Jessica Grimmond, Data curation , Formal analysis , Investigation , Methodology , Project administration , Validation , Visualization , Writing – original draft , Writing – review & editing , 1 Rachel Kornhaber, Conceptualization , Data curation , Formal analysis , Investigation , Methodology , Supervision , Validation , Visualization , Writing – original draft , Writing – review & editing , 1 Denis Visentin, Data curation , Formal analysis , Investigation , Methodology , Supervision , Validation , Visualization , Writing – original draft , Writing – review & editing , 2 and Michelle Cleary, Conceptualization , Data curation , Formal analysis , Investigation , Methodology , Project administration , Resources , Supervision , Validation , Visualization , Writing – original draft , Writing – review & editing 1, *
1 School of Nursing, College of Health and Medicine, University of Tasmania, Sydney, NSW, Australia
Find articles by Jessica Grimmond1 School of Nursing, College of Health and Medicine, University of Tasmania, Sydney, NSW, Australia
Find articles by Rachel Kornhaber2 School of Health Sciences, College of Health and Medicine, University of Tasmania, Sydney, NSW, Australia
Find articles by Denis Visentin1 School of Nursing, College of Health and Medicine, University of Tasmania, Sydney, NSW, Australia
Find articles by Michelle Cleary Soraya Seedat, Editor 1 School of Nursing, College of Health and Medicine, University of Tasmania, Sydney, NSW, Australia2 School of Health Sciences, College of Health and Medicine, University of Tasmania, Sydney, NSW, Australia
Stellenbosch University, SOUTH AFRICA Competing Interests: The authors have declared that no competing interests exist. Received 2019 Jan 7; Accepted 2019 May 14. Copyright © 2019 Grimmond et alThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Suicide remains a global issue with over 800,000 people dying from suicide every year. Youth suicide is especially serious due to the years of life lost when a young person takes their own life. Social interactions, perceived support, genetic predisposition and mental illnesses are factors associated with suicide ideation.
To review and synthesize qualitative studies that explored the experiences and perceptions of suicide in people 25 years old and younger.
Qualitative systematic review.
PubMed, PsycINFO, Scopus and CINAHL were searched alongside hand-searching reference lists up to October 2018.
Methodological quality was assessed using the qualitative Critical Appraisal Skills Programme checklist. The 27 studies included in the review centered around youth suicide and included interviews with young people and members of the wider community. Thematic synthesis focused on factors leading to suicide attempts, elements important to recovery, beliefs within the community, and treatment/prevention strategies.
Thematic analysis of the articles revealed four categories: i) triggers and risks leading to suicidality; ii) factors involved in recovery; iii) need for institutional treatment/prevention strategies; and iv) beliefs about suicide at a community level. The first category was further subdivided into: i) behaviours; ii) feelings/emotions; iii) family influences; iv) peer influences; and v) other. The second category was split into: i) interpersonal; ii) cultural; and iii) individual influences, while the third category was divided into i) education; and ii) treatment.
Youth suicide is a complex issue with many causes and risks factors which interact with one another. For successful treatment and prevention, procedural reform is needed, along with a shift in societal attitudes toward emotional expression and suicide.
Suicide impacts the lives of many people across the globe and is a concerning public health issue [1]. Almost 800,000 people’s deaths are the result of suicide internationally each year, accounting for 1.4% of all deaths [2]. The incidence of suicidal ideation universally increases during adolescence [3], with suicide the second leading cause of death worldwide in the 15 to 29 years age group [2]. Hence the impact of suicide on the families and communities is significant. Since the proportion of suicide deaths among young people is high, youth suicide should be considered a serious health issue due to the broader social cost and the years of life lost when a young person takes their own life.
A number of theoretical models provide a framework for understanding the complex interaction between biopsychosocial influences on suicidality. While each of these models provides a different explanation and emphasises different specifics, there are similarities throughout. The Interpersonal Theory of suicide (IT) [4], the Integrated Motivational-Volitional Model of suicidal behaviour (IMV) [5] and the Three-Step Theory (3ST) [6] each separate suicidal ideation from actual attempts and explore the differences between suicidal thoughts and suicidal actions. While the IT was developed to provide a comprehensible and potentially falsifiable framework of suicidality [4], the IMV model was borne out of a need to predict factors which influence suicide ideation and the circumstances whereby these thoughts are acted upon [5]. Similar to the IT, the 3ST is a demonstration of what Klonsky and May call an “ideation-to-action" framework [7] based in empirical evidence [6], though it emphasises different factors. Each of these models provides a detailed perspective of the cognitive, social and physiological contributors to suicidal ideation and attempts.
Psychological factors and personality differences such as hopelessness, impulsivity and resilience all have a bearing on a person’s likelihood of experiencing suicidal ideation [3]. Hence, identifying and understanding these factors is an important step in predicting and preventing suicide. The first step in the 3ST centres around experiences of hopelessness and pain which are usually, but not exclusively, emotional. [6]. They posit that frequent experiences of pain act as punishment, resulting in the individual “essentially being punished for living” [6], but that pain must also be coupled with psychological experiences of hopelessness [6]. Empirical data supports this, as both pain and hopelessness were strongly related to suicidal ideation and with one another [6]. While this theory is not specific to young people, the results remain consistent in the youth age bracket [6].
The IT also highlights the importance of psychological experiences. A key element of the IT is the perception of burdensomeness whereby low self-esteem and feelings of expendability (among others) contribute to dimensions of self-hate and liability [4]. These dimensions combine to result in perceived burdensomeness [4]. The IT suggests that when perceived burdensomeness is coupled with barriers to socialisation, and these are viewed as ‘stable and permanent’ [4] states, suicidal ideation may occur. These barriers to socialisation are termed ‘thwarted belongness’ and include feelings of loneliness and a lack of reciprocal care [4]. In this way, the IT provides a dynamic explanation of suicidal ideation as it considers the psychological influences in conjunction with social ones [4].
Other theoretical frameworks also consider social factors to have a strong influence on suicidality. In the second phase of the IMV model, the motivational phase, feelings of defeat and humiliation can progress to those of entrapment when threats to self-moderators, such as the inability to adequately resolve social problems, exist [5]. Like the IT, the IMV model considers thwarted belongingness to be an important social factor and, here, it acts as a motivational moderator which sees feelings of entrapment develop into suicidal ideation [5]. Research supports this model suggesting those who are more sensitive to the social judgements of others are more likely to feel defeat and entrapment, which are central to the motivational phase of the IMV model [5].
Socialisation is also considered a factor in the 3ST. The second step in this theory relates to connectedness which usually describes interpersonal relationships, but can also be extended to include an attachment to work or hobby interests [6]. In this model, connectedness protects against progression from moderate to severe ideation [6]. In this way, the 3ST differs from the IT, as it acknowledges factors which can stem progression [6], where the IT focuses on predictive factors alone [4]. In the 3ST, the psychological experiences of pain and hopelessness can lead to suicidal ideation, but only when these feelings are combined with a disruption to connectedness is it possible for a person to move from ideation to suicide attempt [6]. Hence, Klonsky and May [6] suggest that social influences play a vital role in suicide.
In line with these theoretical models, difficulty with socialisation and interpersonal conflicts have been identified as predictors of suicidality in adolescents [1]. The death of a loved one has been linked to suicidality in adolescents [1, 3] and research has identified that adolescents who have been exposed to suicide and related behaviours were far more likely to self-report similar related behaviours [8]. The causes for this link, however, are unclear. Experiencing the suicide of a family member may offer a behavioural model for young people who are already vulnerable [1, 5] or it may simply make it more salient in a young person’s mind as a solution to a problem [5].
In a similar way, the presence of ‘cluster effects’ and the concept of peer contagion highlights the important role of socialisation, especially in adolescents [9]. However, since the causes of these phenomena are poorly understood, misconceptions about the social transmission of suicide exist within society. The belief that incidents of suicide become higher when ideation and related behaviours are discussed is common and has informed public policy. These beliefs, however, are not based in empirical evidence [10]. Nonetheless, these ‘cluster effects’ do exist, and adolescence seems to be the peak time for peer contagion and social influence [9].
One explanation for these cluster effects is that people are more attracted to those who they perceive as being similar to themselves [11]. The group will likely experience similar stressors and events [1] and an adolescent’s experience of depression can be well predicted by those of their friends [9]. Therefore, rather than a ‘copycat’ explanation of suicide, it is reasonable to assume that some of the factors contributing to suicidal ideation in one person will also be affecting that person’s peers [9]. In fact, experiencing a peer’s suicide, itself, may elicit feelings of hopelessness and thwarted belongingness which are linked with suicidal ideation in the discussed theoretical models [4, 6].
The acceptance of suicide as an appropriate response to negative life events may also become normalised as a shared belief between members of social groups or certain subcultures [12, 13]. In this way, attitudes and understanding become shaped by the experiences and beliefs of others [12]. It is also important to consider, however, that those with pre-existing vulnerabilities may be drawn to likeminded people or subcultures (eg. Goth or EMO) from the outset, which will bias the sample and overemphasise the social influences on suicidality [12, 13].
When considering the social impact that a family member’s suicide may have, it is impossible to separate the possible predisposition to psychiatric disorders associated with suicidality [1]. Autopsies indicate a prevalence of psychiatric disorders of over 90% in those who have died by suicide, though these are not always diagnosed while the person is alive [3]. A family history of mental health problems or suicide can also be a predictor of suicidality [4, 13], though the genetic influence is unclear.
These biological influences are also well explained in the current theoretical models. The IT explains that for a person to progress from ideation to attempt, they must acquire the capability for suicide [4]. This capability can be acquired cognitively, through a reduced fear of death, or physically through increased pain tolerance [4]. Similarly, the 3ST acknowledges that lower pain sensitivity can provide a dispositional capacity for suicide, while it can also be acquired through repeated exposure socially or through practical access to means [6]. It is clear through these models that physiology has a part to play in suicidality, but that both suicidal ideation and suicide attempts involve a complex combination of biopsychosocial factors.
Since there are so many influences on suicidality, identifying them and exploring their relationships to one another is an important step in prevention and treatment approaches. It is also important to consider that, while the current models of suicide provide a strong framework of the issue, they are not age specific. Since the experiences of adolescents will vary greatly from those further into adulthood, research that centres on young people is necessary [3]. While information gathered from quantitative studies is important in assessing various aspects of youth suicide, detailed thematic analysis of qualitative data [14] can provide unique and specific insights into the thoughts and feelings of those directly affected, as well as the wider community.
The need to explore societal perceptions of suicide has been identified [3] and the ability to compare these views with the lived experience of suicidal young people, for example, can provide a deeper understanding of the issue. Hawton, Saunders and O’Connor [1] have also suggested that future research should explore the factors that assist in moving away from suicidality. While various studies focus on specific aspects of suicide such as prevention strategies [15, 16], psychiatric factors [17], and treatment strategies, there is a need for a review which takes a more macro approach. Therefore, this review focuses on the suicidal behaviour of young people and explores not just the experiences of suicidal people, but includes the opinions of health professionals, parents and members of the wider community in order to explore the true complexity of the issue.
To review and synthesize qualitative studies that explored experiences and perceptions of suicide in people 25 years old and younger.
This qualitative systematic review was guided by the thematic synthesis methodology of Thomas and Harden [14] with reporting meeting the Enhancing Transparency in Reporting the Synthesis of Qualitative research statement (ENTREQ) consisting of 21 reported items (S1 Table) [18].
Included studies met the following criteria: i) original qualitative studies published in peer-reviewed journals in the English language with no date restriction; ii) participants were either adolescents or young adults (25 years of age or younger) who had attempted suicide, friends or family members of those who had attempted suicide or experienced suicidal ideations, professionals working with young people or members of the wider community; iii) qualitative interviews primarily discussing youth suicide and suicidal ideation in young people. Excluded studies were abstracts, editorials, conference proceedings, theses, and secondary research sources (e.g. reviews). Studies which were quantitative were excluded.
A comprehensive literature search was conducted up until October 2018 without time limits (by RK, MC) using four electronic databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsycINFO. Boolean connectors AND and OR were used to combine the following MeSH and search terms: adolescen*, teenager*, suicidal ideation, suicide, attempted suicide, trigger*, risk factors, perception* and qualitative research. As each database uses different indexed terms, the search strategy was adapted for differences in syntax and indexed/MeSH terms for each database (S2 Table).
Title and abstract screening of all papers identified by the search strategy was independently performed by authors MC, RK and JG with reference to the published inclusion/exclusion criteria.
A total of 617 studies were identified. Following removal of 160 duplicates, 457 title and abstracts were then screened of which 406 did not meet the inclusion criteria. Fifty-one full text articles were therefore retrieved and screened for eligibility and 31 were excluded. Review of the reference lists of the remaining studies identified 7 further studies meeting the inclusion criteria. In total, 27 qualitative studies met the inclusion criteria for this systematic review. The study selection process is detailed in the PRISMA Flow Diagram [19] ( Fig 1 ).