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Importance of Comorbid Disorders to Suicide Risk in PTSD

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Comprehensive Guide to Post-Traumatic Stress Disorder

Abstract

The aim of this chapter is to explore the role of comorbid disorders in predicting suicidal ideations, plans, attempts, and completed suicide in individuals with posttraumatic stress disorders (PTSD).

Recent relevant publications and reviews were selected which assessed a range of comorbid disorders for their ability to (i) partly or fully explain the relationship between PTSD and suicidal behaviors or (ii) combine with PTSD to compound the risk of suicidal behaviors.

The findings are not unanimous and based largely on cross-sectional samples, but the majority found that PTSD predicted suicidal ideation, plans and attempts, which also compared well with relevant reviews. In addition, PTSD may specifically predict suicide attempts without a plan, and while relevant meta-analyses recommend further investigation on the link between PTSD and completed suicide, recent studies suggest PTSD is a risk factor for completed suicide. Most studies assessing the combined effect of PTSD and a comorbid condition on suicidal behaviors have reported the combined excess risk to be less than the sum of the separate excess risks associated with PTSD and the comorbid condition. However, comorbidity with alcohol and substance use disorders, phobias, and personality disorders may leave individuals with PTSD at elevated risk for suicidal behaviors compared with other comorbid disorders.

The available evidence suggests that PTSD has an independent and clinically meaningful effect on the risk of suicidal ideation, attempts, and completion, with a stronger impact on attempts. In general, the effect of PTSD combined with a comorbid disorder is less than the sum of the two separate effects. However, some specific comorbid diagnoses are potentially more predictive of suicidal behavior among individuals with PTSD than others.

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Abbreviations

AUD:

Alcohol use disorder

BD:

Bipolar disorder

BPD:

Borderline personality disorder

MDD:

Major depressive disorder

PTSD:

Posttraumatic stress disorder

SI/SP/SA/SR:

Suicidal ideation/plan/attempt/risk

SUD:

Substance abuse disorder

TBI:

Traumatic brain injury

References

  • Anestis MD, Tull MT, Bagge CL, Gratz KL. The moderating role of distress tolerance in the relationship between posttraumatic stress disorder symptom clusters and suicidal behavior among trauma exposed substance users in residential treatment. Arch Suicide Res. 2012;16:198–211.

    Article  PubMed  PubMed Central  Google Scholar 

  • Barnes SM, Walter KH, Chard KM. Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD? Rehabil Psychol. 2012;57:18.

    Article  PubMed  Google Scholar 

  • Barzilay S, Apter A. Predictors of suicide in adolescents and adults with mood and common comorbid disorders. Neuropsychiatry. 2014;4:81–93.

    Article  Google Scholar 

  • Betts KS, Williams GM, Najman JM, Alati R. The role of sleep disturbance in the relationship between post-traumatic stress disorder and suicidal ideation. J Anxiety Disord. 2013;27:735–41.

    Article  PubMed  Google Scholar 

  • Bishop TM, Pigeon WR, Possemato K. Sleep disturbance and its association with suicidal ideation in veterans. Mil Behav Health. 2013;1:81–4.

    Article  Google Scholar 

  • Blanco C, Xu Y, Brady K, Pérez-Fuentes G, Okuda M, Wang S. Comorbidity of posttraumatic stress disorder with alcohol dependence among US adults: results from National Epidemiological Survey on Alcohol and Related Conditions. Drug Alcohol Depend. 2013;132:630–8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Bolton JM, Robinson J. Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population. Am J Public Health. 2010;100:2473–80.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brenner LA, Betthauser LM, Homaifar BY, Villarreal E, Harwood JE, Staves PJ, Huggins JA. Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among veterans receiving mental health services. Suicide Life Threat Behav. 2011;41:416–23.

    Article  PubMed  Google Scholar 

  • Bryan CJ, Clemans TA. Repetitive traumatic brain injury, psychological symptoms, and suicide risk in a clinical sample of deployed military personnel. JAMA Psychiatry. 2013;70:686–91.

    Article  PubMed  Google Scholar 

  • Calabrese JR, Prescott M, Tamburrino M, Liberzon I, Slembarski R, Goldmann E, Shirley E, Fine T, Goto T, Wilson K. PTSD comorbidity and suicidal ideation associated with PTSD within the Ohio Army National Guard. J Clin Psychiatry. 2011;72:1072.

    Article  PubMed  Google Scholar 

  • Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med. 2003;33:395–405.

    Article  PubMed  Google Scholar 

  • Chartrand H, Sareen J, Toews M, Bolton JM. Suicide attempts versus nonsuicidal self-injury among individuals with anxiety disorders in a nationally representative sample. Depress Anxiety. 2012;29:172–9.

    Article  PubMed  Google Scholar 

  • Conner KR, Bohnert AS, McCarthy JF, Valenstein M, Bossarte R, Ignacio R, Lu N, Ilgen MA. Mental disorder comorbidity and suicide among 2.96 million men receiving care in the veterans health administration health system. J Abnorm Psychol. 2013;122:256.

    Article  PubMed  Google Scholar 

  • Davidson CL, Babson KA, Bonn-Miller MO, Souter T, Vannoy S. The impact of exercise on suicide risk: examining pathways through depression, PTSD, and sleep in an inpatient sample of veterans. Suicide Life Threat Behav. 2013;43:279–89.

    Article  PubMed  Google Scholar 

  • Dore G, Mills K, Murray R, Teesson M, Farrugia P. Post-traumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug Alcohol Rev. 2012;31:294–302.

    Article  PubMed  Google Scholar 

  • Foa EB, Keane TM, Friedman MJ, Cohen JA. Effective treatments for PTSD: practice guidelines from the International Society for traumatic stress studies. New York: Guilford; 2008.

    Google Scholar 

  • Galatzer-Levy IR, Nickerson A, Litz BT, Marmar CR. Patterns of lifetime PTSD comorbidity: a latent class analysis. Depress Anxiety. 2013;30:489–96.

    Article  PubMed  Google Scholar 

  • Gradus JL, Qin P, Lincoln AK, Miller M, Lawler E, Sørensen HT, Lash TL. Posttraumatic stress disorder and completed suicide. Am J Epidemiol. 2010;171:721–7.

    Article  PubMed  Google Scholar 

  • Gradus JL, Suvak MK, Wisco BE, Marx BP, Resick PA. Treatment of posttraumatic stress disorder reduces suicidal ideation. Depress Anxiety. 2013;30:1046–53.

    PubMed  Google Scholar 

  • Guerra VS, Calhoun PS. Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample. J Anxiety Disord. 2011;25:12–8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Harned MS, Rizvi SL, Linehan MM. Impact of co-occurring posttraumatic stress disorder on suicidal women with borderline personality disorder. Am J Psychiatry. 2010;167:1210–7.

    Article  PubMed  Google Scholar 

  • Ilgen MA, Bohnert AS, Ignacio RV, McCarthy JF, Valenstein MM, Kim HM, Blow FC. Psychiatric diagnoses and risk of suicide in veterans. Arch Gen Psychiatry. 2010;67:1152–8.

    Article  PubMed  Google Scholar 

  • Jakupcak M, Hoerster KD, Varra A, Vannoy S, Felker B, Hunt S. Hopelessness and suicidal ideation in Iraq and Afghanistan war veterans reporting subthreshold and threshold posttraumatic stress disorder. J Nerv Ment Dis. 2011;199:272–5.

    Article  PubMed  Google Scholar 

  • Kanwar A, Malik S, Prokop LJ, Sim LA, Feldstein D, Wang Z, Murad MH. The association between anxiety disorders and suicidal behaviors: a systematic review and meta-analysis. Depress Anxiety. 2013;30:917–29.

    PubMed  Google Scholar 

  • Kraemer HC, Stice E, Kazdin A, Offord D, Kupfer D. How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. Am J Psychiatry. 2001;158:848–56.

    Article  PubMed  Google Scholar 

  • Kramer JM, Kochinke K, Oortveld MA, Marks H, Kramer D, DE Jong EK, Asztalos Z, Westwood JT, Stunnenberg HG, Sokolowski MB, Keleman K, Zhou H, VAN Bokhoven H, Schenck A. Epigenetic regulation of learning and memory by Drosophila EHMT/G9a. Plos Biol. 2011;9:e1000569.

    Article  PubMed  PubMed Central  Google Scholar 

  • Krysinska K, Lester D. Post-traumatic stress disorder and suicide risk: a systematic review. Arch Suicide Res. 2010;14:1–23.

    Article  PubMed  Google Scholar 

  • Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, Hegerl U, Lonnqvist J, Malone K, Marusic A, Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke A, Shaffer D, Silverman M, Takahashi Y, Varnik A, Wasserman D, Yip P, Hendin H. Suicide prevention strategies: a systematic review. JAMA. 2005;294:2064–74.

    Article  PubMed  Google Scholar 

  • Müller M, Vandeleur C, Rodgers S, Rössler W, Castelao E, Preisig M, Ajdacic-Gross V. Factors associated with comorbidity patterns in full and partial PTSD: findings from the PsyCoLaus study. Compr Psychiatry. 2014;55:837–48.

    Article  PubMed  Google Scholar 

  • Nadorff MR, Nazem S, Fiske A. Insomnia symptoms, nightmares, and suicide risk: duration of sleep disturbance matters. Suicide Life Threat Behav. 2013;43:139–49.

    Article  PubMed  PubMed Central  Google Scholar 

  • Nepon J, Belik SL, Bolton J, Sareen J. The relationship between anxiety disorders and suicide attempts: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depress Anxiety. 2010;27:791–8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Nock MK, Hwang I, Sampson NA, Kessler RC. Mental disorders, comorbidity and suicidal behavior: results from the National Comorbidity Survey Replication. Mol Psychiatry. 2010;15:868–76.

    Article  PubMed  PubMed Central  Google Scholar 

  • Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, Kessler RC. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70:300–10.

    Article  PubMed  Google Scholar 

  • O’Hare T, Shen C, Sherrer M. Lifetime trauma and suicide attempts in people with severe mental illness. Community Ment Health J. 2013;50:673–80.

    Google Scholar 

  • Pagura J, Stein MB, Bolton JM, Cox BJ, Grant B, Sareen J. Comorbidity of borderline personality disorder and posttraumatic stress disorder in the US population. J Psychiatr Res. 2010;44:1190–8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Panagioti M, Gooding P, Tarrier N. Post-traumatic stress disorder and suicidal behavior: a narrative review. Clin Psychol Rev. 2009;29:471–82.

    Article  PubMed  Google Scholar 

  • Panagioti M, Gooding PA, Tarrier N. A meta-analysis of the association between posttraumatic stress disorder and suicidality: the role of comorbid depression. Compr Psychiatry. 2012;53:915–30.

    Article  PubMed  Google Scholar 

  • Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Anxiety Disord. 2011;25:456–65.

    Article  PubMed  PubMed Central  Google Scholar 

  • Quarantini LC, Miranda-Scippa Â, Nery-Fernandes F, Andrade-Nascimento M, Galvão-de-Almeida A, Guimarães JL, Teles CA, Netto LR, Lira SB, de Oliveira IR. The impact of comorbid posttraumatic stress disorder on bipolar disorder patients. J Affect Disord. 2010;123:71–6.

    Article  PubMed  Google Scholar 

  • Ribeiro JD, Pease JL, Gutierrez PM, Silva C, Bernert RA, Rudd MD, Joiner Jr TE. Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. J Affect Disord. 2012;136:743–50.

    Article  PubMed  Google Scholar 

  • Rojas S, Bujarski S, Babson K, Dutton C, Feldner M. Understanding PTSD comorbidity and suicidal behavior: associations among histories of alcohol dependence, major depressive disorder, and suicidal ideation and attempts. J Anxiety Disord. 2014;28:318–25.

    Article  PubMed  Google Scholar 

  • Ruby E, Sher L. Prevention of suicidal behavior in adolescents with post-traumatic stress disorder. Int J Adolesc Med Health. 2013;25:283–93.

    PubMed  Google Scholar 

  • Selaman ZM, Chartrand HK, Bolton JM, Sareen J. Which symptoms of post-traumatic stress disorder are associated with suicide attempts? J Anxiety Disord. 2014;28:246–51.

    Article  PubMed  Google Scholar 

  • Selby EA, Yen S. Six-month trajectory of suicidal ideation in adolescents with borderline personality disorder. Suicide Life Threat Behav. 2013;44:89–100.

    Article  PubMed  PubMed Central  Google Scholar 

  • Skopp NA, Trofimovich L, Grimes J, Oetjen-Gerdes L, Gahm GA. Relations between suicide and traumatic brain injury, psychiatric diagnoses, and relationship problems, active component, US Armed Forces, 2001-2009. MSMR. 2012;19:7–11.

    Google Scholar 

  • Spoormaker VI, Montgomery P. Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature? Sleep Med Rev. 2008;12:169–84.

    Article  PubMed  Google Scholar 

  • Stein DJ, Chiu WT, Hwang I, Kessler RC, Sampson N, Alonso J, Borges G, Bromet E, Bruffaerts R, DE Girolamo G. Cross-national analysis of the associations between traumatic events and suicidal behavior: findings from the WHO World Mental Health Surveys. PLoS One. 2010;5:e10574.

    Article  PubMed  PubMed Central  Google Scholar 

  • Stevens D, Wilcox HC, Mackinnon DF, Mondimore FM, Schweizer B, Jancic D, Coryell WH, Weissman MM, Levinson DF, Potash JB. Posttraumatic stress disorder increases risk for suicide attempt in adults with recurrent major depression. Depress Anxiety. 2013;30:940–6.

    PubMed  PubMed Central  Google Scholar 

  • Tang TC, Yen CF, Cheng CP, Yang P, Chen CS, Yang RC, Huang MS, Jong YJ, Yu HS. Suicide risk and its correlate in adolescents who experienced typhoon-induced mudslides: a structural equation model. Depress Anxiety. 2010;27:1143–8.

    Article  PubMed  Google Scholar 

  • Tarrier N, Picken A. Co-morbid PTSD and suicidality in individuals with schizophrenia and substance and alcohol abuse. Soc Psychiatry Psychiatr Epidemiol. 2011;46:1079–86.

    Article  PubMed  Google Scholar 

  • Uebelacker L, Weisberg R, Millman M, Yen S, Keller M. Prospective study of risk factors for suicidal behavior in individuals with anxiety disorders. Psychol Med. 2013;43:1465–74.

    Article  PubMed  PubMed Central  Google Scholar 

  • VAN Minnen A, Harned MS, Zoellner L, Mills K. Examining potential contraindications for prolonged exposure therapy for PTSD. Eur J Psychotraumatol. 2012;3.

    Google Scholar 

  • Wasserman D, Rihmer Z, Rujescu D, Sarchiapone M, Sokolowski M, Titelman D, Zalsman G, Zemishlany Z, Carli V. The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. Eur Psychiatry. 2012;27:129–41.

    Article  PubMed  Google Scholar 

  • Watson D. Differentiating the mood and anxiety disorders: a quadripartite model. Annu Rev Clin Psychol. 2009;5:221–47.

    Article  PubMed  Google Scholar 

  • Wedig MM, Silverman MH, Frankenburg FR, Reich DB, Fitzmaurice G, Zanarini MC. Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up. Psychol Med. 2012;42:2395–404.

    Article  PubMed  PubMed Central  Google Scholar 

  • WHO Suicide Prevention (SUPRE) [Online]. Geneva; 2014. Available http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/. Accessed 25 Mar 2014.

  • Yen S, Weinstock L, Andover M, Sheets E, Selby E, Spirito A. Prospective predictors of adolescent suicidality: 6-month post-hospitalization follow-up. Psychol Med. 2013;43:983–93.

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Kim S. Betts .

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Betts, K.S., Williams, G.M., Alati, R. (2015). Importance of Comorbid Disorders to Suicide Risk in PTSD. In: Martin, C., Preedy, V., Patel, V. (eds) Comprehensive Guide to Post-Traumatic Stress Disorder. Springer, Cham. https://doi.org/10.1007/978-3-319-08613-2_15-1

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  • DOI: https://doi.org/10.1007/978-3-319-08613-2_15-1

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