Evidence-Based Reviews

Will my patient attempt suicide again?

Current Psychiatry. 2008 November;7(11):19-31

Risk factors help you identify patients who need immediate hospitalization for safety.

References

1. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Suicidal thoughts, suicide attempts, major depressive episode, and substance use among adults. Rockville, MD: US Department of Health and Human Services; 2006.

2. Pfeffer CR, Klerman GL, Hurt SW, et al. Suicidal children grow up: rates and psychosocial risk factors for suicide attempts during follow-up. J Am Acad Child Adolesc Psychiatry 1993;32:106-13.

3. Lewinsohn PM, Rohde P, Seeley JR. Psychosocial risk factors for future adolescent suicide attempts. J Consult Clin Psychol 1994;62:297-305.

4. Brown GK, Beck AT, Steer RA, et al. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol 2000;68:371-7.

5. Hultén A, Jiang GX, Wasserman D, et al. Repetition of attempted suicide among teenagers in Europe: frequency, timing, and risk factors. Eur Child Adolesc Psychiatry 2001;10:161-9.

6. Harris EC, Barraclough B. Suicide as an outcome for mental disorders: a metaanalysis. Br J Psychiatr 1997;170:205-28.

7. Spirito A, Valeri S, Boergers J, et al. Predictors of continued suicidal behavior in adolescents following a suicide attempt. J Clin Child Adolesc Psychol 2003;32(2):284-9.

8. Moscicki EK. Epidemiology of completed and attempted suicide: toward a framework for prevention. Clin Neurosci Res 2001;1:310-23.

9. Beck AT, Steer RA. Clinical predictors of eventual suicide: a 5- to 10-year prospective study of suicide attempters. J Affec Disord 1989;17:203-9.

10. Petrie K, Chamberlain K, Clarke D. Psychological predictors of future suicidal behaviour in hospitalized suicide attempters. Br J Clin Psychol 1988;27:247-57.

11. Dahlsgaard KK, Beck AT, Brown GK. Inadequate response to therapy as a predictor of suicide. Suicide Life Threat Behav 1998;28:197-204.

12. Young MA, Fogg LF, Scheftner W, et al. Stable trait components of hopelessness: baseline and sensitivity to depression. J Abnorm Psychol 1996;105(2):155-65.

13. Talbot NL, Duberstein PR, Cox C, et al. Preliminary report on childhood sexual abuse, suicidal ideation, and suicide attempts among middle-aged and older depressed women. Am J Geriatr Psychiatry 2004;12:536-8.

14. Andover MS, Zlotnick C, Miller IW. Childhood physical and sexual abuse in depressed patients with single and multiple suicide attempts. Suicide Life Threat Behav 2007;37(4):467-74.

15. Heikkinen M, Aro H, Lönnqvist J. The partners’ views on precipitant stressors in suicide. Acta Psychiatr Scand 1992;85(5):380-4.

16. Bunch J, Barraclough B. The influence of parental death anniversaries upon suicide dates. Br J Psychiatry 1971;118:621-6.

17. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 1999;56(7):617-26.

18. Goldston DB, Daniel SS, Reboussin DM, et al. Suicide attempts among formerly hospitalized adolescents: a prospective naturalistic study of risk during the first 5 years after discharge. J Am Acad Child Adolesc Psychiatry 1999;38:660-71.

19. Rudd MD, Joiner T, Rajab MH. Relationships among suicide ideators, attempters, and multiple attempters in a young-adult sample. J Abnorm Psychol 1996;105(4):541-50.

20. Foreman EM, Berk MS, Henriques GR, et al. History of multiple suicide attempts as a behavioral marker of severe psychopathology. Am J Psychiatry 2004;161(3):437-43.

21. Miranda R, Scott M, Roger H, et al. Suicide attempt characteristics, diagnoses, and future attempts: comparing multiple attempters to single attempters and ideators. J Am Acad Child Adolesc Psychiatry 2008;47:32-40.

22. Joiner TE, Rudd MD. Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. J Consult Clin Psychol 2000;68(5):909-16.

23. Suominen K, Isometsä E, Suokas J, et al. Completed suicide after a suicide attempt: a 37-year follow-up study. Am J Psychiatry 2004;161:562-3.

24. Owens D, Wood C, Greenwood D, et al. Mortality and suicide after non-fatal self-poisoning: a 16-year outcome study of patients attending accident and emergency. Br J Psychiatry 2005;187:470-5.

25. Haw C, Bergen H, Casey D, Hawton K. Repetition of deliberate self-harm: a study of the characteristics and subsequent deaths in patients presenting to a general hospital according to extent of repetition. Suicide Life Threat Behav 2007;37(4):379-96.

26. Whitlock J, Knox KL. The relationship between self-injurious behavior and suicide in a young adult population. Arch Pediatr Adolesc Med 2007;161:634-40.

27. Joiner TE. Why people die by suicide. Cambridge, MA: Harvard University Press; 2005:46-93,203-22.

28. Gliatto MF, Rai AK. Evaluation and treatment of patients with suicidal ideation. Am Fam Physician. 1999;59(6):1500-6.

Ms. J, age 32, comes to our mental health clinic seeking treatment for depression and anxiety. She reports she has attempted suicide 3 times. Ms. J describes the first 2 attempts—both of which occurred when she was in her 20s after the end of a relationship—as “cries for attention” that were relatively innocuous. Her third suicide attempt, however, was an acetaminophen overdose approximately 1 year ago that resulted in hospitalization and irreversible liver damage.

Ms. J acknowledges that over the last several weeks she has been thinking about suicide almost constantly, especially as the anniversary of her fiancé’s death approaches. She says she has a nearly full bottle of zolpidem in her medicine cabinet and fantasizes about taking all of them and just “going to sleep.”

Many patients—especially those with depression—experience recurrent thoughts of death or a wish to die, but only about 10% attempt suicide.¹ To identify those who are at highest risk and warrant hospitalization, it is vital to assess how a history of suicidal behavior and other factors impact the risk for future suicide attempts. This article:

examines research on patients who have attempted suicide and risk factors for repeat suicide attempts
describes characteristics of patients with multiple attempts
explores the link between a history of self-injurious behavior and suicide attempts.

A strong predictor

A previous suicide attempt is among the strongest predictors of future suicide attempts.^2-4 In a sample of clinically referred European adolescents, those who had attempted suicide were 3 times more likely to try again during the 1-year follow-up compared with those who had never attempted suicide.⁵ In addition, Harris et al⁶ found that patients with a previous suicide attempt were 38 times more likely to eventually commit suicide than those with no past attempts.

Other risk factors

Other factors might help predict which individuals will continue to engage in suicidal behavior after a first attempt (Table 1).^7,8 Spirito et al⁷ followed 58 adolescent suicide attempters for 3 months after their initial attempt. Seven (12%) made a subsequent attempt, and 26 (45%) reported continued suicidal ideation. Depressed mood was the strongest predictor of subsequent suicidal behavior, followed by poor family functioning, affect regulation difficulty, and hopelessness.

Hopelessness. Beck et al⁹ found that patients who scored ≥9 on the Beck Hopelessness Scale (BHS)—the most common self-report measure of hopelessness—were approximately 11 times more likely to commit suicide than patients who scored ≤8. A study of hospitalized suicide attempters found that BHS scores were unique predictors of future suicide attempts.¹⁰ Several studies have found that persons who remain consistently hopeless are more likely to kill themselves compared with those who have fluctuating hopelessness levels.^11,12

Clinical Point

Persons with a previous suicide attempt are 38 times more likely to commit suicide than those with no past attempts

Psychiatric diagnoses. More than 90% of persons who eventually commit suicide have a diagnosable mental disorder.⁸ Although almost all Axis I and II disorders can increase the likelihood of a suicide attempt, certain disorders—including major depression, bipolar disorder, schizophrenia, substance use disorders, eating disorders, borderline personality disorder, and antisocial personality disorder—increase risk more than others.⁸

History of abuse—specifically sexual abuse—is associated with suicidal behavior. A study of depressed women age >50 found that among those who were sexually abused before age 18, 83% reported 1 suicide attempt and 67% made multiple attempts.¹³ Among women who had not experienced childhood sexual abuse, 58% reported a past suicide attempt and 27% made multiple attempts.¹³

In a separate study of psychiatric inpatients, those who had been physically or sexually abused were more likely to have made a suicide attempt than patients with no such history.¹⁴ This study did not find a difference in reported abuse between single and multiple suicide attempters.

Stressors. In many cases suicide attempts are precipitated by acute or chronic stressors, including:

job stress
chronic illness
financial problems
relationship discord
retirement and declining physical health (especially for older men)
death of a loved one.¹⁵

Anniversaries of the death of a loved one or other difficult life events can increase the risk for suicide attempts.¹⁶

Risk is not necessarily cumulative—and not all risk factors are weighted equally. In general, however, the more risk factors a patient has, the greater the likelihood that he or she may attempt suicide.¹⁷

Table 1

Repeated suicidal behavior: Factors that increase risk

History of ≥1 suicide attempts
Feelings of hopelessness
Presence of an Axis I or II disorder
High levels of perceived stress
History of physical or sexual abuse
Source: References 7,8

Red flag: Multiple attempts

When assessing a patient’s suicide history, ask about the number of attempts. A person who makes >1 suicide attempt—a multiple attempter—has a significantly higher chance of making subsequent attempts compared with those with 1 or no attempts.^18,19