methodology: Study participants were an anonymous sample of 713 internet users, predominantly female (77.1%), Caucasian (78.5%), and were aged 18 to 71. Using the Suicide Behaviors Questionnaire-Revised (SBQ-R), 401 were grouped as suicide-risk, and 312 as non-suicidal. Participants completed a 20-30 minute anonymous online survey, including items on five domains of risk behaviours and perceptions (i.e., Financial, Social, Ethical, Recreational, and Health/Safety), using the DomainSpecific Risk-Taking (Adult) Scale (DOSPERT). Demographic information included age, sex, education, and ethnicity. MANCOVA analyses were conducted to investigate group differences in risk perceptions and behaviours between suicide-risk and non-suicidal participants, controlling for age and education. A further MANCOVA assessed risk behaviour differences between participants who scored EXPLORING RISK-TAKING BEHAVIOURS 2 high and those who scored low on an SBQ-R item relating to future suicidal intent, in order to better identify potential proximal behavioural warning signs. Results: Several behavioural and perceptual differences were found between suiciderisk and non-suicidal participants. Suicidal participants reported greater likelihood to participate in the following behaviours: engaging in extra marital affairs, passing off someone else’s work as their own, keeping a wallet that they found containing $200, betting a day’s income at a high-stake poker game, riding in a car without a seatbelt or on a motorcycle without a helmet, walking home alone at night in an unsafe area and going bungee jumping. Analyses investigating more proximal warning signs found that participants with high suicidal intent were more likely to engage in extra-marital affairs, drive a car without a seatbelt, and walk home alone at night in an unsafe area, compared with participants with low suicidal intent. General conclusions and implications: The implications of these findings are farreaching in terms of their clinical utility; clinicians and gatekeepers can be alerted to a new range of risk factors and possible warning signs to indicate a distal or proximal suicide risk. Definite differences were found in risk behaviours between suicide-risk and non-suicidal adults, indicating that risk-taking is an important risk factor for suicide, beyond adolescence. These differences are broader and more complex than simply putting one’s life at risk. Further research in the area is needed to confirm the current findings, investigate a broader range of health risk behaviours, explore the meaning behind these findings and examine these behaviours as warning signs for people who have actually made a suicide attempt or completed suicide. EXPLORING RISK-TAKING BEHAVIOURS 3 Critical Literature Review The role of suicide risk identification The World Health Organisation (2012) has identified suicide as one of the top causes of death worldwide, with an estimated one million people dying by suicide yearly. In spite of this, suicide remains one of the world’s most preventable causes of death, and suicide prevention research has produced tools and resources to reduce the number of suicides. Research in this area aims to identify those at risk for suicide, to provide evidence for the establishment and evaluation of early detection and intervention strategies, and to promote public awareness of warning signs and interventions (WHO, 2012). Informative risk factors need to be easily identifiable before the onset of serious suicidal behaviour (Burns & Paton, 2000). Recognising who is at risk of suicide is the first step towards early detection and intervention of suicidal behaviours. Warning signs are the earliest detectable indication that someone may be experiencing suicidal ideation or intent (Rudd, 2008). Risk-taking behaviours have been repeatedly identified as an early warning sign for suicide, with the rationale that suicidal people may engage in life-threatening behaviours as an indirect method of taking one’s life (Adams, Giffen, & Garfield, 1973; Litman & Farberow, 1961; Mandrusiak et al., 2006). Literature currently identifies certain reckless behaviours as warning signs for suicide in adolescents, including substance use, getting into physical fights, unsafe sexual activities and dangerous driving (Flisher et al., 2000; King et al., 2001; Patton et al., 1997; Sosin, Koepsell, Rivara, & Mercy, 1995; Woods et al., 1997). However, a broader range of risk-taking behaviours as warning signs for suicide have not been thoroughly explored in adult populations. It is the aim of this researcher to investigate the nature of risk behaviours and risk perceptions in suicidal EXPLORING RISK-TAKING BEHAVIOURS 4 and non-suicidal individuals, so that new behavioural warning signs for suicide in adult populations might be identified. This information can then be disseminated to clinicians and gatekeepers to contribute to suicide prevention efforts. There are many competing theories on suicide which conceptualise the suicidal mind and processes in differing ways. This work was guided by Schneidman’s theory of suicide, which emphasises the 10 commonalities of the suicidal mind (Schneidman, 1996). Schneidman’s conceptualisation of the suicidal mind is that the suicidal individual is seeking a solution; experiences a cessation of consciousness; feels unendurable psychological pain; has frustrated psychological needs; has a fluctuating state between helplessness and hopelessness; feels ambivalence about the wish to live and the wish to die; has constricted cognitions (they cannot see other options); has a wish to escape; communicates their intention to suicide; and experiences a restricted pattern of lifelong coping mechanisms. This review of the literature will explore risktaking behaviour as an indirect method of suicide, in accordance with Schneidman’s theory that suicidal individuals are ambivalent about life and death. Schneidman further theorised that ambivalent individuals engage in risky behaviour including dangerous driving or playing risky sports as an indirect form of suicide, which he referred to as subintentional death. Life-death ambivalence is also reflected in Kovacs and Beck’s (1977) study which revealed that suicidal individuals have both a wish to live and a wish to die; however Schneidman’s theory specifically addresses risktaking behaviour as a as well as other commonalities that relate to suicide risk factors and warning signs, which are the focus of this work. Suicide Risk Assessment Most experts in the field of suicide research agree that there is a clear set of processes that most people undergo before attempting suicide. Suicide expert EXPLORING RISK-TAKING BEHAVIOURS 5 Silverman (2004), theorises that the presence of risk factors and absence of protective factors, combined with distress, can result in suicidal ideation. If unresolved, this ideation can develop into suicidal intent, where the individual has some intent to end their own life. At this stage, suicidal gestures or warning signs for suicide become apparent, such as talking or writing about suicide, engaging in risky behaviours or giving away one’s possessions. These actions can be followed by a suicide attempt, which might result in a completed suicide. Suicide screening assessment attempts to identify known risk factors that can occur at any stage of the suicidal process; however it is important to note that the rate at which individuals progress through these stages is varied. In addition, some may skip some of the processes altogether (Silverman, 2004). Screening tools have been developed to identify suicide-risk individuals through assessing known suicide risk factors, including depression, substance abuse problems, recent and frequent suicidal ideation, having a plan to attempt suicide, and past suicide attempts (Gould, Greenberg, Velting, & Shaffer, 2003; Wingate, Joiner, Walker, Rudd, & Jobes, 2004). Such suicide assessment tools include the Beck Scale for Suicidal Ideation (Beck, Brown, & Steer, 1997), The Beck Hopelessness Scale (Beck, Brown, Berchick, Stewart, & Steer, 1990; Beck & Weissman, 1974) and the Suicidal Behaviour Questionnaire-Revised (Osman et al., 2001). These tools have demonstrated success in identifying suicidal individuals and thus decreasing suicide rates when used in school-based intervention programs (e.g., Zenere & Lazarus, 1997), however programs are not commonly implemented in most settings, including the Australian school system. Suicide prevention programs are also rare in institutions housing adults on a day-to-day basis, such as tertiary education facilities and workplaces. Therefore, at-risk individuals need to be able to be identified by a broad EXPLORING RISK-TAKING BEHAVIOURS 6 scope of gatekeepers including doctors, mental health professionals, friends and family, teachers and colleagues. This could be achievable through disseminating information about suicide risk factors and warning signs to the professionals and the general public, such that suicidal individuals can be bette