Adolescent Research Review

, Volume 3, Issue 2, pp 155–172 | Cite as

Why Suicide?

Reasons for Suicide Attempts as Self-Reported by Youth: A Systematic Evaluation of Qualitative Studies
  • Alexandra Nicolopoulos
  • Katherine Boydell
  • Fiona Shand
  • Helen Christensen
Qualitative Review

Abstract

Suicide is a complex phenomenon, and no two suicides are ever the same. While current theoretical models of suicide are heavily informed by first-rate epidemiological and clinical knowledge, little research has qualitatively investigated the motivation for a suicide attempt, from the personal perspective of the person who makes the attempt. These perspectives are particularly absent for youth, whose cognitive interpretation and reasoning skills are less likely to be adequately established than those of adults, and who may need to be approached differently to adults to ensure their reported reasons are genuinely reflected in the published literature. This study sought to identify and examine past qualitative research which has investigated motivating factors for suicide attempts among youth aged 12–25. MEDLINE, EMBASE, and PsycINFO databases were searched and a systematic narrative review of qualitative studies was undertaken. Independent raters assessed comprehensiveness of reporting of included studies. Thematic networks analysis was used to analyze the data. From 17 studies involving 613 participants, basic and organizing themes were identified and grouped into four major themes: intrapersonal, sociocultural, interpersonal and historical factors, as those directly attributed to suicide attempts. Comprehensiveness of reporting among studies was assessed, and particular subdomains identified as inadequately reported, i.e., relationships with participants, theoretical frameworks, and design and implementation of studies. We conclude that more robust and comprehensive theoretical frameworks could enhance the knowledge base of the complex and multiple factors that motivate youth to take their own lives. These findings revealed that comprehensive qualitative inquiry is essential in effectively identifying central themes which may otherwise be minimized or missed in clinical and epidemiological studies.

Keywords

Suicide attempt Adolescents Qualitative Self-report Youth 

Introduction

Research investigating why individuals attempt suicide continues to be of high importance and priority, and it seems we are making some steady progress in identifying related risk factors. (Lachal et al. 2015). There is no uncertainty as to the laudable diversity present in suicide theory literature, and there is no shortage of interpretations with regard to the reasons why people engage in suicidal behaviours. A number of theoretically diverse hypotheses represent a wide range of reasons why an individual may make the decision to attempt suicide (Lachal et al. 2015), while multiple theories further identify the motives for, and the causes of, suicide. This factor alone highlights the complexity of this phenomenon.

Thomas Joiner’s Interpersonal Theory of Suicide (IPTS) (Van Orden et al. 2010) (IPTS), for example, suggests that individuals choose suicide based on the perception that they are alone and do not belong, and that their existence is an unceasing burden to others. IPTS also reasons that a suicide attempt requires the combination of suicide desire with suicide capability. A theory more derivative of a social psychology interpretation is that of Roy Baumeister (1990), who resolved that suicide is fundamentally the outcome of an individual’s attempt to escape from oneself and escape from (the way in which they internally view) the world. And then there is “Psychache”, a term penned by Edwin Shneidman at the end of his career as a renowned suicidologist. Psychache, which Shneidman theorized to be the primary cause of suicide, refers to the inability of an individual to regulate intense emotions which have become unbearable (Shneidman 1993). These psychological conceptions of suicide form part of a broader range of theoretical constructs spanning biological (Schwartz and Corcoran 2010), sociological, social (Thoits 1999), (River 2015) and clinical (Rudd et al. 2006). Rory O’Connor’s contemporary Integrated Motivational–Volitional Model (IMVM) (O’Connor and Nock 2014), further purports that, while biological, social, cultural and historical factors are those which put a person at risk for suicide, it is the resulting intrapersonal factors such as many of those associated with “Psychache” that—much like in the IPTS model—result in suicidal ideation, and when paired with the desire and/or a capability for suicide, lead to a suicide attempt.

Collectively, current theory suggests that it is when a person at risk experiences an inability to understand, regulate and/or cope with the ensuing intrapersonal factors relative to their experience(s) that these risk factors commonly result in suicidal ideation. These models further suggest that suicidal ideation is likely to progress to a suicide attempt when a desire and/or a capability for suicide are present. While theories such as these have become the foundation of many an investigation regarding theoretical reasons for suicide attempt, very little research has sought to investigate what suicide actually means to individuals who have attempted, relative to their understanding of themselves and their own experience.

While much of this present theory and perspective has allowed us to understand more about suicide as a phenomenon (Santos 2015), suicide still continues to claim 800,000 human lives every year (World Health Organization 2014), and remains the 15th highest cause of death worldwide (de Oliveira et al. 2015). More alarming than this statistic are those that identify suicide among our younger generations as being of epic proportions. Suicide is the 2nd highest cause of death worldwide in the 15–29 year age group, the 3rd leading cause of death among Americans and Australians aged 15–24, and the 1st leading cause of death among Americans and Australians aged 5–17. World Health Organization (WHO) (2014) also reports that youth suicide is increasing at a greater rate than that of any other age demographic. It is very important to consider these statistics when considering empirical gaps exploring the reasons why people attempt suicide.

Qualitative research about the general population’s reasons for suicide attempts is limited (Biddle et al. 2013). Further, current qualitative research focusing on adolescents and young adults, has been given even less attention than it has for the general population. Given the alarming figures regarding youth suicide, and all suicide alike, this absence of inquiry is an important issue that must be addressed if we are to work toward understanding suicide. Adolescence/early adulthood is not only a significant time for identity formation, establishing a sense of self, and developing emotional resilience (Doumen et al. 2012), but also a time when not having established them could potentially contribute to suicidal ideation becoming suicidal behaviour (Joiner et al. 2005).

While the studies informing current suicide theories continue to provide essential insight into suicide as a global phenomenon, most studies have been clinical and/or epidemiological in nature. Comparatively, there is an under representation of qualitative inquiry regarding self-reported, lived experience of suicide (Biddle et al. 2013). Particularly absent are the perspectives of youth, who comprise one of the most at risk populations for suicide globally (WHO 2014). The significance of qualitative inquiry in this space is paramount if we are to understand the motives for suicide garnered from first person accounts of youth (Stewart et al. 2016).

The Current Study

There is a clear need to investigate what currently exists in literature on the lived experience of youth regarding their motives for suicide. This systematic narrative review (Saini and Shlonsky 2012; Thomas and Harden 2008) of qualitative studies aims to synthesise available evidence using a narrative approach regarding the lived experiences of youth who have attempted suicide. Secondary data in the form of published articles were used, thus research ethical approval was unnecessary.

Methods

Eligibility Criteria

Peer-reviewed studies1 published over a 20 year period (1995–2015) and utilising a qualitative or mixed-method approach (with a specific focus on the qualitative components of the mixed-method studies) were included. Participants in included studies were required to have had at least one previously recorded suicide attempt, be between 12 and 25 years of age, and to have self-reported the reason(s) why they attempted suicide in a way which allowed for their own perspectives to be verbalized, i.e., interview, focus group, case study.

Study Search and Selection

An Information Scientist at University of New South Wales Library was consulted by the first author to ensure the rigour of the study selection processes. Subsequent to this, the first author consulted with the third author to ensure minimal bias in the final search term delineation. Mutual agreement was reached and search terms (Table 1) entered into three online databases: Medline, PsycInfo and Embase (8 July 2015). The Cochrane Library of Systematic Reviews was consulted (23 July 2015) to ensure no similar reviews had been conducted.

Table 1

Search terms (keywords) as entered directly into database(s)

#

Search terms

1

Suicide attempt OR self injur$ OR self-harm OR self harm OR overdose OR poisoning

2

Reason OR why OR understanding OR suicide meaning

3

Self report OR self-report OR qualitative OR interview

4

Children OR adolescent OR child$ OR adolesce$ OR youth OR young

5

1 AND 2 AND 3 AND 4

Search limits: Human AND English Language AND Date of Publication (1995–2015)

The study selection process was informed by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) (Shamseer et al. 2015), a validated decision-making tool designed specifically for study selection purposes. The first author and third author independently reviewed abstracts against inclusion criteria. Consensus meetings were held, differences resolved, and full text articles mutually agreed upon. Figure 1 illustrates the selection process.

Fig. 1

Database origin and study selection process

Comprehensiveness of Reporting

The Consolidated Criteria for Reporting Qualitative Research (COREQ): (Tong et al. 2007) was used to gauge study quality. COREQ is a 32-item checklist that endorses completeness of reporting in qualitative inquiry, and highlights three key ‘domains’: (1) Research Team and Reflexivity, (2) Study Design and (3) Study Analysis, to be considered when reporting qualitative results. To ensure consistency with regard to COREQ comprehensiveness, the second author—a mental health professor with considerable expertise in qualitative analysis (Baker et al. 2015; Boydell et al. 2010)—conducted an independent review and ranking of randomly selected studies (25%) prior to inclusion of comprehensiveness ratings. Studies were not excluded from review based on the COREQ assessment.

Theme Extraction

To ensure the original representation of themes within studies was not confused with analyses conducted in this review, originally reported themes were documented and independently analysed (Table 2). They were further summarized and rearranged independently by multiple reviewers, from dissimilar backgrounds, to ensure objectivity (Pope et al. 2000) and eliminate bias. Each reviewer then independently analyzed all themes as per Attride-Sterling (2001)’s Thematic Networks Analysis process (Appendix A).

Table 2

Basic Themes originally identified within studies

Beekrum et al. (2011)

Bostik and Everall (2006)

Dieserud et al. (2010)

Everall (2000)

1. Hopelessness

2. Despair

3. Stressful home environment

4. High parental expectations

5. Family conflict

6. Inability to communicate with family

7. Peer vs cultural conflict

8. Stigma around family circumstances

9. Do not know how else to seek help

10. Inability to regulate emotions

11. Family relationship difficulties

12. High parental expectations

13. Unloved, rejected, unwanted

14. Low emotional expression

15. No support/unable to seek help

16. Unhealthy home environment

17. Poor family/peer communication

18. Peer relationship difficulties

19. Unhealthy social environment

20. Inability to regulate emotions

21. Inability to express emotions

22. Family dysfunction

23. Drugs or alcohol

24. Work/school problem

25. Mental health problems

26. Negative life events

27. Interpersonal relationship conflict

28. Do not understand the meaning of negative emotions therefore do not know how to regulate them

29. Do not have the ability, education or resources to help seek

30. Family difficulties in childhood

31. Burdensomeness

32. Negative social relationships/isolation

33. Internal and external expectation pressures

34. Negative emotional experiences

35. Inability to regulate emotion

36. Rejection (real and perceived)

37. Depression

38. No control over others or self

Everall et al. (2005)

Everall et al. (2006)

Herrera et al. (2006)

Keyvanara and Haghshenas (2011)

39. High parental expectations

40. High self expectations

41. Inability to regulate emotions

42. Unhealthy social environment

43. Alienated

44. No control over life

45. Lack of support

46. Peer difficulties

47. Family relationship difficulties

48. Desperation/hopelessness

49. Helplessness

50. Hating oneself

51. Shame related to negative emotion/inability to regulate

52. Alienation/loneliness

53. No control over life

54. Inability to reach-out

55. Stigma of life circumstances

56. Poverty

57. Inability to access help—no one to go to/do not know how/shame

58. Conflicts with family

59. Physical/Sexual abuse

60. Escapism

61. Helplessness/hopelessness

62. Inability to understand and/or regulate emotions

63. Desperation

64. Loneliness/isolation

65. Shame related to emotions

66. Difficulties with partner

67. Religious vs internal views

68. Conflict within the family

69. High parental expectations

70. High self expectations

71. Poverty

Kidd and Kral (2002)

Kienhorst et al. (1995)

Klineberg et al. (2013)

Obando Medina et al. (2011)

72. Traumatic childhood experience

73. Family relationship conflicts

74. No control over self or others

75. Low self-worth (prostitution)

76. Drug/alcohol/financial dependence

77. Isolation/rejection/betrayal

78. Difficult romantic relationships

79. Only way to reduce pain

80. Desperation/escape pain

81. Only way of help-seeking

82. No control over life

83. Rejected/misunderstood

84. Revenge

85. Burdensomeness

86. Helplessness

87. Negative life experiences/situation

88. Desire for escape

89. Hopelessness

90. Burdensomeness

91. Helplessness

92. Indirect help seeking

93. Revenge

94. Inability to seek help/communicate with family/professionals

95. Poverty

96. High expectations from family/self

97. Desperate only way to cope/escape

98. Hopelessness

99. Suicide contagion

100. Alcohol/drug abuse

101. Negative life event

Orri et al. (2013)

Shilubane et al. (2012)

Wasserman et al. (2008)

Yang (2012)

102. Alienated/unaccepted/rejected

103. Shame/guilt about state of life

104. Hopelessness/‘nothing left’/escape

105. No control over self or life

106. Revenge/only way to communicate

107. Communication barriers in family and peer relations

108. Inability to communicate and seek help (do not know how/where)

109. Negative family relationships

110. Inability to regulate emotions

111. Family relationship(s) conflict

112. Worthlessness

113. Poverty

114. False accusations/ being wrongly ‘blamed’ or accused

115. Lack of family/community and/or peer support

116. Lonely/isolated from peers

117. Depression

118. Inability to regulate and understand emotions

119. Negative life events

120. Inability to deal with negative emotions/thoughts

121. Revenge

122. Relationship conflict in family

123. Conflict with partner

124. Inability to seek help

125. Lack of adequate support

126. Hopelessness

127. Negative life circumstances

128. False accusations/ being ‘blamed’ for faults that are not their own

129. Revenge

130. Stigma of family status

131. Family relationship conflict

132. Pressure to succeed

133. Shame in expressing emotion

134. Inability to regulate emotion

135. Hopelessness

136. Peer/community rejection

Zayas et al. (2010)

137. Inability to regulate and/or cope with negative emotions

138. Escapism/‘only option’

139. Isolation/peer alienation

140. Revenge

141. Conflict among family/peers

142. Domestic/family violence

Results

Study Selection

The search yielded 642 articles, 17 of which met all inclusion criteria. Fourteen were qualitative studies and three employed mixed methods. Data collection and analysis methods differed throughout, as did the number of participants in each study. The total number of individuals in the synthesis was 613 (M = 36.06) with the range of participant numbers comprising n = 1 to n = 254. Individual characteristics of each study are reported in Table 3.

Table 3

Relevant features of previous studies which have explored self- reported reasons of suicide attempt in young people

Characteristics of reviewed studies

Methodology

Participants

Study

Country

Aims

Author discipline

Data collectiona

Data analysisb

n =

Age

Beekrum et al. (2011)

South Africa

To investigate how cultural influences may contribute to suicidal behaviour(s) of Indian adolescent females residing in South Africa

Psychology

FI

TA

10

14–17

Bostik and Everall (2006)

Canada

To investigate the relationship between suicide attempts as self-reported by adolescents, and their attachment profile

Counselling

SSI

GT

50

13–19

Dieserud et al. (2010)

Norway

To present and assess trends over a 22 year period relating to triggers and reasons for suicide attempt in Norwegian adolescents

Public health, psychiatry

SSI, Q

PH, TA, RA

254

13–19

Everall (2000)

Canada

To qualitatively explore the meaning of suicide attempts relative to the individual experience of young adult attempters

Counselling

SSI

II

19

20–24

Everall et al. (2005)

Canada

To explore how developmental factors may interrelate and influence the relationship between suicidal ideation and behaviour

Counselling

CS

N/A

1

20

Everall et al. (2006)

Canada

To obtain self-reported emotional experiences of young people relative to when they were in a suicidal state

Counselling, psychology

SSI

GT

50

15–24

Herrera et al. (2006)

Nicaragua

To examine how adolescents report the events leading up to, and the influence of these events, on suicide attempt(s)

Sociology, psychiatry

SSI, N

GT, TA, CA

8

12–19

Keyvanara and Haghshenas (2011)

Iran

To explore the social and cultural factors reported as reasons for suicidal behaviours in Iranian youth

Social science

SSI

ETH, TA

25

14–17

Kidd and Kral (2002)

USA

To qualitatively capture the experiences of youth who live on the streets, relative to their individual suicidal behaviour(s)

Psychology

SSI,N

GT, CA

29

17–24

Kienhorst et al. (1995)

Netherlands

To explore the behaviours, cognitions and emotions reportedly experienced by youth before and during their suicide attempt

Psychology, public health

SSI, Q

PCA

48

14–21

Klineberg et al. (2013)

England

To explore youth attitudes pertaining to help-seeking behaviours, their help-seeking methods, and how they are understood

Public health, psychiatry

SSI

ETH, TA

30

15–16

Obando Medina et al. (2011)

Nicaragua

To examine how adolescents report the events leading up to, and the influence of these events, on suicide attempt(s)

Public health, sociology

SSI

ETH, GT

12

15–24

Orri et al. (2013)

Italy

To explore why adolescents and young adults attempt suicide, and to ascertain whether they are driven, even in part, by revenge

Psychology, public health

SSI

PH

16

15–25

Shilubane et al. (2012)

South Africa

To obtain an understanding of how adolescents perceive their psychosocial environment as catalysts for their suicide attempts and how this may help inform appropriate intervention

Psychology, public health, nursing

SSI

PH, ETH, GT

14

13–21

Wasserman et al. (2008)

Vietnam

To explore how young persons’ living in a rural community express their suicidal ideation, their understanding of the suicidal process, and potential contributing psychosocial factors

Public health, psychiatry

SSI, N

GT, TA, CA

19

15–24

Yang (2012)

South Korea

To explore the life history of a young female adolescent who has a history of attempting suicide, her understanding of her situation, and what she reports as the meaning behind her suicidality

Public health

LH, N

PH, ETH, LH

1

16

Zayas et al. (2010)

USA

To explore what factors are reported as catalysts for suicide attempts in young adolescents of ethnic minority background, and how they reflect on their attempt(s)

Public health, sociology

SSI, Q

PH, ETH, TA

27

11–19

aData collection: SSI semi-structured interview, N narrative, LH life history, FI focused interview, Q questionnaire, CS case study

bData analysis: PH phenomenology, ETH ethnography, GT grounded theory, II interpretive inquiry, PCA principal component analysis, RA regression analysis, TA thematic analysis, CA content analysis

Comprehensiveness of Reporting

Given that the tool used to assess comprehensiveness of reporting (COREQ) is specifically designed for interviews and focus groups, Study 5—a case study—was not included in the studies assessed for comprehensiveness of reporting, leaving an n of 16. A rating system was devised based on the extent to which each of the eight COREQ subdomains had been addressed, as reported in each individual study. Due to each subdomain comprising a different number of items, each was allocated a rating of Comprehensiveness: “High” (71–100% of items met): “Medium” (41–70% of items met): and “Low” (under 40% of items met). This was then assessed relative to the three major COREQ domains (Domain 1: Research Team and Reflexivity, Domain 2: Study Design and Domain 3: Study Analysis), and an overall rating obtained. Comprehensiveness of reporting was found to be variable.

Of the 16 studies, four (25%) were considered to be highly comprehensive overall, five (31%) were considered average, and seven (44%) were considered low. The level of COREQ subdomains rated as being highly comprehensive varied considerably: selection of participants (81%), reporting of results (50%), personal characteristics of participants (44%), data analysis (38%), adequate theoretical framework (38%), data collection (25%), and relationship with participants (25%).

Thematic Analyses

Thematic Network Analysis (Attride-Sterling 2001) was used to robustly and systematically assess the qualitative data for recurring patterns and/or themes. Applying this framework to the 17 articles examined in this review, four global themes were identified, each consisting of their own distinct organizing themes, and directly extracted basic themes (Table 4). These global themes: Intrapersonal, Interpersonal, Sociocultural and Historical were considered to best reflect all represented themes, and are detailed below. While each of these themes are presented as distinct, they are intimately intertwined.

Table 4

Results of thematic network analysis; basic, organising and global themes

Basic themesa

Organising themes

Global themes

5, 6, 11, 17, 18, 27, 46, 47, 58, 66, 68, 78, 84, 93, 101, 106, 107, 109, 111, 114, 121, 122, 123, 128, 129, 131, 140, 141

Emotional mental state

Presence of negative emotions

Desperation, escape, control

Health factors

Global theme 1

Intrapersonal factors = suicide attempt

1, 2, 10, 13, 20, 21, 23, 25, 28, 31, 35, 36, 37, 41, 43, 44, 48, 49, 50, 51, 52, 60, 61, 62, 63, 64, 65, 73, 74, 75, 76, 77, 79, 80, 82, 83, 85, 86, 88, 89, 90, 91, 97, 98, 100, 102, 103, 104, 105, 110, 112, 116, 117, 118, 120, 133, 134, 135, 137, 138

Support access issues

Socioeconomic adversity

Reactive response

Expectations of self/others

Global theme 2

Sociocultural factors = suicide attempt

3, 4, 7, 8, 9, 12, 14, 15, 16, 19, 22, 24, 26, 39, 32, 33, 38, 39, 40, 42, 45, 53, 54, 55, 56, 57, 62, 67, 69, 70, 71, 81, 92, 94, 95, 96, 99, 108, 113, 115, 124, 125, 126, 130, 132, 136, 139

Relationship conflict

Revenge

Isolation and loneliness

Global theme 3

Interpersonal factors = suicide attempt

30, 34, 59, 72, 87, 119, 127, 142

Traumatic life events

Other negative life events

Global theme 4

Historical factors = suicide attempt

aNumerical representation of each originally reported theme as represented in Table 2

Intrapersonal Conflicts and Challenges

Intrapersonal conflicts and challenges accounted for 42.3% of self-reported reasons for suicide attempt. Basic Themes were identified as internal conflicts and distresses: that is, the feelings and emotions experienced at the time of the attempt and inability to effectively manage these feelings and emotions. These were subsequently categorised into four Organisational Themes: Emotional Mental State, Presence of Negative Emotions, Desperation/Escape/Control and Health Factors.

Emotional Mental State

Feelings of hopelessness, helplessness, worthlessness, burdensomeness, emptiness and shame were commonly reported in most studies. Not only did participants report experiencing one or more of these feelings for a prolonged period, many reported these factors as direct contributors to their attempt. This 23-year-old male expressed that hopelessness and entrapment quelled his desire to live:

Everything seemed dark in a lot of ways. I had the feeling of being trapped, sometimes hopelessness, like I wasn’t ever going to get out of it, it wasn’t ever going to end. I knew I couldn’t take another day of feeling like this and I didn’t want to. I saw no alternative other than suicide (Everall et al. 2006, p. 378).

Worthlessness was a common catalyst for a suicide attempt throughout the studies. Its presence was identified more than 75% of studies, with a further 10% of studies containing participant responses which suggested that while worthlessness had not been directly stated, it had indeed been a contributing factor.

I felt worthless, that I’d be better off dead. All I thought was that I don’t have a purpose. I don’t want to be on this earth: maybe I’m better off dead (Beekrum et al. 2011, p. 66).

That day, I took the pills looking myself in the mirror… I kept repeating that I was disgusting, that no one really cared about me… [I was thinking] that everything about me was wrong! That nothing I did came out right… I don’t know, I continued this thing of not feeling accepted, not feeling that anybody cared about me… (Orri et al. 2014, p. 3).

Presence of Negative Emotions

There were a significant number of responses in which participants indicated their suicide attempts were due to the presence of obstinate negative emotions. Whether they reported attempting suicide due to an inability to understand the source of these emotions, or because they had little or no ability to regulate the emotions once they arose, nearly all of those who attributed their attempt to negative emotions identified that the emotions were present immediately before the attempt, and a definite contributing factor.

I was totally negative. I was so angry at everything. I was depressed and angry and I didn’t know why I was feeling that way (Everall et al. 2005, p. 701).

I was a ticking time bomb really. I could at any moment cry, scream, have explosive anger. It came out at strange times. It was lonely, scary, because you don’t trust anyone but you don’t trust yourself either. It’s isolating (Bostik and Everall 2006, p. 280).

With regard to the actual act of attempting suicide, participants reported that although the inability to regulate/understand their emotions had been a considerable driving force behind the reason they had attempted suicide, the act itself was generally driven by an impulsive urge to be rid of the emotional turmoil.

… all of a sudden it’s just all there and you can’t escape it… your past is there, your present is there, your hopeless future, it’s all just in front of you. So at that point, how do I get rid of all these visions in my head, and want to just kill myself (Kidd and Kral 2002, p. 424).

Control, Desperation and Escape

Desperation, desire for escape, and a significant lack or loss of control, were reported by many participants as being directly attributed to their attempt. Further, participants who reported their attempt to have been impulsive were more likely to have reported these three triggering factors, than those who did not.

Control

It was widely reported that respondents felt they had lost complete control over themselves and their circumstances, as well as having no control over the actions and opinions of others. Further to feeling lack of control, many respondents reported attempting suicide in a desperate effort to regain control over something (i.e., they felt partaking in the act itself could only be controlled by them).

Not being in control of your life, I guess I just had it. I thought if life is just going to keep on going like this, this isn’t normal… so there wasn’t anything else to do. There wasn’t anything else to control, just to call my own (Everall 2000, p. 120).

Desperation

While participants widely reported a desperate desire for control, they also tended to openly disclose “not knowing what else to do”. Some indicated they felt “stuck” in their condition and unable to find a way of becoming ‘unstuck’.

A lot of times for me it was just being there and empty, and it is impossible to explain to someone who has never been there. They can’t understand. When you have no money, no food, no home, no clothes, no possessions, that’s when you feel empty (Kidd and Kral 2002, p. 423).

Escape

“Escape” was a recurring term used among respondents, and was found to be a common theme throughout many of the studies. Irrespective of whether suicide attempts were directly attributed to the desire to escape, many participants reported they were desperately seeking an escape from their inner turmoil at the time of their attempt.

I was trying to meet new people or find ways out of [feeling suicidal] but the fact remained that I was still at home with the same problems. I would go home to the things that were making me miserable. There was no real way out of it (Bostik and Everall 2006, p. 277).

Health Factors

Within the global theme of intrapersonal conflicts and distresses, health factors were the least prevalent of reported reasons given by participants as to why they attempted suicide. The importance of including health factors as an organizing theme, however, became apparent when the content of these responses was considered. Where dependence on alcohol and other drugs was given as a reason for suicide attempt, e.g., there were several other issues present, independent of the addiction (i.e., desperation, escapism, hopelessness).

It is the crashing, because after the high is gone, you have nothing. The high is gone, you are feeling depressed again, you can’t afford anymore drugs, you know, problems are back all over again (Kidd and Kral 2002, p. 422).

Other health factors found to contribute to the suicide attempt of participants were: the status of their psychological health at time of the attempt (whereby a suicide attempt was directly reported to be related to presence of an existing diagnosis, e.g., Post-Traumatic Stress Disorder), and the physical health status of themselves and/or those close to them. Like drug and/or alcohol dependence, where the addiction is often accompanied by other mitigating variables, physical illness was often accompanied by other risk factors. The response below, given by a 19-year-old female who attempted suicide after becoming a full-time carer to her sick mother, encapsulates that although the illness was stated as the reason for the attempt, many other contributing factors were at play.

My mother is sick. I found it this year that my mother is HIV positive because most of her pills she showed them to me, because myself I knew those pills before, she ended up telling me. Then I saw if I do not go to school there is no one who will work for me and my mother, it is me who has to take care of my mother (Shilubane et al. 2012, p. 183).

Sociocultural Factors

Sociocultural factors accounted for 33.1% of the reasons reported by all participants for their suicide attempt. Basic Themes were identified pertaining to negative and unfavourable sociocultural environment, including the presence of socioeconomic hardship, inability to access support, and significant cultural divide. These were subsequently categorised into the following four Organisational Themes: Support Access, Socioeconomic Adversity, Rejection and Internal and External Expectations.

Support Access

While issues with accessing support may be considered more of a contributing factor to suicidal ideation rather than a factor contributing to suicide attempt, and while participants in most studies confirmed that their inability to access support contributed to much of their suicidal ideation, it also became evident that access to support can be imperative for a young person who has escalated from ideation to attempt, or perhaps even prevent them from doing so.

If you had someone there it wouldn’t come to your mind to do those things but it’s at a time when you, when kids have no one at all that you would do the craziest things and not care at all how it hurts you (Klineberg et al. 2013., p. 6).

Participants identified some universal barriers which prevented access to support, and which they considered to be substantial contributing factors to their attempt. Most commonly reported was an upbringing that discouraged help seeking for mental health issues. Negative family attitudes affected access to support as evidenced by numerous reports of inability/apprehension to seek support from family members in times of crisis.

I wasn’t used to sharing my feelings because I’d never really had feelings, because I wasn’t really allowed. I was told how to feel my entire life (Everall et al. 2006, p. 383).

Further, participants reported developing an inability to reach out to others, as a result of becoming accustomed to the deeply engrained philosophy that you should not seek support:

Well… in my family everybody makes their own lives and nobody share anything with anybody, nor even a word or sample of love. Maybe if I had someone to support and listen to me, maybe I would stop thinking crazy things. Maybe this person would advise me (Herrera et al. 2006, p. 810).

Given the young age of respondents in these studies, emotional vulnerability, fear of being stigmatised and fear of peer rejection, were additional barriers. Although participants did not directly attribute these to the reason why they made the attempt, many—like the 19-year-old female below - indicated a relationship between these factors and their inclination to seek help/access support.

I didn’t want people to know I was suicidal. I was just really ashamed and worried that people would find out and look down on me (Everall et al. 2006, p. 379).

Another commonly reported barrier preventing participants from accessing support was availability of support itself. There were reports of participants turning to a suicide attempt because they did not know of anything/anyone who was available amidst their crisis.

All my attempts were done by myself. No one was there. So I am all alone. I am by myself, there is nothing there, no one cares (Kidd and Kral 2002, p. 423).

Another perception among participants regarding availability of support was that even where support was available and/or accessible, there were limitations on where, when and how these supports could be accessed, and their subsequent availability. The general attitude regarding this was that support for suicidal ideation/behaviours could be accessed, but only conditionally.

There is a priest who only helps members of his church (Beekrum et al. 2011, p. 68).

Socioeconomic Adversity

Growing up poor, living in poverty, and struggling with socioeconomic circumstances of themselves and/or their families, were issues reportedly faced by many participants. The act of attempting suicide was frequently attributed directly to socioeconomic adversity. One participant, aged 15, simplified her suicide attempt to that which appeared as a simple mathematical equation.

I am living with my family. My family is big. We are 7 sisters and brothers. My father does not have a skilled job…His income is so low that he cannot support us… Last night, when I realised my father had no money to buy food I became so Narahat [sad]. We slept while all of my sisters and my brothers were hungry. I thought the best way to reduce some of the family expenses would be the removal of family members. Therefore, I thought by taking my own life family’s difficulties would be eased (Keyvanara and Haghshenas 2011, p. 533).

Other respondents reported their socioeconomic circumstances to be one of the reasons why they attempted suicide, but not the sole reason. As indicated below, an 18-year-old male participant stated clear intent to die attributed (in part) to socioeconomic hardship.

My intention was to die in order to forget about everything because in most time my stepfather tells my mother to take everything that belongs to her and leave his home. He says he cannot afford to buy food for the children that are not his, we have to go to our biological father (Shilubane et al. 2012, p. 181).

Rejection

Rejection, both real and perceived, was reported by many participants. Whether rejection by peers, rejection by family members and/or rejection by their communities, nearly every study reported at least one participant who reported feelings of rejection. As previously mentioned of socioeconomic adversity, rejection was rarely the sole reason for a suicide attempt. It was, however, regarded as a contributing factor by many.

I felt alienated and alone all those years… I was searching for closeness with my family. I’ve always wanted to feel like my mom loved me or that I sort of belonged somewhere I guess. I always felt like I was different in some way that I never fitted in anywhere. And I never understood why (Everall 2000, p. 118).

I sometimes felt my life was meaningless, and I wanted to put an end to my life. I was the only son in my family, but most of my family members have hardly spoken to me. An only son is said to be treated beautifully, but it seemed to be the opposite in my case. Almost every day, I was blamed for various things during mealtimes. I was even treated worse than a dog… (Wasserman et al. 2008, p. 49).

Rejection, in some instances, was reported as either the sole reason for a suicide attempt, or a contributing factor for why the suicide attempt occurred, even with the co-occurrence of other factors. In these cases, it appeared respondents had experienced multiple rejections, across multiple platforms. This is exemplified by the following quote by a young homosexual male who lived on the streets, and worked as a sex worker.

Some of us [gay persons] go through a lot of shit. Like me, and my parents… my dad holding me up by my neck, three inches off the ground when he found out I was gay, saying why are you a fucking faggot. [regarding the attempt] I was just feeling abandoned because I was adopted, and then my parents kicked me out of the house after they adopted me and just issues like that, and I just felt worthless (Kidd and Kral 2002, p. 420).

Internal and External Expectations

Many respondents referred to a personal struggle or inability to meet expectations they had set for themselves, and/or the expectations set for them by others (real or perceived). Moreover, there were some reports that the pressure of maintaining an image associated with these expectations contributed to why help/support was not sought, henceforth, why an attempt may have subsequently occurred.

I had this idea that asking for help or telling somebody how you’re feeling would be a sign of weakness. I had a real tough image back home. I was a body builder. I was over 200 pounds. I never lost a fight. So I couldn’t talk to my friends because it was a sign of weakness and I didn’t talk to my parents much at all. I didn’t want to burden them. I didn’t want to trouble them. I didn’t want them to worry (Everall et al. 2006, p. 379).

Well, you know… In my family we (men) are used to support our women; if she needs something well she just have to ask for it! We (men) are here to help the women not the other way around… sincerely I am not used to the fact that she supports me. I am really ashamed to say that… She is working and I am not… I just feel like a clown! (Obando Medina et al. 2011, p. 22).

Respondents who reported struggling to meet external expectations placed upon them identified a range of expectations from diverse external sources. While expectations of peers and family members were regarded as important, and having a negative impact on respondents when they could not meet them, educational and cultural expectations (which were often the basis of expectations set by family and peers) and the pressure associated with meeting these were more commonly reported.

“My mother prepared me seriously for exams from the 4th grade. She did not let me sleep until I memorised the whole exercise book. I tried to memorise it until 2–3o’clock in the morning… Until high school, my mother used to sit in front of me and watch me studying during the exam week” (Yang 2012, p. 262).

Interpersonal Relationship Conflicts and Challenges

Interpersonal relationship conflicts and challenges accounted for 19.7% of the reasons reported by participants for their suicide attempt. Basic Themes were identified pertaining to conflicts among family members, friends and/or romantic partner and challenges with developing, maintaining and sustaining interpersonal relationships (perceived and/or real). Upon further investigation and analysis of these basic themes, three Organisational Themes: Relationship Conflict, Revenge and Isolation and Loneliness, were developed.

Relationship Conflict

Many studies indicated that steady and strong interpersonal relationships were important to participants, irrespective of whether they considered their own relationships to be as such. Those who reported conflicts within their interpersonal relationships tended to express longingness for resolution. Conflict with family members was the most significant relationship conflict reported as a reason for attempting suicide (in comparison to peers and romantic partners), particularly if participants perceived the conflict as unresolvable.

During dinner my mother like always repeatedly blamed various things on me. Moreover, my older sister came home and backed my mother up in the way she was speaking to me. I became very upset because I thought I was right, yet I was seriously blamed by my sister and my mother. I was tired after a long day’s work, and very irritable. I did not have any hope for a change in my life. I stopped eating, left the living room, and went to my bedroom. This was a small room next to the living room, separated from it by a curtain. I poured a packet of pesticide into my mouth without hesitation… (Wasserman et al. 2008, p. 50).

Conflicts and issues existing within romantic relationships of participants were reported as a reason for suicide attempt in a few studies, however, it appeared that romantic relationships may have been conflated with family relationships in some instances.

Every day my husband gambled and his behaviour affected our family finances. I tried to tell him, but he did not change. On that day, my husband continued gambling. I felt angry. We had an argument, I felt that life was not worth living and I went out to buy raticide (Wasserman et al. 2008, p. 49).

With regard to reported conflicts with peers being a catalyst for suicide attempt, it was difficult to ascertain the difference between real and perceived peer conflict. Very few investigators probed further regarding the nature of the conflict reported, or the reasons for which the relationship challenges arose (i.e., conflict as a result of isolating oneself vs conflict as a result of bullying).

They (peers) were different. They had no clue. I think that was a big part of why I didn’t have any friends was because I couldn’t relate to anybody. They were all smiling and laughing, and there I was feeling like my world was crushing me (Bostik and Everall 2006, p. 279).

Reactive Response

Suicide attempt as a reactive response appeared throughout a number of studies. This was sometimes conceptualised as “revenge” but more commonly reported as a desperate attempt to make a powerful statement as a result of inadequately being able to express feelings and thoughts. Among those who reported a reactive response, some described their act as an impulsive reaction to direct conflict, while others reported their attempt as calculated or as being attributed to ongoing conflict.

I knew I was not going to die. I just wanted to do something to change my mothers’ attitude (Beekrum et al. 2011, p. 66).

There was a big fight. She got on my nerves. I was so mad. I was so mad that I couldn’t think anything. I said to myself, ‘I will just drink it [methyl alcohol]! This is the end!’ Then, I took it… I did not plan it. It was an impulsive action. Rather than trying to really kill myself, I think I wanted to show my mother how angry I was (Yang 2012, p. 263).

Isolation and Loneliness

Isolation and loneliness were reported a lot. Although there was a significant thematic presence in reported feelings of isolation and loneliness, there was also no direct indication as to whether the isolation and loneliness was solely attributed to feeling isolated and alone (which would perhaps make this an intrapersonal factor), or whether their circumstances were causing others to isolate them, resulting in loneliness.

I felt I was in a world where I didn’t belong. I just wanted to be normal when I was suicidal. I wanted to be the same as everyone else. But I felt very different, like I was the outsider (Everall et al. 2006, p. 380).

The above quote of a 20-year-old female who attributed isolation and loneliness as a reason for her suicide attempt is indicative of the nature of many of the responses given across studies. Like others, however, this depiction does not indicate whether her reported feelings of isolation and loneliness are supported by actually being lonely and isolated. Even where reference was made to loneliness in the physical sense it had not been separated from feeling.

I felt as if on this earth I am just alone, in actual fact I felt as if there is no person who I can talk to and understand. I then got into the house and felt so lonely, and did not know what to do (Shilubane et al. 2012, p. 182).

Historical Factors

Historical factors accounted for 4.9% of the reasons reported by all participants for their suicide attempt. Basic Themes were identified as life events which had been traumatic in nature and/or had had another form of negative influence, and subsequently, delineated by two Organisational Themes: Traumatic life events and other negative life events.

Traumatic Life Events

Traumatic life events were considered those in which respondents explicitly attributed a traumatic event, or an ongoing series of traumas, as the catalyst for their attempt. Physical/sexual abuse was the most commonly reported traumatic life event directly correlated with suicide attempt. Below is a description by a young male, of how a lifetime of ongoing physical abuse contributed to his suicide attempt.

Getting beat up almost every day sometimes and… you go through many years of that, especially as a child, and you don’t have any self-worth. Nobody has taught you to have self-worth. You are just taught that you are nothing and anything you do you deserve to be beaten and you deserve to die (Kidd and Kral 2002, p. 420).

The decision to attempt suicide as a result of traumatic experience(s) was also attributed to single incidences of sexual abuse/rape, as communicated by this 13-year-old female:

he started touching me around my chest area and I was telling her “I want to go home, I wanna go home”. She started yelling at me. She was like “You’re not coming home, you’re not coming home”. She wanted to start her summer with her husband… She was only worrying about herself. She didn’t let me go home. Two nights after that, that’s when it happened [attempted suicide with Tylenol and Codeine] (Zayas et al. 2010, p. 8).

Other Negative Life Events

Other negative life events were considered non-recurring traumatic events, such as suicide of a loved one or loss in general. What differentiated other negative life events from traumatic life events was that those suicide attempts considered “other”, appeared to be the eventual consequence factors such as an ongoing grieving process which had been undealt with, rather than a direct response to the traumatic incident itself.

My father killed himself when I was 8. I saw him hanging from a tree (Beekrum et al. 2011, p. 67).

After my brother’s death I felt lonely and needed someone to talk to since he was the one I was sharing my problems with (Shilubane et al. 2012, p. 181).

The way in which negative life events may precipitate suicidal behaviour(s) can vary among youth. This became particularly evident when comparisons were made between the reasons given by youth from different cultural backgrounds. For example, a 16-year-old Korean girl whose mother had lied to her about her father’s death to protect them against the stigma associated with being a single-parent family in Korea, described the lie to be more traumatic than the news of the death.

My mother eventually told me as she wept. I was so shocked that I could not control my urination for a while. It was more shocking than my father’s death itself that my mother had to lie to me (Yang 2012, p. 260).

Discussion

Current theoretical models of suicide, such as Joiner’s IPTS (2005) and O Connor’s IMVM (2011), purport that suicide is a three-phase process comprising a risk phase, an ideation phase, and an attempt phase. The risk phase is generally characterized by an individual’s exposure to a range of background and triggering factors, while the ideation phase is associated with a range of resulting intrapersonal factors, as well as the subsequent inability to effectively regulate, manage and/or cope with associated emotions. It is when these intrapersonal factors are paired with a capability and/or desire for suicide, that the attempt phase is likely to occur.

While the studies informing current suicide models continue to provide essential insight into suicide as a global phenomenon, most of them have been clinical and/or epidemiological in nature. Comparatively, there has been an under representation of qualitative inquiry regarding self-reported, lived experience of suicide. Particularly absent have been the perspectives of young people, who comprise one of the most at risk populations for suicide globally. In this review, we comprehensively examined the qualitative perspectives of youth regarding their motives for suicide. Consistent with the risk-ideation-attempt trajectory purported by current models of suicide, we found that nearly half of all self-reported motives for suicide attempt pertained directly to intrapersonal factors.

Additionally, adolescence/early adulthood is a significant time for identity formation, establishing sense of self, and developing emotional resilience (Doumen et al. 2012). Consequently, it might be reasonable to expect that intrapersonal conflicts and challenges would be those most commonly reported by young participants as reasons for suicide attempt. Our review also supported this. What is not highlighted in current suicide theory, however, and what we found to be true in this study, is that the majority of reported motives for suicide attempts when investigated qualitatively, are directly attributed to factors that are not essentially intrapersonal—namely: sociocultural, interpersonal, and historical factors.

Thematic Network Analyses

Themes were extracted from each of the 17 studies, grouped into “basic” and “organizing” themes and further classified into four “major” themes. Despite the basic and organizing themes being presented in a linear fashion, the reasons are complex and interdependent. We identified a total of four major themes regarding youth perspectives: intrapersonal, sociocultural, interpersonal and background/triggering factors. As abovementioned, intrapersonal factors accommodated for just under half (42%) of the self-reported motives for suicide attempt. Among those intrapersonal factors most commonly reported by participants as being present at the time of their attempt were worthlessness, helplessness and hopelessness. Additional intrapersonal themes commonly identified were desperation, a desire for escape, and a desire for control (of self and/or others).

Sociocultural factors, particularly poverty and issues with accessing support, were reported by the majority of participants, with most studies conducted in low-income and/or ethnically diverse populations (62%). Further, these sociocultural factors were cited as direct reasons for suicidal behaviour(s), rather than only risk factors, which current theory would suggest. Although less common than sociocultural factors, responses directly attributing interpersonal and historical factors as reasons for suicide attempt were also frequent—a finding not in keeping with the current literature that details the risk-ideation-attempt sequence. O’Connor’s IMVM, one of the most current and widely utilised suicide models, explicitly identifies—as do a number of other models (O’Connor and Nock 2014) - that these factors contribute to individuals being at risk for suicide. One-third of participants in our narrative review, however, reported that one or more of these factors were directly attributed to their attempt.

In short, current models do not reflect youth’s self-reported motives. Our findings indicate that models of suicide might need to consider self-reported motives for suicide. Theoretical frameworks of suicide might be more comprehensive and more explanatory if they were to place more emphasis and consideration on examining the sociocultural and intrapersonal factors that youth describe as being directly implicated in a suicide attempt.

Comprehensiveness of Reporting

Using COREQ to assess the comprehensiveness of reporting, we found many studies failed to provide detail regarding the ways in which they had systematically considered quality appraisal in the study design and/or implementation phases. Reporting of the process for establishing participant relationships (with the researcher) were rarely reported in a comprehensive manner. It is essential that quality relationships be established when conducting suicide based research, particularly regarding qualitative research. Interviewer/interviewee relationships should be prioritised at study onset, and throughout. When undertaking health research, particularly when it is of such a sensitive nature as suicide, it is essential to the quality of the research that participants feel they can understand, as well as be understood (Dickson-Swift 2005). This proves even more vital when considering research with youth exhibiting suicidal ideation and/or behaviours, as they are a particularly vulnerable and high risk population (Bertolote and Fleischmann 2015). It is highly possible that the research setting may be the first time they have articulated their experience, potentially setting a precedent for how they communicate highly sensitive information in the future.

Similarly lacking was comprehensive reporting of data collection processes. The theoretical frameworks or methodological orientations employed to support study rationale/s were another area of concern, with most studies indicating low to medium levels of comprehensiveness in terms of reporting these frameworks. Further, one-third of all studies failed to provide any evidence of adequate consideration of theoretical and/or conceptual frameworks. Low levels of comprehensiveness in reporting relative to the design and implementation of studies was also found, pointing to a further area that needs to be addressed.

Limitations

The purpose of this review was to explore reasons for suicide attempt as self-reported by youth. The suitability of studies was carefully considered, pertinent selection criteria was employed, and stringent reviewing processes were undertaken, to ensure information remained relative to the purpose, and to minimise risk of selection bias. Seventeen studies were selected from a pool of 642 and while exclusion of studies was well justified, this may have resulted in the loss of additional information. Studies considered for inclusion were English language only, consequently, additional data might have been revealed from including non-English language studies.

Overall, a low rate of comprehensiveness in reporting was found, as per the application of the COREQ guidelines. The COREQ has been used to rank reporting of a variety of other qualitative in the past, resulting in thousands of citations, with a similar lack of comprehensiveness commonly found (Irving et al. 2012; Luker et al. 2017). Particular areas of concern in this review were reporting of research team relationships with participants, comprehensiveness in reporting data collection, and the study’s theoretical and/or conceptual frameworks. We acknowledge that COREQ guidelines are only one of many available tools for assessing qualitative inquiry, and subsequently used them as a guide rather than a prescriptive rule, given that many fine pieces of work would be rendered not adequately comprehensive as per the COREQ alone. It is, however, a useful guideline for novice qualitative researchers to use when making considerations pertaining to how qualitative inquiry is conducted. Irrespective of the comprehensiveness ranking of each individual study, it is important to note that our thematic analysis rendered the identification of similar codes and categories throughout, i.e., common themes identified among studies ranked as highly comprehensive were also present among those ranked as less comprehensive.

Although data could be adequately synthesised, omission of crucial details in a number of studies placed limitations on potential for further synthesis. For example, demographic characteristics of research participants were not evenly represented across studies. Our rigorous approach to analysing and synthesising all studies sought to address this as best as possible.

Implications for Theory and for Further Research

Suicide theory could be enhanced by drawing on the qualitative perspectives reported in this study, as they have the potential to enhance existing theoretical frameworks that tend to render direct motivations for suicide (such as poverty, rejection and isolation) less visible. More robust and comprehensive theoretical frameworks could enhance the knowledge base of the complex and multiple factors that motivate youth to take their own lives, and test their contribution to a comprehensive model.

Future research should move beyond the scope of current qualitative studies, and aim to identify, in a rigorous and thorough manner, a broader and more comprehensive range of consumer perspectives pertaining to the lived experience of suicide. In order to achieve this a number of theoretical and methodological methods would need to be advanced. We recommend: (1) a strong, theoretical conceptual or methodological framework to underpin and/or inform the study, (2) the use of innovative, arts-based methodologies which have been shown to be appealing to youth in order to help them effectively depict experiences which are often difficult to put into words, and (3) taking a longitudinal approach that involves more than just a single, cross-sectional interview.

Conclusion

More robust and comprehensive theoretical frameworks may enhance knowledge of the complex and multiple factors that motivate young people to take their own lives. The comprehensiveness and quality of studies, from conception to completion, is also a necessary consideration to be made in view of future research. It is imperative that studies are rigorously designed and conducted relative to target populations, if they are to reliably reflect consumer perspectives. This review highlighted the capacity of comprehensive qualitative inquiry to identify central themes which may otherwise be minimised or missed in clinical and epidemiological studies. Qualitative methods represent an umbrella term that reflect a wide variety of methodologies, each of which are associated with different theoretical underpinnings and varied ways of thinking about knowledge (Kuper et al. 2008). In all of these theoretical models, individuals construct, negotiate, and interpret meanings for their actions and the social context within which they live their lives. Of further importance is that these design details be included in peer reviewed publication and not censored by restrictive word counts typical of many journals in the mental health space. Research provides an opportunity for consumer language to be translated to the rest of the world. Successfully translating the innate unadulterated language of the young suicidal mind is not only our responsibility, but our privilege.

Footnotes

  1. 1.

    While grey literature can provide important information pertaining to unique content in certain disciplines, this study employed a traditional, scientific approach, using only peer-reviewed journals, as per the evidence-based Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al., 2009).

Notes

Acknowledgements

The NHMRC Centre of Research Excellence in Suicide Prevention (CRESP) and The Anika Foundation both sponsor Ms Nicolopoulos as a PhD candidate. We therefore acknowledge their full support of the research reported in this article.

Authors’ Contribution

AN conceived of the study and its design and coordination, directed the design and interpretation of data, and drafted the manuscript. KB participated in the interpretation of data and measurement outcomes, and helped to draft the manuscript. FS participated in the design and coordination of the study, as well as assisting in the design and interpretation of data. HC oversaw the design of the manuscript in its entirety. All authors read and approved the final manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors report no conflicts of interest.

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Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Black Dog Institute. University of New South Wales: School of PsychiatrySydneyAustralia

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