METHOD

The first variable was suicide behaviour, which distinguishes participants as having high or low levels of suicidality. The second variable was executive function, and this

consisted of measures for nine components of executive function categorized into two groups of processes; the Behavioural Regulation Index (BRI) and the Metacognitive Index (MI). There was a separate scoring for BRI, for MI and for a total score on the

Global Composite Index (GCI)

Behavioural Regulation Index

(BRI)

Inhibit Shift Emotional control Metacognitive Index (MI) Initiate Working memory Plan/ Organize task- monitor Organization of materials self- monitor

overall executive function (GEC). The third variable was coping, which incorporated three separate scores for problem-focused coping, emotion-focused coping, and avoidance-focused coping. Cultural background (HK or the UK) was a between-

participant variable. All the studies in this thesis have obtained ethical approval from the Ethics Committee of the School of Health Sciences at the University of Salford and informed consents were always obtained from all participants.

2.5.3.2 Participants

One hundred and thirty-three undergraduate Psychology students were recruited in this study. Sixty-four participants (7 males, 57 females) were studying at the University of Salford in the UK. Their ages ranged from 18 to 40 years, with a mean of 23.14 years (SD = 5.51). Sixty-nine participants (25 males, 44 females) were from The Open University in HK. Their ages ranged from 18 to 36 years, with a mean of 21.06 years (SD= 2.97).

2.5.3.3 Materials

A total of 3 questionnaires (Appendix 1.1-1.3) were used for this study in order to measure each of the dependent variables. Suicide behaviour was measured using the Suicidal Behaviour Questionnaire - Revised (SBQ-R; Osman, Bagge, Gutierrez, Konick, Kopper, & Barrios, 2001). This is a 4-item inventory that explores different dimensions of suicidality. Item 1 measures lifetime suicide ideation and/or suicide attempts, item 2 assesses the frequency of suicidal ideation in the previous 12 months, item 3 quantifies the threat of a suicide attempt, and item 4 is the self-reported likelihood of future suicide

behaviour. Each question was answered using a Likert scale and each scale differed slightly. The scales ranged from a minimum of 0 to a maximum of 6, with lower numbers indicating a relatively low level of suicidality. Total scores range from 3 to 18 and

represent overall severity of suicide behaviour whereby higher scores represent higher levels of suicidality.

Executive functions were measured using the Behaviour Rating Inventory of Executive Functions - Adult Version (BRIEF-A; Malloy & Grace, 2005). This is a 75- item questionnaire to assess executive functions in daily life by capturing an individual’s purposeful, goal-directed, problem solving behaviour. The questions are answered on a 3- point Likert Scale (1= Never, 2= Sometimes, 3= Often). High scores on the BRIEF-A indicate a “disorder of executive functions” in a specific domain. Executive functions are divided into a Metacognitive Index (MI) that includes self-monitoring, initiate, working memory, planning, task monitoring, and organization of materials, and a BRI which includes inhibition, shifting, and emotional control. The BRIEF-A inventory also

provides a GEC that is the sum of the BRI and the MI. Raw scores are collected from the BRIEF-A and are then transformed into different T scores according to the age of the participant. Higher GEC represents deficits in executive functions (Isquith, et al., 2006).

Coping was measured using the COPE inventory (Carver, Scheier, & Weintraub, 1989). This is a 60-item inventory that assesses different behavioural responses to stress. This inventory divides coping into 15 subscales: active coping, planning, suppression of competing activities, restraint coping, and seeking of instrumental social support are all categorized as problem-focused coping; seeking emotional social support, positive

coping; and focus on and venting of emotions, behavioural disengagement, and mental disengagement fall under the category of avoidance-focused coping. Each question is answered using a four-point scale (1 = I usually don’t do this at all, 2 = I usually do this a little bit, 3 = I usually do this a medium amount, and 4 = I usually do this a lot). Each subscale of coping is measured using 4 questions, giving a minimum score of 4 and a maximum of 16. There are a total of 5 coping subscales under each of the following coping categories: problem-focused, emotion-focused, and avoidance-focused coping, therefore each category has a minimum score of 20 and a maximum of 90. A higher score indicates the use of a particular coping strategy to a greater extent.

2.5.3.4 Procedure

All participants were given an information sheet (Appendix 1.1- 1.3) and consent form (see Appendix 3) together with the questionnaires. They were asked to read the

instructions and then complete each questionnaire at their own pace. The completion of the questionnaires took approximately 30 minutes and following completion participants were debriefed by the researcher (Appendix 4.1).

2.5.4 RESULTS

Responses of all three questionnaires for each participant were collated. The median and range of all variables are presented in Table 2.2. A total of 30 participants (22.6%) scored higher than 7 on the SBQ-R (median = 10.00, range = 7-15) which indicates a relatively high suicide risk. There were 10 of them (i.e. 7.63% of the total sample) reporting a history of at least one suicide attempt, there were 103 participants reporting lower risk of

suicidality as they scored below 7 on the SBQ-R (median = 3.00, range = 3-6). A cross- cultural comparison was made illustrating that 14 out of 69 HK participants (20.29%) reported a suicide risk compared to 16 out of 64 in the UK group (23.19%). To compare suicidality according to cultural background a Mann Whitney test was used as the data did not conform to parametric assumptions (see Appendix 6.1.1). The result showed no significant difference in suicidality between the UK and HK (U =1868, z = -1.601, p = .109).

Table 2.2. Descriptive statistics of the suicide, coping, and executive functions for the UK and HK participants.

UK n=64

HK n=67

Median Range Median Range

Global Executive Composite 123 84-157 121 91-156

Behavioural Regulation 47 37-64 47 37-60 Meta-cognitive Index 71 41-106 71 45-104 Problem-focused coping 53 34-69 54 35-70 Emotion-focused coping 49.5 25-65 47 30-69 Avoidance-focused coping 33.5 19-50 31 20-53 Suicidality 4.5 3-15 3 3-15

Regarding the cross-cultural difference in coping strategies adopted between HK and the UK participants (Table 2.3), a Mann Whitney test was used to compare the use of different coping strategies by individuals in the UK and HK group. As there were 15 comparisons, a Bonferroni adjustment was applied and the alpha was adjusted to 0.003. Results showed significant differences between the UK and HK in that HK participants used certain coping strategies to a greater extent (Appendix 6.1.2). These were denial (U = 1460.5, z = -3.399, p = .001), behavioural disengagement (U = 1468.5, z = -3.356, p = .001) and restraint (U = 1560, z = -2.95, p = .003)

Table 2.3: Descriptive statistics of the 15 coping strategies for the UK and HK participants.

UK HK

Median Range Median Range

Positive growth 11.50 0-16 13.00 6-16

Mental disengagement 10.00 0-16 10.00 5-16

Focus of emotion 11.00 0-16 9.00 4-16

Instrumental social support 11.00 0-16 11.00 5-16

Active coping 11.00 0-15 11.00 7-16 Denial 6.00 0-11 7.00 4-14 Religious coping 4.00 0-16 6.00 4-16 Humour 8.00 0-16 10.00 5-16 Behavioral disengagement 7.00 0-14 8.00 4-14 Restraint 9.00 0-14 10.00 6-13

Emotional social support 12.00 0-16 11.00 4-16

Substance use 4.00 0-16 4.00 4-13

Acceptance 11.00 0-16 11.00 8-16

Suppression 9.50 0-15 10.00 7-16

Planning 11.00 0-16 11.00 7-16

2.5.4.1 Suicidality and executive functions

Given that there was no difference in suicidality between the two groups, when assessing the relationship between the study variables, all participants were merged into a single group and the variable of culture was not considered in further analysis. A series of Spearman’s correlations were conducted as the data did not conform to parametric assumptions. Correlational analyses (Appendix 6.1.3) were conducted to assess the relationship between suicidality and executive functions. Higher levels of suicidality were significantly correlated with greater deficits of executive functions. Increased suicidality was related to higher scores for GEC (r (131) = .41, p = .001), MI (r (131) = .32, p = .001, and BRI (r (131) = .47, p = .001). Deficits in all components of the BRI were significantly, positively correlated with suicidality: emotional control, r (131) = .42, p = .001, inhibit, r (131) = .30, p = .001, and shift, r (131) = .31, p = .001. Therefore, poor emotional control, difficulty with inhibition and shifting were all related to increased suicidality. Similarly, deficits in almost all components of the MI were

significantly and positively correlated with suicidality: working memory, r (131) = .26, p = .001, initiate, r (131) = .36, p = .001, organization of material, r (131) = .36, p = .001, plan/organization, r (131) = .25, p = .001, task monitor, r (131) = .20, p = .001. The only aspect of MI that did not correlate with suicidality was self-monitor, r (131) = .17, p = .053.

As most of the executive functioning components were significantly associated with suicidality, a multiple regression analysis was further performed with suicidality as the dependent variable to see which of the specific executive function components confer the most predictive variable for suicidality. Using the enter method, a significant model emerged (F (8, 124) = 5.424, p = .001) Adjusted R square = 0.21 (Appendix 6.1.4). Significant executive function variables that increased suicidality were difficulties with emotional control (Beta = 0.276, p = .018), organization (Beta = -0.299, p = .013), and initiate (Beta = 0.345, p = .02).

2.5.4.2 Suicidality and coping

Correlational analyses were conducted to assess the relationship between each coping strategy and suicidality (Appendix 6.1.6). The only emotion-focused coping that was significantly correlated with suicidality was religious coping, and this showed a negative correlation, r (131) = -.21, p = .013. Higher scores on avoidance-focused coping were associated with increased suicidality such as mental disengagement, r (131) = .32, p = .001, venting of emotion, r (131) = .30, p = .001, and alcohol-drug disengagement, r (131) = .41, p = .001. In contrast to the hypothesis, problem-focused coping was not associated with reduced suicidality (active coping, r (131) = .03, p >.05, planning, r (131)

= -.04, p >.05, seeking social support for instrumental reasons, r (131) = .07, p >.05, suppression of competing activities, r (131) = .17, p >.05, and restraint coping r (131) = .12, p >.05).

To further explore which specific coping strategies confer the most predictive variable for suicidality, a multiple regression analysis was performed with suicidality as the dependent variable and different coping strategies as predictor variables. Using the enter method (Appendix 6.1.6), a significant model emerged (F (9,117)= 5.133, p = .001, adjusted R square = 0.32) Significant variables that reduced suicidality were related to greater use of emotion-focused coping: positive growth (Beta = -0.337, p = .034), turning to religion (Beta = -0.183, p = .031), and acceptance (Beta = -0.317, p = .016). Greater use of two coping strategies was associated with increased suicidality and these came under the category of avoidance-focused coping: venting of emotion (Beta = -0.285, p = .008) and alcohol-drug disengagement (Beta = -0.33, p = .001).

2.5.4.3 Coping and executive functions

Correlational analyses were conducted to assess the relationship between each coping strategy and executive functions. In terms of the relationship between coping strategies and difficulties in executive functions (as indexed by BRIEF-A), analysis indicated that difficulties in executive function were significantly associated with increased use of all avoidance coping strategies. These include venting of emotion, r (131) = .25, p < .005, mental disengagement, r (131) = .35, p < .001, alcohol-drug disengagement, r (131) = .23, p <.05, behavioural disengagement, r (131) = .33, p <.001, and humor, r (131) = .18,

p < .05. In contrast, deficits in behavioural regulation were inversely correlated with planning, r (131) = -.172, p < .05.

2.5.4.4 The relationship between suicidality, coping, and executive functions

To assess the impact of executive functions and coping on suicide behaviour, suicidality was entered into a linear regression with those variables that correlated most highly. Emotional control (an aspect of executive functions) and alcohol-drug disengagement (avoidance coping) were entered into step 1 of the regression. Both variables were identified as the strongest predictors of suicidality, accounting for 24.6% of the variance. In step 2 of the regression, an additional variable, organization (an aspect of executive functions) was entered, allowing for a total of 32% of the variance to be explained (see Appendix 6.1.4).