Suicide in rural areas has not received significant attention in the research literature to this point, although suicide rates are higher among adults and older adults in rural areas than in urban areas. The aims of the study were as follows: (1) establish the feasibility of assessing suicide ideation and history of suicidal behavior; (2) determine preliminary estimates of the prevalence of suicide ideation, and history of suicide attempts; and (3) examine the effectiveness and acceptability of safety and referral plans for individuals whose responses indicated elevated suicide risk, in rural communities with limited access to referral care. Participants were 96 adults aged 40 to 85 years old (M = 57.34, SD = 11.47) residing in West Texas. Our results indicate that 26% of participants endorsed a lifetime history of suicide ideation and/or suicide attempt(s) and 12.5% reported suicide ideation in the past year. In addition, 93.4% of participants reported that participation in our suicide-focused study was an excellent or good experience. Results suggest that individuals in rural communities are willing to talk about suicide, found the experience helpful, and were satisfied with the referral process.

This research project demonstrates the importance of the use of Cognitive Behavioral Therapy for Post-Traumatic Stress Disorder and its relationship to the frequency of suicidal thoughts in veterans through the use of the positivist paradigm. The correlation that was found showing that Cognitive Behavioral Therapy does reduce the frequency of suicide ideation through the collection of quantitative data, and the understanding of Cognitive Learning Theory it is this study offers clinicians another tool to combat suicide in veterans.

Suicidal behavior represents the most severe, yet inherently preventable, outcome of psychiatric disease. Despite tremendous efforts to improve the awareness and treatment of psychiatric illness, suicidal behavior rates have been on the rise. The greatest challenge to confronting this crisis is the effective identification and treatment of those at risk for suicide. This challenge has been difficult to address due, in part, to the lack of a clear biological basis for suicidal behavior. Toward addressing this knowledge gap, evidence has been identified of a significant heritable component to suicidal behavior. Subsequent genetic research efforts have focused on the examination of common sites of genetic variation within candidate genes and throughout the genome. These efforts have identified many potentially important risk loci, but the majority of the risk expected to arise from genetic variation remains unexplained by current data. The primary objective of this dissertation was to examine the contribution of largely unexplored rare and potentially damaging genetic variation within suicidal behavior. To do this, targeted next-generation sequencing approaches were employed within a cohort of individuals diagnosed with bipolar disorder, a group particularly enriched for suicidal behavior. Sequence data was generated that examined essentially all protein-coding regions of the human genome (“exome”), with expanded sequencing around and within candidate genes hypothesized to play a role in suicidal behavior risk. The secondary objective of this dissertation focused on the assessment of rare variation within bipolar disorder through sequenced pedigrees and followup in a large collaborative bipolar disorder versus normal control sequencing dataset. These objectives were addressed through the thoughtful application of diverse and complimentary methods. These methods were selected to investigate individual variants, genes, and biological pathways. This approach offered examinations of the potential impact of rare genetic variation within focused regions and across complex biological process pathways that could be disrupted through damaging variation in many different genes. The presented efforts represent the largest examinations of rare functional variation with suicidal behavior and bipolar disorder performed, to date. No individual variant or gene survived correction for multiple testing for either phenotype. These results are consistent with other initial sequencing efforts in complex psychiatric phenotypes, offering conclusions that larger samples will likely be required to identify significant associations for single variants and genes. Within pathway analyses, however, we identified a significant enrichment of rare damaging variation that segregated within bipolar disorder pedigrees in genes that have been implicated in de novo studies of autism. This finding was further replicated within three large case/control sequencing samples, providing support to emerging evidence of a potential overlap of risk loci for autism and bipolar disorder. Many additional results approached significance that bear further consideration. These results offer potential candidate genes and pathways that could be utilized in future sequencing efforts for suicidal behavior and bipolar disorder. In addition, highly valuable resources in the form of datasets strongly enriched for novel rare loci were produced that can significantly contribute to ongoing efforts to investigate bipolar disorder and suicidal behavior. These data can be used in combination with other emerging datasets to generate more powerful meta- and mega-analyses to confidently identify risk loci for both phenotypes.

Non-suicidal self-injury (NSSI) is the direct, purposeful self-infliction of injury, which results in tissue damage, is performed without conscious suicidal intent and through methods that are not socially sanctioned (Nixon & Heath, 2009). The phenomenon of self-injurious behaviours is alarming, especially among adolescents and young adults (Muehlenkamp, 2005). In fact, it is estimated that lifetime prevalence of NSSI in young adults within the general population is around 12% to 38% (for reviews, see Heath, Schaub, Holly, & Nixon, 2009; Jacobson & Gould, 2007; Rodham & Hawton, 2009). While this proportion declines when assessing recent NSSI (i.e., usually performed in the past six months or in the past year), the numbers are still disturbing with 2.5% to 12.5% of young adults reporting current NSSI (for reviews, see Heath et al., 2009; Jacobson & Gould, 2007; Rodham & Hawton, 2009). The goal of this thesis is to investigate the associations between romantic relationships and NSSI in young adults and to address two major limitations that emerge from the literature, namely: a) several theoretical hypotheses have yet to be validated despite considerable advances in the scientific study of NSSI; and b) with the exception of one study, the few studies available relating romantic relationships and NSSI solely focused on the individual level of analysis instead of including both partners in the model. This goal will be addressed through three articles, each targeting specific objectives. For the sake of methodological rigor and for adequate evaluation of the constructs under study, the purpose of the first study was to validate the factorial structure of the English version of the Dyadic Coping Inventory (DCI; Bodenmann, 2008). A confirmatory factor analysis (CFA) corroborated the measurement theory of the DCI by revealing the presence of five coping factors (i.e., stress communication, supportive dyadic coping, delegated dyadic coping, negative dyadic coping, common dyadic coping) and two target factors (i.e., one’s own dyadic coping and partner’s dyadic coping). The English DCI also demonstrated good internal reliability and yielded preliminary evidence of concurrent validity. All together, these findings lead to the conclusion that the English DCI is an accurate and reliable measure of dyadic coping, and that researchers can use the English DCI confidently in their research to evaluate dyadic coping processes. The established factorial structure of the English DCI was then used in subsequent studies of this thesis. The purpose of the second study was to investigate direct and indirect associations between insecure romantic attachment, difficulties in emotion regulation and common dyadic coping strategies, and endorsement of NSSI behaviours. From an empirical standpoint, this study is the first to explore these specific relationships in one comprehensive model, targeting both interpersonal and intrapersonal strategies to deal with stressful experiences and the role it might have on one’s NSSI behaviours. Overall, the results revealed that difficulties in emotion regulation mediated the relationships between romantic attachment insecurity (i.e., attachment anxiety and attachment avoidance) and NSSI, whereas no such effects were found for common dyadic coping strategies. Findings from this study suggest that intrapersonal strategies (i.e., emotion regulation) might be more influential on one’s NSSI behaviours than behavioural strategies (i.e., common dyadic coping). This study also offers a first step towards the understanding of the romantic relational context of individuals struggling with NSSI behaviours. The next step remains to explore the couple as the unit of analysis rather than focusing on only one member of the relationship, giving way to the third study of this thesis. The primary aim of the third study was to generate a general portrait of young women’s romantic relationship functioning, distinguishing women who recently self-injured from those who have never self-injured. This study was designed to permit the exploration of not only the individual-level effects, but also potential effects from the romantic partner. Through a series of nonparametric Mann-Whitney U tests, results revealed that women who engage in NSSI behaviours are more likely to report subjective distress in the form of attachment anxiety and distrust compared to women who do not engage in NSSI behaviours. They also reported good, but slightly lower levels of, relationship satisfaction and adaptive dyadic coping strategies compared to women who have never engaged in NSSI. Findings also showed that partners of women who engage in NSSI behaviour reported more attachment anxiety than partners of women who do not engage in NSSI behaviours. The women and their partner’s reports about their romantic relationship experiences provide unique insight into the similarities and differences of individuals who self-injure and those who do not. Furthermore, a cursory exploration of the partners’ NSSI behaviours revealed that nearly one-third of the partners in a relationship with women who self-injured also reported having recently engaged in NSSI behaviours. These findings add some depth to the understanding of the relational context of those who are struggling with NSSI and provide future directions in research.

Suicide attempts and opioid dependence are important clinical issues, as both are associated with a high degree of psychiatric morbidity and elevated risk of mortality. Research has identified a number of risk factors for suicide attempts among the general population, and to a lesser extent, among heroin users. Due to a lack of case-control studies, however, it is still not known to what extent opioid dependence per se is a risk factor for suicide attempts. This thesis comprised the first study to directly examine whether opioid dependence is a unique risk factor of suicide attempts. This thesis examined suicide attempts, associated risk factors, and related comorbidity among an opioid-dependent case group and a non-opioid-dependent control group. A structured interview was used to collect data from 726 opioid-dependent cases and 399 non-opioid-dependent controls. This thesis identified a number of important findings. Firstly, although opioid-dependent individuals were more likely to report lifetime suicide attempts compared to controls, the risk factors were largely the same for both groups. It appeared that opioid-dependent individuals were characterised by a higher likelihood of the same risk factors for suicide attempts, rather than having different risks. Cases appeared to be at increased risk of suicide attempts because of increased levels of multiple risk factors. Secondly, borderline personality disorder (BPD) and impulsivity were identified as important risk markers for suicidal behaviour, especially among opioid-dependent individuals. The study concluded that the treatment of BPD should be prioritised among this group. Third, self-mutilation was identified as a clinically significant problem in its own right, however, when combined with a history of attempted suicide, the psychological dysfunction observed was found to be very high. Fourth, non-fatal opioid overdose and suicide attempts were found to be distinct behaviours. The risk factors for each were completely different. While drug-related risks were associated with non-fatal overdose, the risk markers for suicide attempts were related to the presence of psychological disorders. This thesis has highlighted important areas of concern for clinical interventions as well as for future research to explore. Considering this is the first study of its kind, future research should focus on its replication.

This research developed two best-fitting structural equation models of risk factors for adolescent depression and suicidality: a core model, which included parenting factors, gender, depression, and suicidality, and an extended model, which also encompassed personality traits (Introversion and Impulsivity) and mood factors (Anxiety and Anger). Further, this research investigated the consistency of model fit across time (Le., 1 month & 12 months) and samples, and explored the effectiveness of the ReachOut! Internet site as a psychoeducational prevention strategy for adolescent depression and suicidality. Gender, age, and location differences were also explored. Participants were 185 Year-9 students and 93 Year-10 students aged 14 - 16 years, from seven secondary schools in regional and rural Victoria. Students were given a survey which included the Parental Bonding Instrument (Parker, Tupling, & Brown, 1979), the Millon Adolescent Personality Inventory (Millon, Green, & Meagher, 1982), the Profile of Mood States Inventory (McNair & Lorr, 1964), items on suicidal behaviour including some questions from the Revised Adolescent Suicide Questionnaire (Pearce & Martin, 1994), and questions on loss and general demographics. Results supported an indirect model of risk factors, with family factors directly influencing personality factors, which in turn influenced mood factors, including depression, which then influenced suicidality. At the theoretical level, results supported Attachment Theory (Bowlby, 1969), demonstrating that perceived parenting styles that are warm and not overly controlling are more conducive to an adolescent's emotional well-being than are parenting styles that are cold and controlling. Further, results supported Millon's theory of personality (1981), demonstrating that parenting style influences a child's personality. Short-term intervention effects from the internet site were a decrease in Introversion for the full sample, and decreased Inhibition and Suicidality for a high-risk subgroup. Long-term age effects were decreased Inhibition and increased Anxiety for the fall sample. There was also a probable intervention effect for Depression for the high-risk subgroup. No location differences for the risk factors were found between regional and rural areas.

<p><strong>Introduktion: </strong>Suicidala patienter är en patientgrupp som väckte känslomässigt engagemang hos vårdpersonalen.  För att kedjan av vårdinsatser mellan den somatiska och psykiatriska vården skulle fungera optimalt behövdes ett väl utvecklat samarbete. <strong>Syfte:</strong> Syftet med studien är att belysa vårdpersonalens upplevelse av att vårda en patient som utfört en suicidal handling samt samarbetet mellan psykiatrisk och intensivvårdsavdelning vid vård av dessa patienter.<strong> Metod: </strong>Studien gjordes med en kvalitativ metod med intervjuer i fem fokusgrupper där resultatet tolkades med hjälp av en manifest innehållsanalys<strong>. Resultat: </strong>Studien visade att vårdpersonalen upplevde den suicidala patienten som en komplext och resurskrävande patientgrupp. Resultatet visade även att man önskade ett mer utarbetat samarbete runt dessa patienter mellan intensivvården och psykiatrin.<strong> Diskussion:</strong> Resultatet tyder på att för att patienter som utfört en suicidal handling ska kunna få ett bra omhändertagande och om attityderna angående denna patient grupp skall kunna förändras inom vården så bör man se över samarbetet mellan de aktuella avdelningarna. <strong>Slutsats: </strong>Det krävs tydligare riktlinjer för hur samarbetet ska se ut mellan avdelningarna detta tillsammans med handledning och utbildning då kan vårdpersonalens osäkerhet minskas och vårdpersonalen kan se varandra som en resurs att använda när situationen kräver detta. <strong></strong></p> / <p><strong>Introduction:</strong> Patients who attempted suicide is a group of patients that arouse many feelings for the caregivers. To optimize the cooperation between the psyciatric and intensive care units needs a developing cooperation. <strong>Aim: </strong>The aim of this study is to highlight the caregivers experience of caring a patient who attempted suicide act and the cooperation  between  psyhiatric and intensive care units for theese patients. <strong>Method: </strong>The study was made as an empirical study with five focus groups where the result interpret with a manifesto contents analysis. <strong>Result:</strong> The result of this stydy shows that the caregivers feels that the suicide patient is a complex and demanding group of patient's. The result even shows that the nursing staff wish a more prepare cooperation between psyciatric and intensive care unit's. <strong>Discussion: </strong>The author's of this study concider that for the patients who had made a suicid attempt should have a good tempory costady and the negative attitudes for this type of patient group demands a increase bethween the current units. <strong>Conclusion: </strong>It requires a straighter  guidelines for the cooperation between the units togheteher with education and supervision for the caregivers can the insecure behavior reduse and cooperation growe when the situation needs that.</p>

Since 1979 Iranians have experienced a variety of events that reasonably will have lasting effects on their mental health. In 1979 the Islamic Revolution took place and in 1980 eight years of Iraq-Iran war started. In recent years there has developed conflicts between Iran and the International society because of the Iranian activities in developing nuclear energy. To these can be added the social and religious limitations on the behavior of people. These limitations are experienced especially strong in the life of adolescents and young people. This thesis covers four different aspects of the mental health of Iranians. General health questionnaire (GHQ-12) was utilized to investigate the mental health of 4599 Iranian 3rd grade high school students (aged 17-18 years). The GHQ cut off was taken 7 or more. A considerable proportion of the students were at risk of suffering from mental health problems (29.5 %), girls more than boys. Periodic mental health surveys in high schools are proposed to identify students at risk and activities to improve their coping skills and problem-solving abilities. To study the methods of poisoning used for deliberate self harm, 2039 medical records in Loghman Hospital in Tehran were reviewed (52.3 % were females). Loghman Hospital is a specialized hospital for intoxication cases. In both genders the greatest proportions of individuals were in the ages 20-29. Drugs, pesticides and other agricultural chemicals were the most commonly used methods in each age group regardless of gender. Females outnumbered males especially in the youngest age group of 10 to 19 years of age. In a cross sectional study of 214 subjects from Tehran the Attitude Towards Suicide (ATTS) instrument was translated and validated in Farsi language. The coefficient alpha for all sections was more than 0.70 except for the Attitude section which was 0.68. Ten latent factors were extracted from the attitude section accounting for 61 % of the variance in the data. It is concluded that the instrument can be used to study suicide ideation and attempts in Iranian populations, but new items with special attention to Iranian cultural characteristics should be added to the attitude section. To make a cross cultural comparison of personality using the Temperament and Character Inventory (TCI) samples of 300 Germans, 300 Swedes and 316 Iranian subjects were studied. The factorial structural analysis using procrustes rotation method showed the structure of personality to be generally rather equivalent across cultures. It is apparent, however, that there are cultural differences between the Iranian and the European subjects mainly concerning character dimensions. These results support the theoretical assumptions that character development is mainly determined by socio-cultural factors during the socialization process. Based on our studies on independent samples in Iran a significant number of people are at risk of various mental health problems. A considerable number of young and adults are at risk of attempting self harm and suicide. Because of many limitations on specific topics of research in Iran including self harm and suicide we cannot present a realistic picture of this phenomenon in our society. There are different sources of tension in adolescent's life in Iran including familial and social sources. They are ever increasing in nature and in number. Besides these domestic sources of inconvenience our people is living in a kind of cold war situation which increases tension over life of all people.

Introduktion: Suicidala patienter är en patientgrupp som väckte känslomässigt engagemang hos vårdpersonalen.  För att kedjan av vårdinsatser mellan den somatiska och psykiatriska vården skulle fungera optimalt behövdes ett väl utvecklat samarbete. Syfte: Syftet med studien är att belysa vårdpersonalens upplevelse av att vårda en patient som utfört en suicidal handling samt samarbetet mellan psykiatrisk och intensivvårdsavdelning vid vård av dessa patienter. Metod: Studien gjordes med en kvalitativ metod med intervjuer i fem fokusgrupper där resultatet tolkades med hjälp av en manifest innehållsanalys. Resultat: Studien visade att vårdpersonalen upplevde den suicidala patienten som en komplext och resurskrävande patientgrupp. Resultatet visade även att man önskade ett mer utarbetat samarbete runt dessa patienter mellan intensivvården och psykiatrin. Diskussion: Resultatet tyder på att för att patienter som utfört en suicidal handling ska kunna få ett bra omhändertagande och om attityderna angående denna patient grupp skall kunna förändras inom vården så bör man se över samarbetet mellan de aktuella avdelningarna. Slutsats: Det krävs tydligare riktlinjer för hur samarbetet ska se ut mellan avdelningarna detta tillsammans med handledning och utbildning då kan vårdpersonalens osäkerhet minskas och vårdpersonalen kan se varandra som en resurs att använda när situationen kräver detta. / Introduction: Patients who attempted suicide is a group of patients that arouse many feelings for the caregivers. To optimize the cooperation between the psyciatric and intensive care units needs a developing cooperation. Aim: The aim of this study is to highlight the caregivers experience of caring a patient who attempted suicide act and the cooperation  between  psyhiatric and intensive care units for theese patients. Method: The study was made as an empirical study with five focus groups where the result interpret with a manifesto contents analysis. Result: The result of this stydy shows that the caregivers feels that the suicide patient is a complex and demanding group of patient's. The result even shows that the nursing staff wish a more prepare cooperation between psyciatric and intensive care unit's. Discussion: The author's of this study concider that for the patients who had made a suicid attempt should have a good tempory costady and the negative attitudes for this type of patient group demands a increase bethween the current units. Conclusion: It requires a straighter  guidelines for the cooperation between the units togheteher with education and supervision for the caregivers can the insecure behavior reduse and cooperation growe when the situation needs that.

Sjuksköterskor inom somatiken möter patienter med psykisk ohälsa i sitt dagliga omvårdnadsarbete. Syftet med studien var att belysa sjuksköterskans upplevelser av omvårdnad av en patient som utfört suicidal handling och vårdas på somatisk akutavdelning/akutmottagning. Författarna använde sig av en kvalitativ metod med intervjuer som datainsamlingsmetod. Tio sjuksköterskor intervjuades som arbetade inom akutsjukvård och hade minst ett års erfarenhet. Resultatet bestod av fyra teman; svårigheter i omvårdnaden, känslor i mötet med patienten, resurser och samarbete med psykiatrin. Resultat visade att allmänsjuksköterskan önskade mer psykologisk grundkunskap för att utveckla sin omvårdnad av den suicidala patienten, med exempelvis samtalsteknik, eftersom de ansåg att kommunikationen med patienten var utmanande. Även ett bättre tillvägagångssätt för att närma sig, bemöta och knyta an i en vårdrelation med patienterna. Samarbetet mellan psykiatrin och den somatiska vården var inte tillfredställande vilket gjorde sjuksköterskans omvårdnadsarbete svårare. Det behövdes en tydlighet i utförandet av omvårdnad och arbetsrutiner för patienter som vårdades inom både somatik och psykiatri. / Nurses’ within the somatic care are encountered with patients with mental illness in their daily work. The aims of the study were to enlighten nurses’ experience of caring for a patient that has committed a suicidal act and are cared for in a somatic acute ward. The authors used a qualitative method with interviews for collecting data. Ten nurses’ were interviewed that worked with acute care and had at least one year experience. The result contains four themes; difficulties with caring, feelings in meeting with the patient, resources and cooperation with psychiatry. Result showed that general nurses’ described a wish for more psychological knowledge to improve their care for the suicidal patient, for example dialogue technique, because they thought that the communication with the patient was challenging. Also a better way to get close, meet and connect in a relationship with the patient. The cooperation between psychiatry care and somatic care were not satisfying which made caring more difficult for the nurse. There were needs to clarify the caring and working routines for patients that are cared for in both the somatic and psychiatry care.