A variety of factors have been identified as being risk factors for suicidal behaviour. One of them is the handling of stressful events. The aim of the present study was to investigate the coping-strategies used by suicide attempters and comparison groups. 37 patients who had recently made a suicide attempt, 38 suicide attempters at follow up, 20 psychiatric follow up controls, and 19 healthy controls filled in the COPE. We found that suicide attempters at long term follow up and healthy controls used more adaptive problem solving strategies than patients who had recently made a suicide attempt, or psychiatric controls at follow up, who used more maladaptive coping strategies. Our findings suggest that suicide attempters in a twelve year follow up are able to use coping strategies similarly to healthy controls by e.g. approaching the stressor actively. Further examinations of the impact of long term professional care and treatment of suicide attempters on their coping strategies are necessary.
A variety of factors have been identified as being risk factors for suicidal behaviour. One of them is the way a person dealing with stressful situations. It is not the stressful situation alone that leads to a serious outcome, but rather the way in which the person copes with it.
Coping is defined as the “cognitive and behavioural efforts used to master, tolerate, and reduce demands that tax or exceed a person’s resources” [
Dieserud et al. [
Suicidal behaviour has been associated with the use of maladaptive coping strategies [8-11] and adaptive coping strategies may serve as protected factors [12-13].
Few studies have investigated whether coping strategies are persistent, or if and how they develop over the time. This is a first step to better understand the coping strategies reported by suicide attempters in an acute or a long term follow up situation, in relation to strategies reported by comparison groups. Our hypothesis was that suicide attempters in general would use weaker coping strategies than others.
Recruitment procedures
The suicide attempters at follow up were originally inpatients recruited shortly after a suicide attempt (i.e. index, 1986-1992). About 12 years later, they were followed up. Before the research appointment, 84 recruitment letters were sent out, asking for participation. Later, a research nurse made a phone call, asked for consent, and offered an appointment for a research investigation. The follow up study started in 1999 and lasted until 2002. Forty-two persons participated, and 38 of them filled in the COPE (19 males and 19 females). Forty-two refrained from participating in the follow up.
The psychiatric controls at follow up were recruited among those who were inpatients during the same time period (index) as the suicide attempters. They had no history of suicide attempt prior to that time. These controls were matched to the followed up suicide attempters according to their principal DSM III-R diagnosis [
From the emergency room, the medical intensive care unit, or from a general psychiatric ward at the University Hospital of Lund, Sweden, 37 patients (16 males and 21 females) were recruited shortly after a suicide attempt during 2006-2007. Their mean ± SD age was 36.2 ± 14.4.
Forty persons from the National Registration were randomly selected and invited to participate in the study. Nine of them were excluded because of disease, and one changed his mind. Twenty-two healthy controls agreed, but 19 actually participated (9 males and 10 females) and their mean ± SD age was 34.7 ± 10.8.
The suicide attempters at long term follow up were originally (at index) diagnosed by two independent psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders 3rd edition, revised [
We used the original edition of COPE [
Problem focused coping contains: active coping, planning, suppression of competing activities, restraint coping and seeking social support—instrumental. Emotional coping contains: seeking social support—emotional, positive reinterpretation & growth, acceptance, and denial. Avoidance coping contains: focus on & venting of emotions, behavioural disengagement, and mental disengagement.
As the data were not normally distributed, non-parametric statistical methods were used. Mann Whitney U-test was used to compare two groups of coping strategies and Kruskal Wallis H was used to compare coping strategies between all groups. We used the Pearson Chi-square to compare gender differences in the different study groups. All statistical calculations were made by use of the Statistical package for the Social Sciences, SPSS, version 15.
The study was approved by the Ethical Committee at the Faculty of Medicine, Lund University, Sweden and all participants gave written informed consent.
In this study, we regard a suicide attempt as a life threatening behaviour with the intent of jeopardizing one’s own life, or to give an appearance of such intent, but which has not resulted in death [
There were no significant gender differences between the different study groups, i.e. the recent suicide attempters, suicide attempters at follow up, psychiatric controls at follow up and healthy controls. As expected, healthy controls and the recent suicide attempters were significantly younger than the followed up study groups (p ≤ 0.000).
There were significant differences between the study groups. Suicide attempters at follow up had the highest value in factor I (median 42.0; total score 60; range 11.0 - 58.0), followed by healthy controls (median 38.0; range 21.0 - 56.0), psychiatric controls at follow up (median 34.0; range 17.0 - 53.0), and the recent suicide attempters (median 31.0; range 0.0 - 48.0), respectively (Kruskal Wallis H p = 0.001) (
There were no significant differences in factor II between the study groups (
The recent suicide attempters had the highest scores in factor III (median 25.0; total score 60; range 4.0 - 52.0), followed by psychiatric controls at follow up (median 18.0; range 6.0 - 25.0), suicide attempters at follow up (median 10.0; range 1.0 - 37.0) and healthy controls (median 10.0; range 0.0 - 17.0) Kruskal Wallis H (p ≤ 0.000). The data of subscales of this factor are shown in
Suicide attempters at follow up had the highest scores in factor IV (median 40.0 total score 60; range 8.0 - 52.0), followed by healthy controls (median 40.0; range 25.0 - 48.0), psychiatric controls at follow up (median 34.0; range 14.0 - 57.0), and the recent suicide attempters (median 30.0; range 3.0 - 48.0) Kruskal Wallis H (p ≤ 0.000,
There were no significant differences between men and women in the COPE factors I - IV of suicide attempters at follow up. In the other study groups (the recent suicide attempters, psychiatric controls and healthy controls), there were significant gender differences in COPE factor II (seeking social support instrumental and emotions, and focus on & venting of emotions). In the recent suicide attempters, men had significantly lower scores in factor II (median 23.0; range 5.0 - 46.0) than women (median 32.0; range 14.0 - 54.0); Mann Whitney U-test (p = 0.003). In psychiatric controls at follow up, men had significantly lower scores in factor II (median 18.0; range 8.0 - 41.0) than women (median 36.0; range 13.0 - 48.0); Mann Whitney U-test (p = 0.04), and in healthy controls, men had significantly lower scores in factor II (median 25.0; range 13.0 - 40.0) than women (median 37.0; range 29.0 - 49.0); Mann Whitney U-test (p = 0.002) (
In the other factors, i.e. I, III and IV, there were no significant gender differences in suicide attempters at follow up, psychiatric controls, or in healthy persons. However, women in the study group of the recent suicide attempters had significantly lower scores in factor IV (restraint coping, positive reinterpretation & growth and acceptance) (median 24.0; range 3.0 - 45.0) than men (median 34.0; range 19.0 - 48.0); Mann Whitney U-test (p = 0.004) (
The purpose of the present investigation was to explore whether suicide attempters more often than comparison groups used deviant coping strategies at stressful situations, regardless of when they were studied. We showed that recent suicide attempters and followed up psychiatric controls without a history of suicidal behaviour had more maladaptive coping strategies than suicide attempters at follow up and healthy controls, respectively.
A weakness of the present study is that suicide attempters were not studied prospectively, which means that we were unable to follow coping capacities over time in the same individual, and in relation to treatment and further experiences of life. Another weakness is that the younger controls and the recent suicide attempters were significantly younger than the followed up study groups. We know that coping changes partly with age, depression and attempt status [
The suicide attempters at follow up had already participated in our study at index, which means that they
(a)
(b)
Statistics: Women vs. men, Mann Whitney U-test, *p < 0.05, **p < 0.001.
were familiar with our study, and were therefore probably curious to participate in a follow up investigation. However, the psychiatric controls at follow up had never before participated in a research study, which could explain our difficulties to recruit them.
We found that the recent suicide attempters and followed up psychiatric controls without a history of suicidal behaviour, more often than others used maladaptive coping strategies, such as denial, behavioural and mental disengagement. This means that individuals belonging to these groups, often refused to accept the problem or pretended or acted as if the problem had not appeared, had urges to give up and/or used alternative activities to bring the mind away from the problem. Our findings are similar as the results by Pollock et al. [
In our study, suicide attempters at follow up and healthy controls more often than the others used adaptive coping styles, such as active coping, planning, suppression of competing activities, positive reinterpretation & growth, and acceptance. Similarly to our healthy controls, Brown et al. [
In our study, another adaptive coping strategy, i.e. seeking social support—instrumental, was scored lower by the recent suicide attempters than suicide attempters at follow up, or healthy controls. This means that the recent suicide attempters were less prone to seek advice and information than the others. This is an important finding, since social support can exert a protective influence against stressors and buffer against the outcome of a stressful event [
In the study group of the recent suicide attempters, women had lower scores than men in the coping strategies; restraint coping, positive reinterpretation & growth and acceptance. This might be explained by an influence of a DSM IV, axis II diagnosis, and especially a borderline personality disorder, as factor IV deals with coping strategies, which ask for emotional control, acceptance of the situation, and to wait for an appropriate opportunity.
Many previous reports have suggested that coping strategies have a relation to the state of illness, e.g. symptoms of depression, anxiety and mood, such as anger and hopelessness [19,29,30]. Elliott et al. [
Our findings make us tempt to suggest that suicide attempters have improved their coping capacity twelve years later, so that they use more adaptive problem solving strategies than before. The healthy people deal with stressful life events by active approaching to the stressor. Both followed up psychiatric controls, which were once treated because of similar diagnoses as the index suicide attempters, and recent suicide attempters are more often used maladaptive strategies such as avoidance. It is interesting in our study, suicide attempters at follow up and matched psychiatric controls had different coping approaches. This might be an effect of discrepant outpatient treatment strategies. Further examinations of the possible influence of long term professional care and treatment of suicide attempters after hospitalization will be necessary in a future comprehensive and prospective follow up study.
The authors gratefully acknowledge the participating subjects in the study. The Swedish Research Council no. 14548-04-3, the Scania ALF foundation and Sjöbring Foundation gave financial support. Professor Arnstein Finset, Oslo, introduced us to the problem of coping and to the COPE-instrument and offered a valuable contribution to the intellectual development of the article, professor of the English language at Lund University, Sven Bäckman.