Accepted Manuscript

Do reasons for living protect against suicidal thoughts and behaviors? A systematic
review of the literature

Camélia Laglaoui Bakhiyi, Raffaella Calati, Sébastien Guillaume, Philippe Courtet

PII: S0022-3956(16)30033-4
DOI: 10.1016/j.jpsychires.2016.02.019
Reference: PIAT 2827

To appear in: Journal of Psychiatric Research

Received Date: 23 October 2015

Revised Date: 22 January 2016
Accepted Date: 26 February 2016

Please cite this article as: Bakhiyi CL, Calati R, Guillaume S, Courtet P, Do reasons for living protect
against suicidal thoughts and behaviors? A systematic review of the literature, Journal of Psychiatric
Research (2016), doi: 10.1016/j.jpsychires.2016.02.019.

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 ACCEPTED MANUSCRIPT
DO REASONS FOR LIVING PROTECT AGAINST SUICIDAL THOUGHTS AND BEHAVIORS?

A SYSTEMATIC REVIEW OF THE LITERATURE

Camélia Laglaoui Bakhiyi , MD, Ph.D.1,2,3, Raffaella Calati, Psy.D., Ph.D. 3,4, Sébastien Guillaume,

MD, Ph.D. 1,3,4, Philippe Courtet, MD, Ph.D. 1,3,4

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Department of Emergency Psychiatry & Acute Care, Lapeyronie Hospital, CHU Montpellier,

Montpellier, France

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Psychiatric Unit, CHU Casablanca, Hassan II University, Casablanca, Morocco
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INSERM U1061, La Colombière Hospital, University of Montpellier UM1, Montpellier, France
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FondaMental Foundation, France
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Corresponding author:
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Camélia LAGLAOUI BAKHIYI

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INSERM U1061, La Colombière Hospital, University of Montpellier UM1, Montpellier, France

Phone number: 00212661484792

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E-mail: camelia.laglaoui@gmail.com
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Abstract (206 words)

Background: Few studies have investigated protective factors against suicide.

Objectives: To identify whether reasons for living (RFL), measured with the Reasons for Living

Inventory (RFLI), protect against suicidal ideation (SI), attempts (SA) and suicide death.

Method: This systematic review followed the PRISMA (Preferred Reporting Items for Systematic

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reviews and Meta-Analysis) statement guidelines. PubMed database was searched for studies

published until October 2015. Studies were eligible if they used RFLI or one of its versions. All

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eligible studies were included, regardless of study design, quality indicators, and target populations.

No publication year limit was imposed. We included 39 studies.

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Results: RFL may protect against SI and SA and yield a predictive value. The role of two specific

reasons for living (Moral Objections to Suicide and Survival and Coping Beliefs) was particularly

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emphasized. No study investigating suicide death was found.
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Conclusion: RFL may moderate suicide risk factors and correlate with resilience factors. Moreover,

RFL may depend on and interact with numerous factors such as DSM-IV Axis I disorders, personality
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disorders and features, coping abilities and social support. Clinicians could develop therapeutic
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strategies aimed at enhancing RFL, like Dialectical Behavior Therapy and Cognitive Behavioral
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Therapies, to prevent suicidal thoughts and behaviors and improve the care management of suicidal

patients.
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Key words: suicide, systematic review of literature, clinical aspects, cognition, treatment, reasons for
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living.
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Abbreviations: suicidal ideation (SI), suicide attempts (SA), reasons for living (RFL), Reasons For

Living Inventory (RFLI), RFL Scale-Older Adult version (RFL-OA), Survival and Coping Beliefs

(SCB), Moral Objections to Suicide (MOS), Responsibility to Family (RF), Child-related Concerns

(CC), Fear of Suicide (FOS), Fear of Social dDisapproval (FSD), Alcohol Use Disorder (AUD),

Borderline Personality Disorder (BPD).

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Introduction

Suicide is a major public health issue. According to the World Health Organization, more than

800,000 people kill themselves every year worldwide. The term suicide encompasses a broad

spectrum ranging from wish to die, suicidal ideation (SI), suicidal plans, suicide attempts (SA) to

suicide death. The magnitude of this phenomenon requires a better understanding of the suicidal

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process and finding more effective solutions to reduce its occurrence, impact and consequences.

Several studies have identified suicide risk factors, such as psychiatric disorders, gender, hopelessness,

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impulsiveness, personal and family history of suicidal behavior, and childhood abuse (Mann et al.,

1999; Oquendo et al., 2004). Efforts to reduce suicide rates mainly targeted these risk factors but these

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strategies remained insufficient and few studies focused on protective factors. A detailed review listed

many resilience factors (Johnson et al., 2011), suggesting that clinicians should screen and target them

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to prevent and reduce suicide risk. Among them, reasons for living (RFL) were mentioned but their
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potential protective effect against suicide has yet to be evidenced. RFL are reasons that one clings to

for “staying alive” and “not killing oneself” (Linehan et al., 1983). Authors postulated that RFL could
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act as protective factors and created the Reasons For Living Inventory (RFLI) (Linehan et al., 1983),
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an instrument designed to identify protective factors against suicide (Malone et al., 2000). It is a self-
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assessment questionnaire that includes six subscales: Survival and Coping Beliefs (SCB), Moral

Objections to Suicide (MOS), Responsibility to Family (RF), Child-related Concerns (CC), Fear of
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Suicide (FOS) and Fear of Social disapproval (FSD). These 6 subscales result in 48 items (72 with the

additional items). Every item is evaluated on a 6-level Likert scale, from 1 (“Not at all important”) to 6
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(“Extremely important”). Therefore, clinicians can assign a total RFLI score, corresponding to the sum
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of all items, and/or a score for each subscale. Higher scores mean that individuals exhibit higher RFL.

RFLI is a well-documented, reliable and validated tool (Cole, 1989; Connell and Meyer, 1991; Dyck,

1991; Linehan et al., 1983; Osman et al., 1999, 1996, 1993; Range and Penton, 1994; Rich and

Bonner, 1987). It was used in clinical samples (Demyttenaere et al., 2014; Malone et al., 2000) and

community groups: adults (Miller et al., 2001; Osman et al., 1999), college students (Osman et al.,

1993; Range and Penton, 1994), adolescents (Cole, 1989; Connell and Meyer, 1991; Osman et al.,

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1996) and older adults (Miller et al., 2001; Segal et al., 2008; Segal and Needham, 2007). Additional

versions were validated: the Brief Reasons for Living Inventory for Adolescents (BRFL-A) (Osman et

al., 1996), the College Student RFLI (CS-RFL) (Lee and Oh, 2012), RFLI for Young Adults (RFL-

YA) (Gutierrez et al., 2002) and RFL Scale-Older Adult version (RFL-OA) (Edelstein et al., 2009).

RFLI was also translated and validated in Spanish (Garza and Cramer, 2011), Italian (Pompili et al.,

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2007), Swedish (Dobrov and Thorell, 2004), Korean (Lee and Oh, 2012), Chinese (Chan, 1995) and

Malaysian (Aishvarya et al., 2014).

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The main objective of this review was to investigate the relationships between reasons for living and

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suicidal behavior. We sought to determine if reasons for living protect against one or more aspects of

suicidal behavior (suicide ideation, suicide attempt, suicide death).

Methods
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This review followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-

Analysis) statement guidelines. A PubMed literature search was conducted by C.L. from October 2014
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to October 2015. We found no Mesh terms for “reasons for living”. The search terms “reasons for
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living”, “reasons for living inventory”, “RFL”, “RFLI” were individually combined with the

following: “suicide”, “suicidal ideation”, “suicidal thoughts”, “suicide attempts”, “suicidal behavior”,
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“suicidal acts”, “self-harm”, “suicide death”, “completed suicide”, “protective” and “resilience”. We

included studies that: (i) used the RFLI or one of its versions; (ii) investigated the link between RFL
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and suicidal thoughts and behaviors as primary or secondary objectives; and iii) were published in
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English, Spanish or French. All studies published from 1983 (date of publication of the first study on
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RFLI) to October 2015 were included, with no publication year limit. All populations were

considered. All studies that had available full text were included, regardless of the study design or its

quality. When the full text was not available, we contacted the authors. Studies with no full text

available were excluded when authors had not replied. Out of 663 studies, 37 were included, and 2

additional articles were included from the references (fig. 1).

Reasons for living and suicidal ideation, attempts and suicide death

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Firstly, a negative association between RFL and suicidal thoughts and behaviors does not imply that

these factors protect against suicide, since other factors might moderate their protective effect

(Johnson et al., 2011). Thus, our results will differentiate the association between RFL and suicidal

thoughts and behaviors (positive or negative), and the protective and predictive value of RFL.

Reasons for living (total score) and Suicidal ideation

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Scientific evidence supported a negative association between RFL and SI (table 1).

All reviewed studies but one showed that high RFL correlated with low levels of SI in clinical samples

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(with mood disorders or schizophrenia), healthy populations, adults, adolescents, and elderly subjects.

The sole study that provided inconsistent findings found that this negative association was true only in

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subjects with no previous SI (Rieger et al., 2014). Although most of these studies were cross-sectional,

a randomized, double blind, parallel-group study and a follow-up survey yielded similar findings

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(Demyttenaere et al., 2014; Zhang et al., 2011). Low scores on the RFLI were found to positively
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predict SI. Overall, results suggested that a high RFL score may protect against SI (Lee, 2011; Zhang

et al., 2011; Rieger et al., 2014).

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Reasons for living (total score) and Suicide attempts

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Eight studies found that individuals with lifetime SA had a significantly lower RFLI score (see table 2)
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(Mann et al., 1999; Edelstein et al., 2009; Aishvarya et al., 2014; Bagge et al., 2014; Oquendo et al.,

2000; Lizardi et al., 2009; Wang et al., 2013a; Blasczyk-Schiep et al., 2011), one study showed that
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this was only true for women (Wang et al., 2013b) and another one reported no association between

history of SA and RFL (Gilbert et al., 2011). A reverse association emerged between number and
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lethality of SA and RFL (Lizardi et al., 2009). Two follow-up studies underlined that RFL predicted
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SA (Oquendo et al., 2004; Galfalvy et al., 2009) and two others evidenced that RFL predicted SA in

women only (Lizardi et al., 2007; Oquendo et al., 2007). According to Lizardi et al (2007), a one-point

increase in the RFL score meant a 3.4% decrease in SA probability. High RFL scores were described

as protective factors against suicidal behavior (Wang et al., 2013a). However, a recent study on a very

high-risk population reported inconsistent findings: RFL did not represent protective factors in

adolescent inpatients who attempted suicide (Consoli et al., 2015).

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RFLI and suicide death

To our knowledge, there are no data linking completed suicide to RFL.

Specific Reasons for Living Inventory subscales and suicidal ideation, attempts and suicide

death

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Moral Objections to Suicide

The Moral Objections to Suicide (MOS) subscale consists of four items: three items relate to religion

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(“only God has the right to end life”; “I am afraid of going to Hell”; “My religion forbids it”) and the

last item is a moral belief (“I consider it morally wrong”). This subscale evaluates the way one

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perceives suicide and to which extent one deems it acceptable.

In 5 out of 9 studies, we found that MOS correlated conversely with SI (table 3). Evidence showed

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that evaluating MOS could be very effective in detecting patients not disclosing their suicidal thoughts
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(Richardson-Vejlgaard et al., 2009a). Inconsistent findings were reported. One study compared

patients with mood disorders belonging to three ethnic groups (Whites, Blacks and Hispanics) and
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found this inverse link in Whites and Hispanics but not in Blacks (Richardson-Vejlgaard et al., 2009b).
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Indeed, Blacks showed the highest MOS scores and, at the same time, the highest levels of SI,
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suggesting that other factors, like cultural affiliation, may influence this association. The remaining

studies provided non-significant results.

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In addition, our review identified 8 studies that assessed the association between MOS and SA; 6

studies showed that low MOS scores correlated with an increased SA risk. Overall, studies
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emphasized the protective role of MOS and suggested that MOS may moderate the risk of SI and SA
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(Garza and Cramer, 2011). Evidence supported that higher MOS scores may lessen the probability of

SA and even if one engaged in a suicidal act, the risk of lethal SA might be significantly reduced

(Malone et al., 2000).

Survival and Coping Beliefs

Survival and Coping Beliefs (SCB) reflect one’s confidence in the ability to cope and act effectively in

difficult circumstances, instead of considering suicide (Pinto et al., 1998). In most studies, a strong

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negative correlation was evidenced between SCB and both SI and SA (table 4). In fact individuals

with low SCB scores were significantly more likely to display SI and SA. Data suggested that SCB

were negatively associated with suicide intent (Oquendo et al., 2005). However, two studies reported

non-significant results regarding the correlation between SCB and SI (Britton et al., 2008; Chang et

al., 2014), one prospective study found that high SCB scores protected against SA, but only in

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previous suicide attempters (Goldston et al., 2001) and one study found that SCB did not predict SA

(Moody and Smith, 2013).

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Fear of Suicide

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Data on Fear of Suicide (FOS) are inconsistent. Out of the seven studies examining associations

between FOS and SI, only two reported that individuals with a strong FOS were less likely to

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experience SI (Pinto et al., 1998; Britton et al., 2008), the remaining studies providing non-significant
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results (Cole, 1989; Lee and Oh, 2012; Garza and Cramer, 2011; Chang et al., 2014; Richardson-

Vejlgaard et al., 2009a). Similarly, one study (Blasczyk-Schiep et al., 2011) out of the total 6 (Cole,
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1989; Malone et al., 2000; Garza and Cramer, 2011; Blasczyk-Schiep et al., 2011; Mohammadkhani et

al., 2015; Moody and Smith, 2013) suggested that strong FOS was associated with a decreased risk of
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SA. Thus, while caution is required, Fear of Suicide did not appear to be a protective factor.
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Fear of Social Disapproval

Few studies investigated the association between Fear of Social Disapproval (FSD) and suicidal
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thoughts and behaviors, yet their results were inconclusive. In fact, 3 studies out of 4 found no
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significant link between FSD and SI (Cole, 1989; Pinto et al., 1998; Chang et al., 2014) and only one
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showed a negative correlation (Richardson-Vejlgaard et al., 2009a). Regarding SA, one study found

that individuals exhibiting strong FSD were less likely to attempt suicide (Malone et al., 2000),

whereas another study found that subjects with strong FSD had an increased risk of SA

(Mohammadkhani et al., 2015) and for two studies the results were not significant (Cole, 1989; Moody

and Smith, 2013).

Child-related Concerns

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Among the few studies examining relationships between Child-related Concerns (CC) and suicidal

thoughts and behaviors, data suggested that individuals with high CC scores were less likely to display

SI or SA (Richardson-Vejlgaard et al., 2009a; Mohammadkhani et al., 2015; Moody and Smith, 2013).

Furthermore, high CC scores may protect against SI and SA and low CC scores may predict suicidal

thoughts and behaviors. However, one study suggested that CC scores were not statistically different

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between attempters and non-attempters (Malone et al., 2000).

Responsibility to Family (RF)

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A reverse association between Responsibility to Family (RF) and SI was reported in 3 studies (Lee and

Oh, 2012; Pinto et al., 1998; Richardson-Vejlgaard et al., 2009a) whereas four studies yielded non-

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significant results (Cole, 1989; Britton et al., 2008; Chang et al., 2014; Oquendo et al., 2005).

Interestingly, one study examined the associations between RFL and the severity of SI in a sample of

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depressed older patients and provided surprising findings: high RF correlated with increased
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hopelessness scores, which in turn, increased SI severity (Britton et al., 2008). In addition, the current

review identified 3 studies suggesting that RF showed a negative correlation with SA (Malone et al.,
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2000; Oquendo et al., 2005; Moody and Smith, 2013), while two studies reported non-significant
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findings (Cole, 1989; Mohammadkhani et al., 2015). Overall, RF did not appear to be a predictive
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factor for SA.

To summarize, overall data suggested that high total RFLI scores might protect against SI and SA.
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RFL seem to be related to other aspects of suicidal behavior such as severity of SI and lethality of SA.

Studies did support the hypothesis that RFL could help differentiate patients who attempted near-lethal
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SA from those exhibiting less severe SA or SI (Blasczyk-Schiep et al., 2011; Demyttenaere et al.,
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2014). Particularly, high MOS subscale scores were strongly and negatively correlated to the lethality

of the attempt (Malone et al., 2000; Oquendo et al., 2005).

However, conclusions cannot be drawn on specific RFLI subscales regarding their potential protective

effect, apart from MOS and SCB. In fact, results from the other subscales were often inconsistent

and/or scarce. Further research is needed to investigate whether these reasons for living may buffer the

risk of suicide.

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Discussion

Overall, the current review supports the protective role of RFL against suicide outcomes (SI and SA),

persisting after adjusting for depression and/or hopelessness (Cole, 1989; Oquendo et al., 2000;

Lizardi et al., 2008), matching the results reported in the few follow-up studies on this topic (Oquendo

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et al., 2004; Lizardi et al., 2007; Galfalvy et al., 2006; Rietdijk et al., 2001). However, in one study on

adolescent inpatients who attempted suicide, RFL did not appear as a protective factor (Consoli et al.,

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2015). This could be due to the fact that the population considered in this study was described at a

very high risk for suicidal thoughts and behaviors. More research is needed to determine whether RFL

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“lose” their protective effect in specific cases. Noteworthy, the link between RFL and suicidal

behavior might not be a direct one, since other factors moderate it (Demyttenaere et al., 2014). These

factors could explain the contradictory results.

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The way RFL may protect against SI and SA remains unclear, but some leads have emerged. The first
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one being that RFL may weaken the association between risk factors and suicidal thoughts and
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behaviors, acting as a buffer. Hopelessness (Beck et al., 1990, 1985), depression (Uebelacker et al.,
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2010) and “clinical suicidality” (defined as a combined index considering hopelessness, subjective

depression and SI) are well-established risk factors for suicide. Data supported an interaction between
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these factors and RFL (Lizardi et al., 2008; Liu et al., 2006). Indeed, high RFL scores may decrease

depression (Labelle et al., 2015; Malone et al., 2000), hopelessness (Bagge et al., 2014), and “clinical
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suicidality” in general (Dean and Range, 1999). A single study on depressed elder patients yielded
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contradictory results, showing that high RF scores increased hopelessness, leading to SI (Britton et al.,

2008). This may be specific to elderly people: RF may generate a feeling of burdensomeness (Britton

et al., 2008), a necessary condition for the suicidal process (Joiner et al., 2009). Further studies are

needed to draw any conclusions, particularly when considering different age ranges. To summarize,

individuals with high RFL scores may be less likely to experience risk factors for suicidal behavior,

and in the case of SI experience, the rate for acting on these negative feelings was significantly lower

(Dobrov and Thorell, 2004). People with higher RFL scores were described as more optimistic and

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less likely to consider suicide as a solution (Mammen et al., 2001). Studies showed that RFL strongly

moderate the association between stressors, coping abilities and suicidal behavior (Bagge et al., 2014;

Wang et al., 2007).

Considering the MOS subscale, a second explanatory lead could be proposed. MOS is the RFLI

subscale referring to religious and spiritual beliefs. One can suppose that RFL could exert their

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protective effect via MOS. Indeed, studies have suggested that strong religious beliefs may prevent

one from committing suicide during a suicidal crisis (Lizardi et al., 2008). Noteworthy, considering

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suicide as morally acceptable (low MOS) does not mean that one wants to die. However, such attitude

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(low MOS) may be a disadvantage when facing a suicidal crisis, but it does not turn into a suicidal

process without the involvement of other vulnerability factors (diathesis, such as impulsivity for

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example) (Richardson-Vejlgaard et al., 2009b).
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A third explanation might be that RFL could relate to resilience factors. Numerous factors were

already acknowledged as resilience factors against suicide: coping styles and problem-solving
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abilities, goal adjustment, self-esteem, agency (i.e. controlling and governing one’s own life, decisions

and actions), life evaluation, social support, religious beliefs, future-related beliefs and suicide-related
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beliefs (Johnson et al., 2011). We evaluated the items included in the “Reasons for Living Inventory”
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(RFLI) and noticed that RFLI items may refer to these well-established resilience factors (see

supplementary material). In the RFLI, the assessment of resilience factors may account for at least one
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third of the scale (18 of 48 items or 25 of 72 if considering additional items). Thus, high RFLI scores

may reflect numerous resilience factors, which might protect against suicidal thoughts and behaviors.
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Interestingly, one study found significant positive correlations between the Suicide Resilience
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Inventory (SRI-25), a scale designed to measure resilience, and reasons for living (Villalobos-Galvis

et al., 2012). Results need to be replicated using other scales assessing resilience, such as the Connor-

Davidson Resilience Scale (CD-RISC).

Beside their protective effect, RFL were described to negatively predict SI and SA variation (Rich and

Bonner, 1987; Goldston et al., 2001; Galfalvy et al., 2006; Bonner and Rich, 1990). These findings

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are clinically relevant. In fact, physicians should include the RFLI in their clinical battery for assessing

suicide risk. However, evaluating RFL in suicidal patients some variables that might moderate or

interact with RFL should be taken into account:

Age: older age was correlated with higher RFL (Edelstein et al., 2009; Durak Batigün, 2005;

McLaren, 2011) and higher scores in specific subscales such as CC and MOS (Miller et al., 2001).

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Gender also appeared to influence RFL. Thus, RFL scores were significantly higher in females on

most of the subscales for comparable suicidal behaviors (Ellis and Lamis, 2007; Linehan et al., 1983;

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Durak Batigün, 2005; Ellis and Jones, 1996). Qualitative differences in RFL between males and

females were also reported: one study showed that the Family Alliance (a subscale included in the

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Korean RFLI for Adolescents) had a protective effect against SI in boys, whereas Peer Acceptance and

Support (a subscale included in the Korean RFLI for Adolescents) had a protective effect in girls (Lee,

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2011). These RFL differences might imply a gender-specific buffering impact on suicide. We do not
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know whether this is due to gender distinct social roles.

A gender-age interaction with RFL was also reported. Indeed, discrepancies between males and
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females tended to decrease with age (Segal and Needham, 2007). It remains unclear whether this is
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due to increased RFL in older males or conversely because older women might exhibit fewer RFL.
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We previously reported results on how RFL might moderate the relationship between mental health

and suicidal thoughts and behaviors. Some evidence suggested that the association between RFL and
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mental health is a two-way relationship and that psychopathology and personality features may in turn,

influence or at least interact with RFL. Psychiatric comorbidities (comorbid depressive disorder with
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obsessive-compulsive disorder) (Diaconu and Turecki, 2009), anxiety disorders (Lee et al., 2014),
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alcohol use disorder (Innamorati et al., 2008) and depressive personality disorder (Segal et al., 2015)

correlated with fewer RFL. In a six-month prospective study, the interaction between borderline

personality disorder (BPD) and RFL predicted suicidal behavior (Rietdijk et al., 2001); BPD patients

with low SCB were 7-fold more likely to display suicidal behavior than controls. Moreover, a recent

study showed that impulsivity interacted with low RFL scores to increase SI (Salami et al., 2015). The

role of personality features and disorders in determining RFL may be very relevant since personality

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features could influence the way people consider themselves and their environment, thus possibly

acting on their abilities to adjust, cope, and manage life difficulties.

Cognitive functioning may also account for RFL variations. Studies reported that coping skills related

to RFL could potentially influence suicidal thoughts and behaviors (Marty et al., 2010; Rietdijk et al.,

2001; Wang et al., 2007). Coping abilities correlated with high scores on the SCB of the RFLI. We

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may hypothesize that psychotherapies focusing on specific aspects such as strengthening coping

abilities could prevent suicidal behavior. Results from an ongoing randomized controlled trial using a

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“web-based self-help” intervention may address this issue (van Spijker et al., 2015).

Life events may also influence RFL. Particularly, negative life events such as childhood trauma were

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found to predict fewer RFL in adulthood (Segal et al., 2015; Segal, 2009). However, one study

compared suicide attempters and non-attempters and found differences in RFL but not in adverse life

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events (Mann et al., 1999), suggesting that the experience of negative life events did not reduce RFL.
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These results should be analyzed with caution, because extremely different adverse events were

studied, and the potential impact of adverse events on RFL may be specific to a particular life event.
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Furthermore, life events might not explain suicidal behavior; people experiencing similar events will
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not react in the same manner because of different cognitive styles influencing their RFL (Oquendo et
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al., 2004).

Evidence suggested that RFL may depend on ethnicity. Indeed, despite higher risk factors for suicide
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among African-American populations, they presented the highest RFL, especially MOS (Richardson-

Vejlgaard et al., 2009b) and the lowest rate of SA (Garlow et al., 2005; Kaslow et al., 2004). Similar
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results were found in Latinos, compared to non-Latinos (Oquendo et al., 2005). Another study found
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that Korean college students had lower scores on RFL than Asian-American and Caucasian students

(Lee and Oh, 2012). Thus, the variation of RFL across ethnic groups might explain the differences in

suicide risk according to cultural factors (Street et al., 2012; Walker et al., 2010). However, RFLI

scores must be interpreted with caution across cultural groups (Pompili et al., 2007; Aishvarya et al.,

2014). In fact, Pompili et al assessed the scale among 340 Italian students and found that the structure

of the original RFLI model did not fit well with this culture, and suggested a scale with a three-factor

structure (Pompili et al., 2007). However, a study found that ethnicity did not really explain RFL

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differences, but other factors did, such as religious beliefs (June et al., 2009). Indeed, religious beliefs

might be associated with higher total RFL scores and MOS (Rieger et al., 2014; Lizardi et al., 2007;

Richardson-Vejlgaard et al., 2009b; Ellis and Smith, 1991) and lower rates of previous SA (Dervic et

al., 2011; Lizardi et al., 2008). MOS were shown to mediate the relationship between religion and

suicide (Dervic et al., 2011). A study provided interesting results: they compared Jews and Protestants

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and explained the lower suicide rates among Jews by their high MOS score based on specificities

related to each religion (Loewenthal et al., 2003).

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Social support is another variable that may account RFL variations. Social support was found to be

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associated with higher RFL scores and shown to moderate the effect of depressive symptoms (Matlin

et al., 2011). Another study reported that family connectedness (measured with 4 items from the RFL-

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OA) correlated negatively with SI (Purcell et al., 2012). Others found that a high sense of belonging
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(i.e. feeling of belonging to a group) was associated with higher RFL scores, particularly SCB, CC and

RF (Kissane and McLaren, 2006).

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All variables listed above appeared to account for RFL variations and should thus be considered in the

assessment of suicidal patients. For instance, based on age-gender RFL differences, one could suppose
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that there are different RFLI thresholds for young and old individuals, males and females. More
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research is needed to define these thresholds and establish a standardized evaluation according to

RFLI scores, age and gender. Up to now, very few studies have investigated factors moderating or
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interacting with RFL, and further works are needed. By better understanding RFL clinicians could

establish therapeutic strategies for targeting factors that moderate or interact with RFL to prevent
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suicidal behavior. Some factors like mental disorders, coping skills, personality and social support
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could be targeted. Mental disorders may be improved by medication and psychotherapies. One

prospective study highlighted the role of antidepressant (duloxetine) in enhancing RFL in 8 weeks

(Demyttenaere et al., 2014); another follow-up study on suicide attempters suggested that a brief

therapy, the Teachable Moment Brief Intervention (TMBI), may enhance RFL in one month time

(O’Connor et al., 2015). Bolstering coping abilities through Cognitive Behavioral Therapies may

increase SCB, which in turn may reduce suicidal behavior. Evidence supported that therapies focusing

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on personality disorders, like Dialectical Behavior Therapy, may strengthen RFL, and make one less

vulnerable to engage in suicidal behavior (Linehan et al., 2015). Moreover, Segal et al postulated that

personality was to some extent an adaptable factor (Segal et al., 2006). Clinicians should also develop

psycho-education programs for families of patients and stress the importance of their support in

preventing suicidal behavior.

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To the best of our knowledge, this is the first review investigating the impact of RFL on suicidal

behavior. However, some limits must be acknowledged. Some data are missing due to lack of response

RI
from authors. The majority of studies were cross-sectional; however, the included cohort studies did

not report contradictory results. Finally we found no data on suicide death and RFL.

SC
In conclusion, RFL appear to have a predictive and protective value for suicidal ideation and attempts.

Future research studies should focus on the link between suicide death and RFL, but also target

U
various population samples to generalize our results. The clinical evaluation and monitoring of
AN
suicidal patients should systematically include a RFL assessment. Clinicians should also take into

account patients’ characteristics: age, gender, religion, cultural affiliation, and psychopathology to
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provide an accurate evaluation and better management for different patients. The care management of
D

suicidal patients might require therapies targeted to strengthening these reasons. However, few studies
TE

have evaluated the relationship between therapeutic strategies and RFL. Follow-up studies are

essential to evaluate therapeutic strategies targeting RFL improvement, especially using

EP

psychotherapies (e.g. Cognitive Behavior Therapy, Dialectical Behavior Therapy) and web-based

programs, to target larger samples.

C
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doi:10.1016/j.jad.2011.05.003

19
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Délégation régionale
Languedoc-Roussillon

Montpellier, January 20th 2016

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To the Editor-in-Chief:

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Florian Holsboer,

SC
We are pleased to re-submit our manuscript “DO REASONS FOR LIVING PROTECT
AGAINST SUICIDAL THOUGHTS AND BEHAVIORS? A SYSTEMATIC REVIEW
OF THE LITERATURE” to be considered for publication in your journal.

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We would like to thank the reviewers for their helpful comments.
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The paper has not been published or submitted in total or in part in any language as a
contribution either to a journal, a book chapter, or abstract.
M

Acknowledgements
C. LAGLAOUI BAKHIYI received a grant from ERASMUS MUNDUS – EU
METALIC II. The authors wish to thank Mrs. Bénédicte Clément who assisted in the
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proof-reading of the manuscript.

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With our best regards,

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Camélia LAGLAOUI BAKHIYI

Raffaella CALATI
Sébastien GUILLAUME
Philippe COURTET
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Camélia LAGLAOUI BAKHIYI, MD, Ph.D.

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Inserm U 1061, Neuropsychiatry: Epidemiological and Clinical Research

University of Montpellier
39, avenue Charles Flahault
34093 Montpellier cedex 5, France
E-mail: camelia.laglaoui@gmail.com
 ACCEPTED MANUSCRIPT

Table 1: Reasons for living and suicidal ideation

Authors Diagnosis Targeted Sample size Gender Mean age Ethnicity Scales Design of follow- Results Statistical P value Other
population (n=) (%) (years) (%) the study up analysis statistical
duration results

Edelstein et MDD Clinical: 181 F=58.56 60.1 + 10.0 Wh=88, RFL-OA, Cross- None RFL ↓, SI- Correlation: < 0.001 SI-C: r = −
al., 2009 n=141, BD I depressed, 50 AA=6, SSI, BDI- sectional C↑ RFL-OA and 0.40,

PT
n=23, BD II of age and American II, SSI-C,
n=4, Dys older patients Indian or MMSE, RFL ↓, SI- SI-W: r = −
n=1, DD Alaskan IADL, W↑ RFL-OA and 0.42

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NOS n=6, Native=1, PSMS, SSI-W
SD n=2 and Hisp or SCID I
SIMD n=4 latino=5 (DSM-IV)
Lee, 2011 High school 406 F = 33 16.4 + 0.53 South KRFL-A Cross- None RFL ↑, SI Correlation < 0.01 r = -0.44,

SC
students Korean sectional ↓ (KRFL-A and
(adolescents) SIQ)

RFL hierarchical < 0.01 B = -5.49,

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moderate regression SE =1.82, β
SI = -0.13,

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Pinto et al., Not detailed Clinical 253 F=66 15.38 + 1.05 Wh = 64, RFLI, Cross- None RFL ↑, SI Pearson <0.001 r = -0.59
1998 sample: AA = 11, SIQ, BDI, sectional ↓ correlation
adolescent Hisp = 2, HSC (RFLI and SIQ)
inpatients (40% Asian = 1;

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suicide missing
attempters, data = 21
30% suicide
ideators, and

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30% non-
suicidal)

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Britton et al., MDD (82%), Clinical, older 125 F=54 60.9 + 10.1 Wh = 97 SCID-I , Cross- None RFL ↑, SI Logistic - Presence of
2008 BD I most patients (adults RFL-OA, sectional ↓ regression SI: OR =
recent 50 years or HDRS, analyses (RFL- 0.98, 95%
episode older receiving BHS, SSI OA and SSI - CI
EP
depressed treatment for a Presence of SI) (0.96−0.99)
(9%), BD I mood disorder)
most recent Linear regression = 0.001
(but not analyses (RFL- Severity of
C

currently) OA and SSI - SI: t(124) =

manic, Severity of SI) 3.53
mixed, or
AC

unspecified
(2%), BD II
(2%), SIMD
(2%), DD
NOS (2%),
Dys (<1%)
Bagge et al., Undergraduate 1075 F=69.3 19.28 Wh = 78, RFLI, Cross- None RFL ↑, SI Pearson < 0.001 r =−0.52
2014 college AA = 13, BHS, sectional ↓ correlation
students Asian BDI-II, (RFLI and
American RFL-YA, MSSI)
 ACCEPTED MANUSCRIPT

= 4, Hisp MSSI
= 1, other
=4
Demyttenaere MDD Clinical: 336 F=74 45 Wh = 96 MINI, Randomized, 8 weeks RFL ↑, SI Pearson < .0001 r = −0.26
et al., 2014 (100%) hospitalized for MADRS double-blind, ↓ correlation
severe item 10, parallel- (MADRS item
depression HDRS, group 10 and RFLI)
CGISIS,

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RFLI
Salami et al., College aged- 130 F = 74.6 19.24 + 1.60 AA = 100 MCSDS, Cross- None RFL ↑, SI Intercoorelations < 0.01 r = -0.43
2015 students MSPSS, sectional ↓ (RFL-YA and

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BDI-II, MMSI)
UPPS,
RFL-YA,
MSSI

SC
Labelle et al., Mood Adolescents 429 Community Community French- LEQ-A, Cross- None RFL ↑, SI Pearson < 0.001 in Community
2015 disorders (clinical and (Community group: F = group: 14- Canadian BDI-II, sectional ↓ correlation almost all group : r
(34%) community group 42; Clinical 15 (59%), = 100 BHS, (RFL-A and correlations ranged from
groups) n=283, group: F = 16-17 RFL-A, BDI-II) with RFL-A -0.39 to -

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Clinical 66 (41%); SS subscales) 0.16 ;
goup n=146) Clinical Clinical

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group: 13- group r
15 (47%), ranged from
16-17 (53%) -0.37 to -
0.21

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Zhang et al., General 997 20–59 Chinese CES-D, Follow-up 12 RFL = Multivariate = 0.044 OR = 0.59,
2011 population DASS-21, survey months significant logistic 95% CI
BHS, inverse regression (0.35–0.99)
RFLI predictors analysis (RFLI –

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for the SI status)
incidence

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of SI
Hocaoglu and SD (100%) Clinical: 120 F = 47.5 36.7 ± 10.5 Turkish SCID I Cross- None RFL ↑, SI Comparison = 0.000 RFLT
Babuc, 2009 patients with (DSM- sectional ↓ according to SI ideators :
SD IV), 210.28 +
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CDSS 38.92 versus
(used to non
assess SI), ideators:
PANSS, 267.43 +
C

RFLI 28.84
Correlation < 0.01
(RFLI and r =-0.585
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CDSS)

Malone et al., MDE Clinical: 84 F = 55 Attempters: Wh = 75 SCID-I Cross- None RFL ↑, SI Pearson < 0.0001 r=–0.48,
2000 (100%) inpatients with 32.6 + 11.4; (DSM-III- sectional ↓ correlation N=68
MDE Non R), (RFLI and SSI)
attempters: HDRS,
36.2 + 12.3 BDI,
BHS,
BPRS,
RFLI, S-
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PRQ,
RLCQ,
SSI, SIS,
MLS
Rieger et al., Students 1245 F = 62.4 20 Canadian RFL-YA, Cross- None RFL = Pearson < 0.001 r = -0.47
2014 = 100 SBQ- sectional protective correlation (SBQ
Revised, factor and RFL-YA)
SCSORF, against SI

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MHI-5, for
CTQ, students
RAPI, with no

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FLS previous
SI
O’Dwyer et Family carers 566 F=78.98 62.93 + Country of CES-D, Cross- none RFL ↓, t tests and =0.00 t=7.75
al., 2015 of people with 11.47 residence: BHS, sectional SI↑ logistic (df=564)

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dementia Australia SBQ-R, regression
= 82, USA Bief RFLI analyses
or Canada and others
=14,

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England,
Ireland,

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Scotland
or Wales =
3, Other =
0.5

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Table legends:

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AA: African American, BD (I or II): Bipolar Disorder (I or II), BDI: Beck Depression Inventory, BHS: Beck Hopelessness Scale, BPRS: Brief Psychiatric Rating Scale, CDSS: Calgary Depression Scale for Schizophrenia,

TE
CES-D: Centre for Epidemiological Studies-Depression Scale, CGISIS: Clinical Global Impressions–Severity of Illness scale, CTQ: Childhood Trauma Questionnaire, DASS-21: Depression Anxiety and Stress Scales short
form, DD NOS: depressive disorder not otherwise specified, DSM: Diagnostic and Statistical Manual of Mental Disorders, Dys: Dysthymic Disorder, F: female, FLS: Forgiveness Likelihood Scale, HDRS: Hamilton Depression
Rating Scale, Hisp: Hispanic, HSC: Hopelessness Scale for Children, IADL: Instrumental Activities of Daily Living Scale, KRFL-A : Korean version of the Reasons for Living Inventory for Adolescents, LEQ-A: Life Events
Questionnaire for Adolescents, MADRS: Montgomery-Asberg Depression Rating Scale, MCSDS: Marlowe-Crowne Social Desirability Scale, MDD: Major Depressive Disorder, MDE: Major Depressive Episode, MHI-5:
EP
Mental Health Inventory-5, MINI: Mini-International Neuropsychiatric Interview, MLS: Medical Lethality Scale, MMSE: Mini Mental State Examination, MSPSS: Multidimensional Scale of Perceived Social Support, MSSI:
Modified Scale for Suicide Ideation, PANSS: Positive and Negative Syndrome Scale, PSMS: Physical Self-Maintenance Scale, RAPI: Rutgers Alcohol Problem Index, RFL: Reasons for living, RFL-A: Reasons for Living
Inventory for Adolescents, RFLI: Reasons for Living Inventory, RFL-OA: Reasons For Living Older Adults Scale, RFLT: total score on Reasons for Living Inventory, RFL-YA: Reasons for Living Inventory for Young Adults,
RLCQ: Recent Life Changes Questionnaire, SBQ: Suicide Behaviors Questionnaire, SCID: Structured Clinical Interview for the Diagnostic and Statistal Manual of Mental Disorders, SCSORF: Clara Strength of Religious Faith
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questionnaire, SD: Schizophrenia, SI: Suicidal Ideation, SI-C: current suicidal ideation, SIMD: substance-induced mood disorder, SIQ: Suicidal Ideation Questionnaire, , SIS: Suicide Intent Scale, SI-W: Suicidal ideation at the
worst point in one’s life, S-PRQ: St Paul-Ramsey Questionnaire, SS: Spirituality Scale, SSI: Scale for Suicide Ideation , SSI-C: SSI for respondents’ current state, SSI-W: SSI for the worst point in their lives, UPPS: UPPS
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Impulsive Behavior Scale, Wh: White

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Table 2: Reasons for living and suicide attempts

Authors Diagnosis Targeted Sample size Gender (%) Mean age Ethnicity Scales Study design Follow- Results Statistical P value Other
population (n=) (years) (%) up analysis statistical
duration results
(years)
Edelstein MDD Clinical: 181 F = 58.56 60.1 + 10.0 Wh=88, RFL-OA, Cross-sectional None RFL ↑, Logistic < 0.01 Wald

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et al., n=141, BD current AA=6, SSI-C, SSI- lifetime SA ↓ regression statistic =
2009 I n=23, BD depression, American W, BDI-II, (Wald ’ s chi- 7.2
II n=4, Dys older Indian or MMSE, square

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n=1, DD Alaskan IADL, statistic)
NOS n=6, Native=1, PSMS, (RFL-OA and
SD n=2 and Hisp or SCID-I SA status)
SIMD n=4 latino=5

SC
Oquendo MDD and Review: RFL:
et al., BD prospective contribution
2006 studies of SA in to the
MDD and BD prediction of

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future SA
Oquendo DSM-III-R Clinical: adults 308 18-75: SCID-I, Prospective 2 years Baseline t test (RFLI < 0.0001 t = -5.4, df

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et al., MDD with MDE With past SCID-II Suicide and SA status) = 232
2004 (79%) or SA: 35.5; (DSM-IV), attempters:
BD (21%) Whithout IPDE, RFL ↓ Cox
past SA: HDRS, BDI, proportional

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39.1 BPRS, hazards -
SANS, Follow-up regression (significant -
SAPS, RFL: = analysis results)
BGAH, prediction of

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BDHI, BIS, future SA
S-PRQ,

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BHS, RFLI,
CSHF, SSI,
SIS, LRS
Oquendo BD (100%) Clinical: 44 Attempters : Attempters : Attempters: SCID Cross-sectional None RFL ↓, Linear < 0.05 -
EP
et al., bipolar M=71; Non- 34.7 + 10.7 ; Wh= 86; (DSM-III- lifetime SA ↑ regression
2000 (attempters attempters Non- non- R), HDRS, model, t test
n=21, non M=30 attempters : attempters BDI, BPRS, (RFLI and SA
attempters 32.7 + 11.1 Wh=87 SAPS, GAS, status),
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n=23) SSI, SIS, controlling for

LRS, BHS, depression
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RFLI,
BGAH,
BDHI, BIS,
S-PRQ
Mann et MDD Clinical: 347 M=51 Attempters : Wh= 68 SCID Cross-sectional None RFL ↓, Two-sample t =0.0001 t = -3.92;
al., 1999 n=176 inpatients with 32.0 + 9.5; (DSM-III- (Attempters/non- lifetime SA ↑ test with equal df = 181
(51%); SD, mood Non- R), SPDE, attempters) variances
SAD, or disorders, attempters : BPRS, (RFLI and SA
SFD n=126 psychoses, and 32.7 + 11.1 SAPS, status)
(36%); other SANS,
other n=45 HDRS, BDI,
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(13%); BHS,
Comorbid BGAH,
BPD n=74 BDHI, BIS,
(21%) S-PRQ,
RFLI, SSI
Bagge et - Undergraduate 1075 F=69.3 19.28 Wh = 78, RFLI, BHS, Cross-sectional None RFL ↓, past- Pearson < 0.001 r =−0.37
al., 2014 college AA = 13, BDI-II, year SA ↑ correlation

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students Asian RFL-YA, (RFLI and
American = MSSI Lifetime SA
4, Hisp = 1, status)
other = 4

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Aishvarya Mood Clinical: 483 F = 61.1 42 Malaysian = RFLI, Cross-sectional None RFL ↓, Logistic < 0.05 estimate =
et al., disorders psychiatric and (psychiatric 53.4, DASS-21, lifetime SA ↑ regression −0.024,
2014 (42%), medical patients Chinese = SWLS, analysis (RFLI OR =
Anxiety outpatients n=283 and 32.5, Indians BHS, RSES, and SA status) 0.977,

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disorders medical = 11, Others PNSII, PSR, 95% CI
(13.4%), patients n = = 3.1 ATHS (0.97,
Comorbid 200 ) 0.99)
anxiety and

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mood
disorders

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(3.1%),
Medical
patients
(41.4%)

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Lizardi et Lifetime Clinical: 190 F = 65.8 35.68 + Wh = 90 SCID-I Cross-sectional None RFL ↓: Multiple
al., 2009 MDD suicide 12.40 (DSM-III- number and regression :
(100%) attempters with R), BLS, lethality of RFLI and = 0.003 β = 0.218
MDD CSHF, SSI, lifetime SA ↑ number SA;

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BGAH, BIS,
S-PRQ, RFLI and BLS = 0.001 β = 0.245

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RFLI
Galfalvy BD (29%), Clinical: 343 F = 65 39.8 ± 11.8 Hisp = 20, HDRS, BDI, Follow-up 1 year RFL ↑, future Cox <0.001 HR=0.8
et al., MDD patients with AA = 11, SSI, BHS, SA ↓ proportional for
2009 (71%) MDE (100%) Wh = 69 RFLI, hazard each 10
EP
BGLAH, regression point
BDHI, BIS, analysis (RFLI increase,
SCID-II, and Future 95%
MLS SA) CI=0.7–
C

0.9
Wang et College 289 F = 72 21.41 + 6.49 AA = 100 SBQ- Cross-sectional None RFL: Bias-corrected - Bootstrap
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al., 2013a students Revised, protective bootstrapping estimate =

CES-D, against -0.10, SE
RFL-YA, lifetime SB = 0.06,
BSAS, SSB through 95% CI (-
negative 0.25, -
correlation 0.01)
with
depressive
symptoms
Blasczyk- Adolescents 116 F = 80 18.4 - Rorschach Cross-sectional None RFL ↑, Correlation p < 0.001 r = -0.39 (-
Schiep et and young test, BDI, suicidal (RFLI and 0.47)
 ACCEPTED MANUSCRIPT

al., 2011 adults RFLI, PSDI, index ↓ Rorschach

VCQ (Rorschach Suicidal
test) Index)
Gilbert et BD I, II, or Clinical: adult 67 F= 44.8 42.2 + 11.5 Wh= 64.2, SCID-I Cross-sectional None No t tests, binary = 0.59 t62 = 0.54
al., 2011 BD NOS inpatients and Non-Wh (DSM IV), association logistic
outpatients (Asian or CSHF, SSI, between RFL regression
with BD I, II, Pacific HDRS-17, and lifetime analysis (RFLI

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or BD NOS Islander, Bl, CARS-M, SA and SA status)
Hisp, other) CTQ, BIS-
= 35.8 II, AQ,
RFLI, IGT

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Lizardi et MDE Clinical: 386 F=58 Attempters: SCID Prospective 2 years Past SA, RFL Baseline <0.001 Baseline:
al., 2007 (MDD or Depressed 34.5 ± 10.0 ; (DSM-III- ↓ (RFLI and past t=-6.46
BD) (100%) inpatients Non R), RFLI, SA status): t 95% CI (-
attempters : BDI, BHS, Test ; 45.04, -

SC
37.7 ± 13.4 CSHF 4.01),
Follow- <0.001
RFL ↓, future up (RFLI-SA Follow-up:
SA within 2-year HR = 0.98,

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probability ↑ period): Cox 95% CI
in women but Proportional (0.96,

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not in men Hazards 0.99)
Regression
Wang et College 341 F = 73 21.56 + 5.70 AA = 100 SBQ- Cross-sectional None RFL ↑, Logistic < 0.001 b = -0.88,
al., 2013b students revised, lifetime SB ↓ regression Wald =

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CES-D, in women analysis (RFL- 19.28,
RFL-YA, only YA and SBQ) 95% CI
SWLS, SAI (0.28-
0.62)

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Oquendo MDE Clinical: 314 F = 59 Men: 37.51 SCID-I, Follow-up 2 years RFL ↓, Cox <0.0001 HR = 0.91,
et al., (100%) Patients with + 12.71, SCID-II future SA ↑ proportional 95% CI

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2007 MDE Women: (DSM-III- in women hazard (0.87,
37.80 + R), IPDE, only regression 0.95)
11.37 HDRS, BDI, analysis (RFLI
BPRS, and SA during
EP
BGAH, the follow-up)
BDHI, BIS,
S-PRQ,
BHS, RFLI,
C

GAS
AC

Table legends:

AA: African American, AQ: Aggression Questionnaire, ATHS: Adult Trait Hope Scale, BD (I or II): Bipolar Disorder (I or II), BDHI: Buss-Durkee Hostility Inventory, BDI: Beck Depression Inventory, BD NOS: Bipolar
Disorder Not Otherwise Specified, BGAH: Brown Goodwin Aggression History, BGLAH: Brown Goodwin Lifetime Aggression History, BHS: Beck Hopelessness Scale, BIS: Barratt Impulsivity Scale, Bl: Blacks, BLS: Beck
Lethality Scale, BPD: Borderline personality disorder, BPRS: Brief Psychiatric Rating Scale, BSAS : Belief Systems Analysis Scale, CARS-M: Clinician-Administred Rating Scale for Mania, CES-D: Center for
Epidemiological Studies Depression Scale, CSHF: Columbia Suicide History Form, CTQ: Child Trauma Questionnaire, DASS-21: Depression Anxiety Stress Scale-21, DD NOS: depressive disorder not otherwise specified,
DSM: Diagnostic and Statistical Manual of Mental Disorders, Dys: Dysthymic Disorder, F: female, GAS: Global Assessment Scale, HDRS: Hamilton Depression Rating Scale, Hisp: Hispanic, IADL: Instrumental Activities of
Daily Living Scale, IGT: Iowa Gambling Task, IPDE: International Personality Disorders Examination, LRS: Lethality Rating Scale, M: Male, MDD: Major Depressive Disorder, MDE: Major Depressive Episode, MLS:
Medical Lethality Scale, MMSE: Mini Mental State Examination, MSSI: Modified SSI, PNSII: Positive and Negative Suicide Ideation Inventory, PSDI: Personality Styles and Disorders Inventory, PSMS: Physical Self-
 ACCEPTED MANUSCRIPT

Maintenance Scale, PSR: Provision of Social Relations, RFL: Reasons for living, RFLI: Reasons for Living Inventory, RFL-OA: Reasons For Living Older Adults Scale, RFL-YA: Reasons for Living Inventory for Young
Adults, RSES: Rosenberg Self-Esteem Scale, SA: suicide attempt, SAD: schizoaffective disorder, SAI: Spiritual Assessment Inventory, SANS: Scale for the Assessment of Negative Symptoms, SAPS: Scale for the Assessment
of Positive Symptoms, SB: Suicidal Behavior, SBQ: Suicide Behaviors Questionnaire, SCID: Structured Clinical Interview for the Diagnostic and Statistal Manual of Mental Disorders, SD: Schizophrenia, SFD:
schizophreniform disorder, SIMD: substance-induced mood disorder, SIS: Suicide Intent Scale, SPDE: structured Personality Disorder Examination, S-PRQ: St Paul-Ramsey Questionnaire, SSB: Social Support Behaviors
Scale, SSI: Scale for Suicide Ideation, SSI-C: SSI for respondents’ current state, SSI-W: SSI for the worst point in their lives, SWLS: Satisfaction with Life Scale, VCQ: Volitional Component Questionnaire, Wh: White

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Table 3: Moral Objections to Suicide and suicidal ideation and attempts

SUICIDAL IDEATION

Authors Diagnosis Targeted Sample Gender Mean Ethnicity Scales Design follow- Results Statistical P value Other

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population size (%) age (%) of the up analysis statistical
(n=) (years) study duration results

Chang et al., SSD (50.6%), Brief Clinical: 89 M = 20.5 + Chinese SSI, Chinese- Cross- None NS Univariate 0.206 OR = 1.28

RI
2014 psychotic disorder individuals 48.3 3.3 bilingual sectional logistic
(24.7%), Delusion with first- SCID-I (DSM- regression
disorder (7.8%), episode IV), IRAOS, analyses
Psychosis NOS psychosis PANSS,

SC
(16.9%) SANS,
MADRS, IS,
BHS, IPC,
BIS, BRFL-A,

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MWCST,
HSCT

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Britton et al., MDD (82%), BD I Clinical: older 125 F=54 60.9 + Wh = 97 SCID-I , RFL- Cross- None NS Logistic OR = 0.95,
2008 most recent episode patients (adults 10.1 OA, HDRS, sectional regression 95% CI
depressed (9%), 50 years or BHS, SSI analyses (RFL- (0.87−1.03)
BD I most recent older receiving OA and SSI)

M
(but not currently) treatment for a
manic, mixed, or mood disorder)
unspecified (2%),
BD II (2%), SIMD

D
(2%), DD NOS
(2%), and Dys

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(<1%)
Oquendo et Clinical: MDD, 460 M = 50 33.0 + Latinos = SCID-I (DSM- Cross- None NS Linear = 0.124 β = -0.08, z
al., 2005 BD or SD 8.9 89, Non- III-Revised), sectional regression (RFLI = -1.54
Latinos = HDRS, BDI, and SSI)
EP
11 BHS, BPRS,
SANS, SAPS,
CSHF, SSI,
SIS, MLS,
C

RFLI
Pinto et al., Not detailed Clinical: 253 F=66 15.38 + Wh = 64, RFLI, SIQ, Cross- None MOS ↑, SI ↓ Pearson <0.001 r = -0.31
1998 adolescent 1.05 AA = 11, BDI, HSC sectional correlation
AC

inpatients (40% Hisp = 2, (RFLI – SIQ)

suicide Asian = 1,
attempters, missing
30% suicide data = 21
ideators, and
30% non-
suicidal)
 ACCEPTED MANUSCRIPT

Richardson- Patients with mood Clinical: 521 F=66 AUD 36 Wh = 74 SCID-I (DSM- Cross- None MOS ↓, SI ↑ Pearson <0.001 r=0.18
Vejlgaard et disorders with and patients with ± 11, IV), CSHI, sectional Correlations
al., 2009a without AUD: mood disorders No SSI, RFLI (RFLI and SSI)
MDD (69%; with and AUD 38
n=360) or BD without AUD ± 12
current episode

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depressed (31%;
n=161)
Lee and Oh, College 277 South- CS-RFL, Cross- None MOS ↑, SI ↓ Hierarchical < 0.001 β = -0.25, t
2012 students Korean MSSI sectional regression = -4.362

RI
analyses (CS-
RFLI and
MMSI),

SC
controlling for
depression and
hopelessness
Garza and Spanish 168 F = 76 26.99 + Hisp = 100 SRFL-I, BDI- Cross- None MOS ↑, SI ↓ Correlation

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Cramer, Speaking 11.38 II, SBQ- sectional (SRFL-I and < 0.01 r = -0.20
2011 Hispanics Revised, MSSI MSSI)

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Direct and Multivariate
moderating regression < 0.01 F = 11.50,
effects of ἠ2p = 0.07, β
MOS on SI = -1.39

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Cole, 1989 High school 285 F=59 Girls: Wh = 94 RFLI, HSC, Cross- None MOS ↑, SI ↓ Partial < 0.05 r ranged
Study 1 students 17.3 + CDI, ESDS, sectional correlations overall between -
1.0, MCSDS, SBQ, (RFLI and SBQ, 0.20 and -

D
boys: ZIPS ZIPS), 0.13
16.9 + controlling for

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0.9 depression and
hopelessness
Richardson- Mood disorders: Clinical: mood 804 F=69 38.7 + Wh = 73, SCID-I (DSM- Cross- None MOS ↓, SI ↑ Partial =0.001 r=0.15
Vejlgaard et MDD (73%) and disordered 17-85 AA = 15, IV), CSHI, sectional in Whites correlation (SSI (overall) (overall)
al., 2009b BD (27%) patients Hisp = 12 LRS, SSI, and and RFLI)
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BGAH, Hispanics;
HDRS, RFLI MOS ↑, SI
↑in Blacks
C
AC

SUICIDE ATTEMPTS

Authors Diagnosis Targeted Sample Gender Mean age Ethnicity (%) Scales Design of the Follow- Results Statistical P Other
population size (%) (years) study up analysis value statistical
(n=) results
Mohammadkhani Substance Clinical: 348 M = - Iranian BSI, SPS, Cross- None NS Pearson - r = 0.001
et al., 2015 abuse or Substance 100 MAAS, sectional correlation
dependence abusers or RFLI (RFLI and
100% dependent SPS)
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(group1:
prisoners
n=233,
groupe 2:
outpatients
n=115)

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Moody and Trans adults 133 36.75 + Wh = 34.9, LOT-R, Cross- None MOS-SB Correlation - r = -0.10
Smith, 2013 13.01 European = 16.3, PSSS-Fr, sectional correlation:
Canadian or PSS-Fa, SRI- NS
French-Canadian 25, RFLI,

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or Québécois = SBQ-Revised MOS do not Hierarchical - t = 0.26
14.7, European predict SB multiple
Canadian = 11.6, regression

SC
Jewish = 4.7, analysis (RFL
Asian = 4.7, – SBQ)
Bi/multi-
ethnicity = 4.7,

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Other = 8.6
Dervic et al., Depressed Clinical: 200 F = 35.6 ± 10.9 Wh = 78.3 SCID, SCID- Retrospective None MOS ↓, SA Logistic < OR = 2.0,

AN
2011 bipolar depressed 59.5 II (DSM-III- case control ↑ regression 0.001 95% CI
patients bipolar R), GAS, study (RFLI – SA) (1.4–3.1)
(100%) patients HDRS-17,
BDI, BHS,
YMRS,

M
BPRS,
BGAH,
BDHI, BIS,

D
S-PRQ,
RFLI, CSHF,

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SSI, LRS,
SIS
Lizardi et al., MDE Clinical: 265 F=60 36.9 ± 12.0 Wh=77.7 SCID I and II Cross- None MOS ↓, SA Logistic =0.036 OR = 1.9,
2008 (100%) depressed (DSM-III-R), sectional ↑ regression 95% CI
inpatients HDRS, BDI, analysis (RFLI (1.04, 3.4)
EP
BHS, GAS, – SA)
BGAH,
BDHI, BIS,
BPRS,
C

SAPS,
SANS, S-
AC

PRQ, RFLI
Malone et al., MDE Clinical: 84 F = 55 Attempters: Wh = 75 SCID-I Cross- None MOS ↑, SA - = t = -3.79,
2000 (100%) inpatients 32.6 + 11.4; (DSM-III-R), sectional ↓ 0.0003 df = 82
with MDE Non HDRS, BDI,
attempters: BHS, BPRS,
36.2 + 12.3 RFLI, S-
PRQ, RLCQ,
SSI, SIS,
MLS
 ACCEPTED MANUSCRIPT

Oquendo et al., Clinical: 460 M = 50 33.0 + 8.9 Latinos = 89, SCID-I Cross- None MOS ↓, SA Logistic = B = -0.05,
2005 MDD, BD or Non-Latinos = (DSM-III- sectional ↑ regression 0.018 Wald =
SD 11 Revised), 5.60, OR
HDRS, BDI, = 1.00
BHS, BPRS,
SANS,

PT
SAPS,
CSHF, SSI,
SIS, MLS,
RFLI

RI
Garza and Spanish 168 F = 76 26.99 + Hisp = 100 SRFL-I, Cross- None MOS ↓, SA Correlation = 0.01 r = -0.20
Cramer, 2011 Speaking 11.38 BDI-II, SBQ- sectional ↑ (SRFL-I and
Hispanics Revised, SBQ)

SC
MSSI
Direct and Multivariate < 0.01 F = 11.60,
moderating regression ἠ2p = 0.07,
effects of β = -0.32

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MOS on
SB

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Cole, 1989 High school 285 F=59 Girls: 17.3 + Caucasian= 94 RFLI, CHS, Cross- None MOS ↓, past Partial = r ranged
Study 1 students 1.0; boys: CDI, ESDS, sectional or recent SB correlation 0.001) between -
16.9 + 0.9. MCSDS, ↑ (RFLI and 0.15 and -
SBQ, ZIPS ZIPS), 0.27
controlling for

M
depression and
hopelessness

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Table legends:

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AA: African American, AUD: Alcohol Use Disorder, BD (I or II): Bipolar Disorder (I or II), BDHI: Buss-Durkee Hostility Inventory, BDI: Beck Depression Inventory, BGAH: Brown Goodwin Aggression History,
BHS: Beck Hopelessness Scale, BIS: Barratt Impulsiveness Scale, BPRS: Brief Psychiatric Rating Scale, BRFL-A: Brief Reasons for Living Inventory for Adolescents, BSI: Brief Symptom Inventory, CDI: Children’s
Depression Inventory, CHS: Children’s hopelessness scale, CSHF: Columbia Suicide History Form, CSHI: Columbia Suicide History Interview, CS-RFL: College Student RFLI, DD NOS: depressive disorder not
EP
otherwise specified, DSM: Diagnostic and Statistical Manual of Mental Disorders, Dys: Dysthymic Disorder, ESDS: Edwards Social Desirability scale, F: female, GAS: Global Assessment Scale, HDRS: Hamilton
Depression Rating Scale, Hisp: Hispanic, HSC: Hopelessness Scale for Children, HSCT: Hayline Sentence Completion Test, IPC: Internality, Powerful Others, and Chance Scale, IRAOS: Interview for Retrospective
Assessment of the Onset of Schizophrenia, IS: Birchwood Insight Scale, LOT-R: Life Orientation Test Revised, LRS: Lethality Rating Scale, M: Male, MAAS: Mindful Attention Awareness Scale, MADRS:
Montgomery-Asberg Depression Rating Scale, MCSDS: Marlowe-Crowne Social Desirability Scale, MDE: Major Depressive episode, MDD: Major Depressive Disorder, MLS: Medical Lethality Scale, MOS: Moral
C

Objections to Suicide, MSSI: Modified Scale for Suicide Ideation, MWCST: Modified Wisconsin Card Sorting Test, NOS: Not otherwise specified, NS: not significant, PANSS: Positive and Negative Syndrome Scale,
PSS-Fa: Perceived Social Support Scale from Family, PSSS-Fr: Perceived Social Support Scale from Friends, RFLI: Reasons for Living Inventory, RFL-OA: Reasons For Living Older Adults Scale, RLCQ: Recent
AC

Life Changes Questionnaire, SA: suicide attempts, SANS: Scale of Assessment of Negative Symptoms, SAPS: Scale for the Assessment of Positive Symptoms, SB: suicidal behavior, SBQ: Suicide Behaviors
Questionnaire, SCID: Structured Clinical Interview for the Diagnostic and Statistal Manual of Mental Disorders, SD: Schizophrenia, SI: Suicidal Ideation , SIMD: substance-induced mood disorder, SIQ: Suicidal
Ideation Questionnaire, SIS: Suicide Intent Scale, S-PRQ: St Paul-Ramsey Questionnaire, SPS: Suicide Probability Scale, SRFL-I: Spanish Reasons for Living Inventory, SRI-25: Suicide Resilience Inventory 25, SSD:
Schizophrenia-spectrum disorder, SSI: Scale for Suicide Ideation, Wh: White, YMRS: Young Mania Rating Scale, ZIPS: Zung Index of Potential Suicide
 ACCEPTED MANUSCRIPT

Table 4: Survival and Coping Beliefs and suicidal ideation and attempts

SUICIDAL IDEATION

Authors Diagnosis Targeted Sample Gender Mean Ethnicity Scales Design follow- Results Statistical P Other

PT
population size (%) age (%) of the up analysis value statistical
(n=) (years) study duration results

Chang et al., SSD (50.6%), Brief Clinical: 89 M = 20.5 + Chinese SSI, Chinese- Cross- None SCB ↓, SI ↑ Univariate =0.003 OR= -0.41

RI
2014 psychotic disorder Individuals with 48.3 3.3 bilingual sectional (univariate logistic
(24.7%) Delusion first-episode SCID-I (DSM- model) regression
disorder (7.8%), psychosis IV), IRAOS, analyses
Psychosis NOS PANSS,

SC
(16.9%) SANS, NS Multivariate NS
MADRS, IS, (multivariate logistic
BHS, IPC, BIS, model) regression
BRFL-A, model (BRFL-A

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MWCST, and SI)
HSCT

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Britton et al., MDD (82%), BD I Clinical: older 125 F=54 60.9 + Wh = 97 SCID-I , RFL- Cross- None NS Logistic - OR = 0.99,
2008 most recent episode patients (adults 10.1 OA, HDRS, sectional regression 95% CI
depressed (9%), BD 50 years or BHS, SSI analyses (RFL- (0.96−1.03)
I most recent (but older receiving OA and SSI)

M
not currently) treatment for a
manic, mixed, or mood disorder)
unspecified (2%),
BD II (2%), SIMD

D
(2%), DD NOS
(2%), and Dys

TE
(<1%)
Pinto et al., Not detailed Clinical: 253 F=66 15.38 + Wh = 64, RFLI, SIQ, Cross- None SCB ↑, SI ↓ Pearson <0.001 r = -0.67
1998 adolescent 1.05 AA = 11, BDI, HSC sectional correlation
inpatients (40% Hisp = 2, (RFLI – SIQ)
EP
suicide Asian = 1;
attempters, 30% missing
suicide ideators, data = 21
and 30% non-
C

suicidal)
Richardson- Patients with mood Clinical: 521 F=66 AUD 36 Wh = 74 SCID-I (DSM- Cross- None ↓ SCB, ↑ SI Pearson <0.001 r=−0.48
Vejlgaard et disorders with and patients with ± 11, No IV), CSHI, sectional Correlations
AC

al., 2009 without AUD: MDD mood disorders AUD 38 SSI, RFLI (RFLI – SSI)
(69%; n=360) or BD with and ± 12
current episode without AUD
depressed (31%;
n=161)
Lee and Oh, College 277 South- CS-RFL Cross- None SCB ↑, SI ↓ Correlation (CS- < r = -0.56
2012 students Korean sectional RFL and SSI) 0.018
 ACCEPTED MANUSCRIPT

Hierarchical
regression β = -0.35, t
analyses, < = -4.656
controlling for 0.001
depression and
hopelessness

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Cole, 1989 High school 285 F=59 Girls: Wh = 94 RFLI, HSC, Cross- None SCB ↑, SI ↓ Partial = r ranged
Study 1 students 17.3 + CDI, ESDS, sectional correlations 0.001 between -
1.0, MCSDS, SBQ, (RFL and SBQ, 0.38 and
Boys: ZIPS ZIPS) 0.30

RI
16.9 + controlling for
0.9 depression and
hopelessness

SC
Oquendo et Clinical: MDD, 460 M = 50 33.0 + Latinos = SCID-I (DSM- Cross- None SCB ↓, SI ↑ Linear = β = -0.48, z
al., 2005 BD or SD 8.9 89, Non- III-Revised), sectional regression 0.000 = -8.57
Latinos = HDRS, BDI, (RFLI and SSI)
11 BHS, BPRS,

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SANS, SAPS,
CSHF, SSI,

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SIS, MLS,
RFLI

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SUICIDE ATTEMPTS

Authors Diagnosis Targeted Sample Gender Mean age Ethnicity (%) Scales Design of Follow- Results Statistical P Other
population size (%) (years) the study up analysis value statistical

D
(n=) results
Mohammadkhani Substance Clinical: 348 M = - Iranian BSI, SPS, Cross- None SCB ↑, SA ↓ Pearson < r = -0.244

TE
et al., 2015 abuse or substance 100 MAAS, sectional correlation 0.01
dependence abusers or RFLI SCB:
(100%) dependent prediction of
(group1: suicide
EP
prisoners probability
n=233, groupe
2: outpatients
n=115)
C

Moody and Trans adults 133 36.75 + Wh = 34.9, LOT-R, Cross- None SCB ↑, SA ↓ Correlation < r = -0.49
Smith, 2013 13.01 European = 16.3, PSSS-Fr, sectional 0.001
AC

Canadian or PSS-Fa,
French-Canadian SRI-25,
or Québécois= RFLI, SBQ- SCB: do not Hierarchical - t = -1.30
14.7, European Revised predict SB multiple
Canadian = 11.6, regression
Jewish = 4.7, analysis (RFLI
Asian = 4.7, and SBQ)
Bi/multi-
ethnicity = 4.7,
 ACCEPTED MANUSCRIPT

Other = 8.6

Lizardi et al., MDE Clinical: 265 F=60 36.9 ± 12.0 Wh = 77.7 SCID I and Cross- None SCB ↑, SA ↓ Logistic < SCB: OR
2008 (100%) depressed II (DSM-III- sectional regression 0.001 = 0.97,
inpatients R), HDRS, analysis (RFLI 95% CI

PT
BDI, BHS, – SA) (0.96-
GAS, 0.98)
BGAH,
BDHI, BIS,

RI
BPRS,
SAPS,
SANS, S-

SC
PRQ, RFLI

Goldston et al., Clinical: 180 F= 14.8 Wh = 80, AA = ISCA, BHS, Prospective Up to SCB ↑, Correlation 0.024 -
2001 inpatients 50.56 16.7, others RFLI, DAS, 6.9 future SA ↓ (SCB- future

U
adolescents (Hisp, Native MEPS years) in previous SA)
American, or of (mean = attempters,

AN
Asian American 4.0, but not in
heritage) median non-
= 4.3) attempters
Malone et al., MDE Clinical: 84 F = 55 Attempters: Wh = 75 SCID-I Cross- None SCB ↑, SA - = t= –3.79,

M
2000 (100%) inpatients 32.6 + 11.4; (DSM-III- sectional ↓. 0.0003 df = 73
with MDE Non R), HDRS,
attempters: BDI, BHS,
36.2 + 12.3 BPRS,

D
RFLI, S-
PRQ,

TE
RLCQ, SSI,
SIS, MLS
Cole, 1989 High school 285 F=59 Girls: 17.3 + Wh= 94 RFLI, CHS, Cross- None SCB ↓, past Partial = r ranged
Study 1 students 1.0; Boys: CDI, ESDS, sectional or recent SB correlation 0.001 between -
16.9 + 0.9. MCSDS, ↑ (RFLI and 0.32 and -
EP
SBQ, ZIPS ZIPS), 0.26
controlling for
depression and
hopelessness
C

Oquendo et al., Clinical: 460 M = 50 33.0 + 8.9 Latinos = 89, SCID-I Cross- None SCB ↓, SA ↑ Logistic = B = -0.01,
2005 MDD, BD or Non-Latinos = 11 (DSM-III- sectional regression 0.006 Wald =
AC

SD Revised), (RFLI and SA 7.64, OR

HDRS, BDI, status) = 0.99
BHS, BPRS,
SANS,
SAPS,
CSHF, SSI,
SIS, MLS,
RFLI
 ACCEPTED MANUSCRIPT

Table legends:

AA: African American, AUD: Alcohol Use Disorder, BD (I or II): Bipolar Disorder (I or II), BDHI: Buss-Durkee Hostility Inventory, BDI: Beck Depression Inventory, BGAH: Brown Goodwin Aggression History,
BHS: Beck Hopelessness Scale, BIS: Barratt Impulsiveness Scale, BPRS: Brief Psychiatric Rating Scale, BRFL-A: Brief Reasons for Living Inventory for Adolescents, BSI: Brief Symptom Inventory, CDI: Children’s
Depression Inventory, CHS: Children’s hopelessness scale, CSHF: Columbia Suicide History Form, CSHI: Columbia Suicide History Interview, CS-RFL: College Student RFLI, DAS: Dysfunctional Attitudes Scale,

PT
DD NOS: depressive disorder not otherwise specified, DSM: Diagnostic and Statistical Manual of Mental Disorders, Dys: Dysthymic Disorder, ESDS: Edwards Social Desirability scale, F: female, GAS: Global
Assessment Scale, HDRS: Hamilton Depression Rating Scale, Hisp: Hispanic, HSC: Hopelessness Scale for Children, HSCT: Hayline Sentence Completion Test, IPC: Internality, Powerful Others, and Chance Scale,
IRAOS: Interview for Retrospective Assessment of the Onset of Schizophrenia, IS: Birchwood Insight Scale, ISCA: Interview Schedule for Children and Adolescents, LOT-R: Life Orientation Test Revised, M: Male,
MAAS: Mindful Attention Awareness Scale, MADRS: Montgomery-Asberg Depression Rating Scale, MCSDS: Marlowe-Crowne Social Desirability Scale, MDE: Major Depressive episode, MDD: Major Depressive

RI
Disorder, MEPS: Means-Ends Problem-Solving Task,MLS: Medical Lethality Scale, MWCST: Modified Wisconsin Card Sorting Test, NOS: Not otherwise specified, NS: not significant, PANSS: Positive and
Negative Syndrome Scale, PSS-Fa: Perceived Social Support Scale from Family, PSSS-Fr: Perceived Social Support Scale from Friends, RFLI: Reasons for Living Inventory, RFL-OA: Reasons For Living Older
Adults Scale, RLCQ: Recent Life Changes Questionnaire, SA: suicide attempts, SANS: Scale of Assessment of Negative Symptoms, SAPS: Scale for the Assessment of Positive Symptoms, SB: suicidal behavior, SBQ:

SC
Suicide Behaviors Questionnaire, SCB: Survival and Coping Beliefs, SCID: Structured Clinical Interview for the Diagnostic and Statistal Manual of Mental Disorders, SD: Schizophrenia, SI: Suicidal Ideation , SIMD:
substance-induced mood disorder, SIQ: Suicidal Ideation Questionnaire, SIS: Suicide Intent Scale, S-PRQ: St Paul-Ramsey Questionnaire, SPS: Suicide Probability Scale, SRI-25: Suicide Resilience Inventory 25, SSD:
Schizophrenia-spectrum disorder, SSI: Scale for Suicide Ideation, Wh: White, ZIPS: Zung Index of Potential Suicide

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AN
M
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C EP
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 Fig.1: Flow diagram
ACCEPTED MANUSCRIPT

Literature search on Pubmed

Matching each one of these key words: “reasons for living”, “reasons for living inventory”, “RFL”, “RFLI” with:
“suicide”, “suicidal ideation”, “suicidal thoughts”, “suicide attempts”, “suicidal behavior”, “suicidal acts”, “self-harm”,
“suicide death”, “completed suicide”, “protective” and “resilience”
Conditions: the use of the RFLI or one of its versions, articles published in English, Spanish or French.
No publication year limits.
All populations considered.

PT
RI
Search results combined (n=663)

U SC
Articles screened on the basis of title and abstract
AN
M

Excluded (n = 601):
Selected (n =62)
Did not use the RFLI (n=515)
Used RFLI or one of its versions but did not explore
D

links between RFL and suicide outcomes (n=48)

Language (Portuguese) (n=1)
TE

No access to the article and author information not

Full-text available (n =30) Full-text non avalaible (n
available (n=36)
=32)
Results not yet published (ongoing study) (n=1)
EP

Included (n=30) Email sent to authors

C

(n=32)
AC

Full-text sent by authors

Included from
(n=12)
references (n=2)

Included (n=7) Excluded (n=5):

Did not use RFLI (n=2)
Used RFLI or one of its versions but did not explore links between RFL
and suicide outcomes (n=2)
Included (n=39) Language (Polish) (n=1)
 ACCEPTED MANUSCRIPT
• A systematic review on links between reasons for living and suicidal behavior
• RFL have a protective effect against suicidal ideation and attempts
• RFL may moderate risk factors for suicide and be linked to resilience factors
• RFL depend on numerous factors and have “state” characteristics
• Therapies enhancing RFL should be developed to prevent suicidal behavior

PT
RI
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AN
M
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C EP
AC
 ACCEPTED MANUSCRIPT

Délégation régionale
Languedoc-Roussillon

Montpellier, January 20th 2016

PT
To the Editor-in-Chief:

RI
Florian Holsboer,

SC
We are pleased to re-submit our manuscript “DO REASONS FOR LIVING PROTECT
AGAINST SUICIDAL THOUGHTS AND BEHAVIORS? A SYSTEMATIC REVIEW
OF THE LITERATURE” to be considered for publication in your journal.

U
The paper has not been published or submitted in total or in part in any language as a
AN
contribution either to a journal, a book chapter, or abstract.

Contributors
M

Philippe COURTET proposed the topic of the study. Camélia LAGLAOUI BAKHIYI
conducted the literature searches and wrote the first draft of the manuscript, and all
authors contributed to and have approved the final manuscript.
D
TE

With our best regards,

Camélia LAGLAOUI BAKHIYI

Raffaella CALATI
EP

Sébastien GUILLAUME
Philippe COURTET
C

Camélia LAGLAOUI BAKHIYI, MD, Ph.D.

Inserm U 1061, Neuropsychiatry: Epidemiological and Clinical Research
AC

University of Montpellier
39, avenue Charles Flahault
34093 Montpellier cedex 5, France
E-mail: camelia.laglaoui@gmail.com
 ACCEPTED MANUSCRIPT

Délégation régionale
Languedoc-Roussillon

Montpellier, January 20th 2016

PT
To the Editor-in-Chief:

RI
Florian Holsboer,

SC
We are pleased to re-submit our manuscript “DO REASONS FOR LIVING PROTECT
AGAINST SUICIDAL THOUGHTS AND BEHAVIORS? A SYSTEMATIC REVIEW
OF THE LITERATURE” to be considered for publication in your journal.

U
The paper has not been published or submitted in total or in part in any language as a
AN
contribution either to a journal, a book chapter, or abstract.

Role of Funding Sources

M

C. LAGLAOUI BAKHIYI received a grant from ERASMUS MUNDUS – EU

METALIC II. ERASMUS MUNDUS – EU METALIC II had no role in the study
design, collection, analysis or interpretation of the data, writing the manuscript, or the
D

decision to submit the paper for publication.

TE

With our best regards,

Camélia LAGLAOUI BAKHIYI

Raffaella CALATI
EP

Sébastien GUILLAUME
Philippe COURTET
C

Camélia LAGLAOUI BAKHIYI, MD, Ph.D.

Inserm U 1061, Neuropsychiatry: Epidemiological and Clinical Research
AC

University of Montpellier
39, avenue Charles Flahault
34093 Montpellier cedex 5, France
E-mail: camelia.laglaoui@gmail.com