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. 2022 Jul 31;79(2):466–476. doi: 10.1002/jclp.23419

Differences in suicide risk correlates and history of suicide ideation and attempts as a function of disability type

Lauren R Khazem 1,✉, Jennifer G Pearlstien 2, Michael D Anestis 3, Kim L Gratz 4, Matthew T Tull 4, Craig J Bryan 1
PMCID: PMC10087921  PMID: 35909343

Abstract

Background

Disability status is associated with correlates of suicide risk (perceived burdensomeness, thwarted belongingness, negative future disposition, felt stigma, suicidal ideation, and suicide attempts).

Aims

This study aimed to examine whether suicide‐related correlates differ significantly as a function of disability type.

Methods

Individuals with mobility and vision disabilities (N = 102) completed semistructured interviews and online‐based questionnaires. Analysis of variance/analysis of covaiance and Fisher's exact tests were conducted to examine whether mean levels of suicide‐related correlates differed significantly between individuals with blindness/low vision (n = 63) versus mobility‐related (n = 39) disabilities.

Results

No significant between‐group differences were observed for most outcomes; however, individuals with vision disabilities reported higher mean levels of felt stigma and positive future disposition than those with mobility‐related disabilities.

Limitations

The limited representation of disabilities among participants precludes generalization to individuals with other forms of disability and the cross‐sectional design prevents inference about causality.

Conclusions

Interventions targeting cognitive processes that underlie suicide risk may be applicable to people with mobility and vision disabilities.

Keywords: blindness, disability, mobility, suicide, suicide correlates

1. INTRODUCTION

People with mobility and vision disabilities comprise a substantial proportion of the US population. Although 170 million Americans are without any form of disability, over 33 million have a mobility disability, and over 12 million have a vision disability (CDC, 2019). In addition to the increased prevalence of negative social outcomes among people with (vs. without) disabilities, including unemployment (Houtenville & Rafal, 2020; McDonnall & Sui, 2019) and discrimination (Ameri et al., 2018; Kruse et al., 2018), this population experiences negative mental health outcomes, including depression, anxiety (Smith et al., 2019), and posttraumatic stress disorder (Schweininger et al., 2015)—all correlates of suicide risk (Chu et al., 2015).

Increased suicide risk among people with disabilities is well‐documented (Giannini et al., 2010). More specifically, those with mobility disabilities are more likely to have a history of suicidal ideation (SI; Russell et al., 2009) and have up to eight times greater prevalence of past‐year suicide attempts (SAs) than those without disabilities (Meltzer et al., 2012). Further, among individuals with a history of SI, those with mobility or vision disabilities were roughly three times as likely to have made a SA than those without disabilities (Khazem & Anestis, 2019). In a nationally representative sample of individuals in the United States, people with vision disabilities had significantly greater odds of past‐year SI, suicide planning, and SA than those without disabilities, whereas those with mobility disabilities were significantly more likely to have engaged in suicide planning (Marlow et al., 2021). These differences in suicide‐related outcomes suggest a possibility of differing mechanisms of suicide risk between people with differing forms of disability. Despite this possibility, and the heightened prevalence of suicide‐related outcomes among those with disabilities, no research has examined whether histories of SI and SA (or known suicide risk factors) differ between those with differing forms of disability. Identifying whether such differences exist between those with differing disability types may elucidate unique mechanisms of suicide risk for specific subgroups of people with disabilities (e.g., mobility or vision). Such preliminary investigation represents a crucial step in advancing the science and practice of suicide prevention in this population.

Potential cognitive mechanisms of suicide risk among people with disabilities have been identified. According to the Interpersonal Theory of Suicide (Joiner, 2005; Van Orden et al., 2010), beliefs related to interpersonal relationships, namely perceived burdensomeness and thwarted belongingness, are key correlates of suicide risk (Joiner, 2005). Perceived burdensomeness is contextualized as individuals’ feelings of being a burden to others to the extent that their death would benefit others more than if they continued living (Joiner, 2005). Heightened levels of perceived burdensomeness have been observed among and correlated with heightened suicide risk in those with various disabilities—including mobility and vision disabilities (Khazem et al., 2015, 2017, 2021; Meltzer et al., 2012). Some have posited that heightened perceived burdensomeness among those with disabilities may be partly attributed to greater assistance or care needs (Lutz & Fiske, 2018; Khazem, 2018; Saxton, 2018), whereas others highlight the role of common media portrayals of people with disabilities as a burden to others and as better off dead (Black & Pretes, 2007). Although there is a consistent association between perceived burdensomeness and SI among people with disabilities, it remains unknown whether these beliefs are held more strongly by people with vision versus mobility disabilities.

Thwarted belongingness (i.e., beliefs of being disconnected from other people or lacking close, meaningful, relationships) is strongly correlated with perceived burdensomeness and associated with suicide risk (Chu et al., 2018; Anestis et al., 2015). For those with disabilities, thwarted belongingness may partly stem from limitations in activities (Lutz & Fiske, 2018). However, findings regarding the association between thwarted belongingness or related states (e.g., loneliness) and suicide risk are mixed. Whereas thwarted belongingness has not consistently been found to be comparatively heightened (Khazem et al., 2015) or a correlate of SI (Khazem et al., 2017) among those with various disabilities, it is associated with SI among youth with irritable bowel syndrome conditions (Roberts et al., 2020). Further, interpersonal distress is associated with SI among those with chronic pain conditions (Wilson et al., 2013) and social isolation is associated with SI among military veterans with multiple sclerosis (Turner et al., 2006). These inconsistent findings highlight the need for further research clarifying the association between thwarted belongingness and SI in people with vision and mobility disabilities. It is possible that thwarted belongingness may differ between and/or be heightened among those with differing experiences or specific types of disability.

In addition to interpersonal‐focused beliefs, other well‐established cognitive risk factors for suicide warrant further examination among those with differing disabilities. Although limited, the extant research base indicates heightened hopelessness and related cognitive attributional styles among people with disabilities. For example, hopelessness was observed as a predictor of suicide among individuals with acquired spinal cord injuries (Charlifue & Gerhart, 1991). Notably, lower positive expectations for the future—also termed negative future disposition (O'Connor et al., 2008)—has been identified as a stronger predictor of SI than hopelessness, and both cognitive attributional styles may be associated with SI through different mechanisms (e.g., depression symptoms, self‐blame; Ballard et al., 2015). Conversely, high positive future disposition (related to optimism) has been implicated as a protective factor against suicide risk (Bryan et al., 2013; Lucas et al., 2020). It remains unknown whether these risk and protective correlates of suicide risk differ significantly between those with different disabilities. Identifying subgroups of people with disabilities experiencing higher negative future disposition or lower positive future disposition will provide insight into potential cognitive targets of treatments aimed at reducing suicide risk among these subgroups.

More specific to people with disabilities, felt stigma refers to the fear of experiencing disability‐related discrimination (enacted stigma) and associated feelings of shame (Scambler & Hopkins, 1986). This form of stigma has been associated with depression and anxiety symptoms, and dissatisfaction with quality of life in individuals with multiple sclerosis (Eldridge‐Smith et al., 2021). Among people with various disabilities, felt stigma was indirectly associated with the self‐perceived likelihood of SI and SA through perceived burdensomeness (Khazem et al., 2021). For those with spinal cord injuries, stigma was negatively associated with various outcomes including self‐efficacy and perceived quality of life (Monden et al., 2020). The visibility of disabilities has been implicated as a contributing factor to stigma, particularly for those who use wheelchairs (Kisala et al., 2015; Monden et al., 2020). Similarly, among those with blindness/low vision, social stigma and fears of losing employment were the primary reasons for refusing to use low vision assistive devices (Sivakumar et al., 2020). Given the experience of felt stigma among those with disabilities and its association with mental health‐ and suicide‐related outcomes, research is needed to better understand whether these experiences differ as a function of disability type.

To date, no research has examined whether correlates of suicide risk, including histories of SI or SA, differ between those with different forms of disability. In response to this dearth of research, this study aimed to examine whether levels of suicide risk correlates differ significantly between individuals with vision versus mobility‐related disabilities. Additionally, we examined whether histories of SI or SA differ significantly between these groups. Differences in these factors between those with differing disability types may highlight the need for targeted suicide prevention efforts for individuals with specific disabilities, whereas an absence of significant differences may indicate the applicability of more generalized suicide prevention efforts among those various disabilities as a group.

2. METHOD

2.1. Participants and procedures

Participants in the United States with various disabilities were recruited through online listservs, forums, and social media, to participate in this study. Recruitment materials did not explicitly refer to suicide, to avoid sampling bias; however, participants were informed about the purpose of the study during the informed consent process. All participants completed a series of phone‐based, semistructured interviews and online self‐report surveys between 2015 and 2019. One hundred and two participants endorsed disabilities impacting vision (n = 63) or mobility (39) and were included in the present analyses. Fourteen participants endorsed other forms of disabilities (e.g., Deaf/deaf/Hard of Hearing 1 , neurological disorders) and were not included in the study due to insufficient sample size for each group. Likewise, participants endorsing co‐occurring forms of disability (e.g., disabilities impacting dexterity in addition to blindness; n = 19) were excluded. All participants received a $45 Amazon gift card as compensation. In the total sample, 43 participants (42.16%) endorsed a history of SI and 13 (12.75%) endorsed a history of SA. This study received Institutional Review Board approval. See Table 1 for sample demographics, including a breakdown of demographics by group.

Table 1.

Demographic and suicide characteristics of the study sample

Overall sample (N = 102) Vision (n = 63; 61.76%) Mobility (n = 39; 38.24%)
Age, M (SD) 43.10 (14.50) 44.11 (14.83) 41.46 (13.98)
Gender, n (%)
Men 36 (35.29%) 24 (38.10%) 12 (30.77%)
Women 61 (61.76%) 38 (60.32%) 25 (64.10%)
Other 3 (2.94%) 1 (1.59%) 2 (5.13%)
Race, n (%)
African American/Black 8 (7.84%) 5 (7.94%) 3 (7.69%)
American Indian/Alaskan Native 1 (0.98%) – 1 (2.56%)
Asian/Pacific Islander 6 (5.88%) 6 (9.52%) –
Hispanic/Latino 6 (5.88%) 3 (4.76%) 3 (7.69%)
White 74 (72.55%) 45 (71.43%) 29 (74.36%)
Other 7 (6.86%) 4 (6.35) 3 (7.69%)
Annual family income
$0–10,000 14 (13.73%) 5 (14.29%) 5 (12.82%)
$10,001–$25,000 26 (25.49%) 12 (19.05%) 45 (35.90%)
$25,001–$50,000 23 (23.55%) 18 (28.57%) 5 (12.82%)
$50,000–$75,000 15 (14.71%) 8 (12.70%) 7 (17.95%)
$75,001–$100,000 13 (12.75%) 10 (15.97%) 3 (7.69%)
>$100,000 11 (10.78%) 6 (9.52%) 5 (12.82%)
History of suicidal ideation, n (%) 43 (43.14%) 30 (47.62%) 15 (38.46%)
History of suicide attempt, n (%) 13 (12.75%) 8 (12.70%) 5 (12.82%)
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2.2. Measures

2.2.1. Disability type

Participants with a disability impacting vision or mobility listed their specific disabilities, which were categorized as related to vision (e.g., blindness/low vision), mobility (e.g., double amputation, paraplegia), or other (e.g., seizures; participants endorsing these [n = 14] were not included in analyses). Participants who endorsed both vision and mobility‐related disabilities (n = 5) were excluded from analyses due to membership in both groups.

2.2.2. Perceived burdensomeness and thwarted belongingness

The 15‐item Interpersonal Needs Questionnaire (Van Orden et al., 2012) is a self‐report measure of perceived burdensomeness and thwarted belongingness. Items are rated on a Likert‐type scale ranging from 1 (Not at all true for me) to 7 (Very true for me). Both subscales demonstrated good internal consistency in this sample (∝ = 0.92 for both subscales).

2.2.3. Disability‐related felt stigma

The Stigma Scale (Jacoby, 1994) is a 3‐item measure of condition‐related felt stigma. Participants select whether they agree with each item (e.g., “Because of my disability/disabilities, I feel that some people are not comfortable with me”; “Because of my disability/disabilities, I feel that some people treat me like an inferior person.”) on a forced‐choice dichotomous scale. The instructions were changed to place focus on “disability/disabilities” instead of “epilepsy;” however, nothing else was modified. The Jacoby Stigma Scale demonstrated good internal consistency (∝ = 0.83).

2.2.4. Positive and negative future disposition

The Positive and Negative Focus subscales of the self‐administered future disposition inventory (FDI; Osman et al., 2010) assess positive future disposition (e.g., optimism) and negative future disposition (e.g., hopelessness). Each subscale consists of eight items, which are rated on a 5‐point Likert‐type scale ranging from 1 (Not at all true) to 5 (Extremely true). Both subscales demonstrated good internal consistency (∝s= 0.87 and 0.91 for the Positive and Negative Focus subscales, respectively).

2.2.5. History of suicide ideation and SAs

Two items from the clinician‐administered Self‐Injurious Thoughts and Behaviors Interview‐Short Form (Nock et al., 2007) were used to assess SI and SA history. Specifically, the items “Have you ever had thoughts of killing yourself?” and “Have you ever made an actual attempt to kill yourself in which you had some intent to die?” were asked to assess for histories of SI and SA, respectively, Responses were coded to reflect the presence or absence of lifetime SI and SA..

2.3. Data analytic plan

All variables were normally distributed, except perceived burdensomeness, which was rank transformed to an acceptable level of skewness (<3.00) before analyses. Bivariate correlational analyses and analyses of variance (ANOVAs) were conducted to identify covariates. Age, race, gender, and self‐reported annual family income were examined as potential covariates due to previously demonstrated associations with suicide‐related outcomes or disability (Okoro et al., 2018; Stack, 2021). Age was significantly negatively correlated with perceived burdensomeness (r = −0.21, p < 0.05) and felt stigma (r = −0.26, p < 0.01). Annual family income was positively correlated with felt stigma (r = 0.28, p < 0.01). Thus, age and annual family income were included as covariates in relevant analyses.

ANOVA and analysis of covariance (ANCOVA) were conducted to examine mean differences in the suicide risk correlates between individuals with vision versus mobility disabilities. Fisher's exact tests were conducted to examine differences in the rates of past SI and SA between these groups. Effect sizes are interpreted based on the following convention (Cohen, 1992): small effect, d = 0.20; medium effect, d = 0.50; large effect, d = 0.80.

3. RESULTS

In examining mean levels of suicide risk correlates between individuals with vision and mobility disabilities, two key findings emerged. Individuals with vision disabilities reported significantly greater felt stigma (p = 0.002, d = 0.54) and positive future disposition (p = 0.04, d = 0.44) than those with mobility disabilities, with medium and small‐to‐medium‐sized effects, respectively. No other significant differences in suicide risk correlates emerged between those with vision versus mobility disabilities. Disability groups did not differ significantly in rates of lifetime SI (p = 0.42) or SA (vision and mobility: p = 1.00). See table 2 for results of analyses.

Table 2.

Results of ANOVA/ANCOVA

Vision (n = 63) Mobility (n = 39)
M (SD) M (SD) F p d
Perceived burdensomeness −0.02 (0.84) 0.14 (95) 0.52′ 0.47 0.18
Thwarted belongingness 21.17 (11.80) 22.97 (12.97) 0.52 0.47 0.15
Negative future disposition 13.32 (5.17) 14.33 (5.64) 0.87 0.35 0.19
Positive future disposition 26.98 (4.59) 24.92 (5.57) 4.88 0.03 0.45
Felt stigma 2.29 (1.07) 1.62 (1.33) 9.68 0.002 0.56
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Note: Age was included as a covariate in models examining perceived burdensomeness and felt stigma. Annual family income was included as a covariate in models examining felt stigma. Per Cohen (1992): Small effect, d = 0.20; medium effect, d = 0.50; large effect, d = 0.80.

Abbreviations: ANCOVA, analysis of covariance; ANOVA, analysis of variance.

4. DISCUSSION

This study explored whether individuals with different types of disability varied significantly in levels of suicide risk correlates or histories of past SI and SA. Except for greater felt stigma and positive future disposition among those with vision disabilities versus mobility disabilities, results revealed no significant between‐group differences in the factors of interest. As such, results suggest that suicide prevention efforts may be applicable to people across these forms of disability, albeit with a few key considerations.

Mean levels of perceived burdensomeness and thwarted belongingness, two mental states proximal to SI (Joiner, 2005), did not significantly differ between participants with disabilities impacting mobility versus vision. However, it is important to note that observed levels of perceived burdensomeness and thwarted belongingness in this sample of people with disabilities were similar to or higher than those observed in research focused on populations with a heightened prevalence of suicide (e.g., undergraduate students with and without disabilities; sexual and gender minority adults; psychiatric inpatients; Cero et al., 2015; Chu et al., 2019; Khazem et al., 2015). Findings of heightened levels of perceived burdensomeness and thwarted belongingness across people with differing disabilities support the possibility that psychotherapeutic interventions targeting these cognitions underlying SI may be applicable across people with vision and mobility disabilities.

Findings regarding negative and positive future disposition should also be considered in the context of previous research. In the current study, there were no significant differences in levels of negative future disposition (i.e., hopelessness) between those with disabilities related to vision versus mobility. However, those with mobility disabilities endorsed a lower mean level of positive future disposition (i.e., optimism) than those with vision disabilities. These findings are notable, as lower positive future disposition has been found to be associated with an increased risk of SI above negative future disposition (O'Connor et al., 2008). However, it also warrants mention that across the two disability groups within this study, mean levels of positive future disposition were lower than those reported in the FDI validation samples (Osman et al., 2010) and consistent with the level reported among individuals with moderate‐to‐severe depression (Ballard et al., 2015). This indicates that levels of positive future disposition were particularly low among those with mobility disabilities rather than high among those with vision disabilities. Given that higher optimism is associated with lower SI (Bryan et al., 2013; Huffman et al., 2016), cognitively focused interventions targeting both positive and negative future dispositions may be particularly helpful in reducing the potential impact of hopelessness on SI while capitalizing on the protective nature of optimism (Tucker et al., 2013). For those with mobility‐related disabilities, such interventions may be particularly salient, especially when maladaptive disability‐related beliefs are also targeted. This recommendation is in line with strengths‐based approaches to psychotherapy for people with disabilities (Wehmeyer, 2013).

In contrast to the findings for positive future disposition, participants with vision disabilities endorsed higher felt stigma or fears about disability‐related discrimination. Given that felt stigma is associated with both perceived burdensomeness and suicide‐related outcomes among people with disabilities (Khazem et al., 2021), comparatively heightened levels of felt stigma among those with vision disabilities are noteworthy and consistent with past research. Specifically, people with blindness cite felt stigma as a common reason for choosing to not use assistive devices or technology (Sivakumar et al., 2020; Spafford et al., 2010), despite the association of these devices with improved psychosocial outcomes (Rees et al., 2010). Cumulative experiences with discrimination and stigma may lead to fears of further discrimination (i.e., felt stigma) in various situations and increase risk of negative outcomes, including increased psychological distress (Kagan et al., 2018) and suicidal intent (Khazem et al., 2021).

Another conceptualization of how stigma may contribute to suicide risk for those with disabilities may be found within the minority stress model of suicidality (Lund, 2021; Michaels et al. 2016), an extension of the Minority Stress Model (Meyer, 2003). According to this model, members of socially oppressed groups (e.g., those with a disability) experience chronic stressors—namely discrimination, harassment, and prejudice—in addition to those typically experienced as part of daily life. The effects of these stressors, particularly when coupled with internalized stigma, are posited to contribute to poor mental health outcomes, including suicide (Lund, 2021; Meyer, 2003; Michaels et al., 2016). For those with disabilities, fears of being discriminated against, experiences of harassment, and internalized ableism (e.g., viewing oneself negatively due to having a disability), coupled with daily and chronic society‐imposed stressors, may increase risk for SI and SA. However, as noted by Lund (2021), no studies to date have investigated this possibility.

The lack of significant differences in rates of lifetime SI or SA between those with vision versus mobility disabilities is noteworthy. Although people with disabilities, as a whole, have significantly higher rates of SA than those without disabilities (Khazem & Anestis, 2019; Marlow et al., 2021), these findings indicate that it may be that the type of disability is not as relevant to the development of SI or the transition to SA. In contrast with this possibility, however, Marlow et al. (2021) observed that, compared to people without disbailities, those with vision disabilities had significantly greater odds of past‐year SI, suicide planning, and SA, while those with mobility disabilities were significantly more likely to have engaged in suicide planning only. While further researh in larger, more representative samples is needed to clarify the relationship bewteen disability type and suicide‐related outomes, the current findings suggest the potential for reducing the occurrence or severity of suicide‐related outcomes across people with vision and mobility disabilities Specifically, findings of heightened levels of perceived burdensomeness and thwarted belongingness among both groups in this study support the possibility that psychotherapeutic interventions targeting these cognitions underlying SI may be applicable across clients with both vision and mobility disabilities.

Taken together, these findings provide potentially valuable clinical insight regarding treatment recommendations for people with disabilities. Specifically, these findings highlight the potential utility of cognitively focused interventions for those with vision and mobility disabilities, who may be experiencing suicide risk. For those who are experiencing SI, one very brief and efficacious intervention, Crisis Response Planning (CRP; Bryan et al., 2017), includes identifying personal reasons for living as one method of decreasing acute suicide risk and is associated with increases in optimism (i.e., future positive disposition; Rozek et al., 2019). CRP may be used as a standalone intervention or implemented as part of other efficacious psychotherapeutic interventions targeting suicide risk, including Brief Cognitive Behavioral Therapy (Bryan & Rudd, 2018), Cognitive Therapy for Suicide Prevention (Brown et al., 2005), or Dialectical Behavioral Therapy (Linehan, 1993). Further, these psychotherapies are flexible and well‐positioned to target felt stigma and other disability‐related cognitions associated with suicide risk among those with disabilities, including perceived burdensomeness and hopelessness.

This study was limited by the range of disabilities studied and sole reliance on self‐report methods to determine disability status. Further, the cross‐sectional design precludes inferences of causality. Likewise, given the small sample size, we were likely underpowered to detect significant group differences in some analyses. We were also unable to assess whether any differences in outcomes were present for those endorsing multiple forms of disability (e.g., vision‐ and mobility‐related disabilities), as those with multiple forms of disability were excluded from analyses due to the heterogeneity of other disabilities endorsed. We also acknowledge that various societal factors and forms of stigma (e.g., enacted and self‐stigma) may differentially and cumulatively impact cognitive processes and suicide risk. Future research in larger and more diverse samples is needed that specifically examines whether the interplay of these factors influences the heightened prevalence of suicidality among those with disabilities. Additionally, purposeful recruitment of people from subpopulations of those with other disabilities (e.g., Deaf/deaf/Hard of Hearing adults) will afford opportunities for comparisons across a broader range of disabilities, including comparisons to individuals with mobility and vision disabilities. Finally, the use of dichotomous items to assess history of SI and SA precludes more detailed investigation of the range of severity or frequency of each outcome.

5. CONCLUSIONS

Despite the limitations of this study, this study represents an incremental step in identifying the factors relating to suicide risk in people with differing forms of disability, revealing no significant differences in perceived burdensomeness, thwarted belongingness, negative future disposition, or rates of SI or SA between people with vision versus mobility disabilities. These findings suggest that people with both vision and mobility disabilities may benefit from suicide prevention interventions targeting these particular suicide‐specific risk factors. However, findings of significant between‐group differences in two other factors that may underlie suicide risk among people with disabilities (positive future disposition and felt stigma) highlight the potential utility of tailoring some of the specific interventions within these treatments to the individual's particular disability.

1. PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1002/jclp.23419

ACKNOWLEDGMENTS

This study was supported by the American Psychological Foundation Scott and Paul Pearsall Grant and the Military Suicide Research Consortium, an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs under Award Number W81XWH‐10‐2‐0181. Opinions, interpretations, conclusions, and recommendations are those of the author and are not necessarily endorsed by the MSRC or the Department of Defense.

Khazem, L. R. , Pearlstien, J. G. , Anestis, M. D. , Gratz, K. L. , Tull, M. T. , & Bryan, C. J. (2023). Differences in suicide risk correlates and history of suicide ideation and attempts as a function of disability type. Journal of Clinical Psychology, 79, 466–476. 10.1002/jclp.23419

ENDNOTE

1

We differentiate between Deaf, deaf, and Hard of Hearing to reflect differences in identity and culture (Ladau, 2021).

DATA AVAILABILITY STATEMENT

Research data are not shared.

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