Highlights From the Latest Articles in Suicide Research

Niki Antypa; Alessandro Serretti


Personalized Medicine. 2014;11(3):255-258. 

In This Article

Understanding the Role of Anger in Suicide Risk

Evaluation of: Hawkins KA, Hames JL, Ribeiro JD, Silva C, Joiner TE, Cougle JR. An examination of the relationship between anger and suicide risk through the lens of the interpersonal theory of suicide. J. Psychiatr. Res. 50, 59–65 (2014).

The theoretical approaches examining the mechanisms that could potentially underlie suicidal behavior have helped us to better characterize this complex phenomenon. The interpersonal theory of suicide (ITS)[1] posits that two factors are pivotal for eliciting suicidal tendencies: perceived burdensomeness (the perception of being a burden to others) and thwarted belongingness (the sense of lacking connection with others). A third factor is necessary to be present to transform these tendencies to a suicidal act, an acquired capacity for suicide – the capability to accept the pain that is involved. Meanwhile several studies have associated traits, such as anger, aggression, hostility and impulsivity with increased risk for suicide,[2] and such traits have been proposed as endophenotypes of suicide.[3]

The study of Hawkins et al. was set out to investigate the relationship between anger and suicide risk through the ITS lens.[4] The authors tested the association between anger and suicidal ideation and whether it is mediated by the three factors of the ITS: perceived burdensomeness, thwarted belongingness and acquired capability to attempt suicide. They assessed all these factors in 215 outpatients with different psychiatric diagnoses. They found that there was a unique association between anger and thwarted belongingness and perceived burdensomeness, but not acquired capacity for suicide. Furthermore, the association between anger and suicidal ideation and behavior was mediated by perceived burdensomeness, which was more strongly associated with the outcomes than thwarted belongingness. Anger was also associated with more exposure to painful and provocative events, which in turn was associated with acquired capability. These associations were observed after controlling for the effects of depression severity. In summary, the study shows that problematic anger is related to two other factors, namely, feeling like a burden on others (increasing desire to kill oneself), and through an increased likelihood to be exposed to painful events (thereby increasing capability of killing oneself). However, from the present study, we cannot tell the direction of the relationships since the design was correlational. Future studies are warranted employing longitudinal or experimental designs to address the directionality of these concepts.

The ITS also supports that hopelessness, a well-known predictor of suicidal behavior also plays a role, although this aspect was not measured in the Hawkins et al. report. Specifically the theory argues that it is a specific feeling of hopelessness regarding these two states (perceived burdensomeness and thwarted belongingness) that is particularly associated with suicide risk. The relationships may differ for age groups or gender, as for example, thwarted belongingness was found to be a more significant predictor in males than in females.[5]

The study of Hawkins et al. emphasizes the need to address feelings of anger during therapy in patients who may be at risk of suicidal behavior. Interventions that focus on improving interpersonal relationships (especially with regard to feelings of being a burden or lack of connection with others) and deal with suppressed anger, could be highly useful for individuals showing these vulnerabilities.[6] Identifying genetic correlates of anger (an endophenotype of suicidal acts[3]) would further assist in identifying patients at risk for suicidal behavior early enough and in tailoring treatment using a personalized approach.