The attempted suicide is the strongest known predictor of completed suicide, and a history of a suicide attempt may indicate suicide risk over the entire adult lifetime. The risk for a completed suicide following an earlier attempt, however, is much higher than previously thought, according to new findings published in The American Journal of Psychiatry.
“Previous studies have limited generalizability because of using convenience samples of specific methods/treatment settings, disregarding previous attempts, or overlooking first-attempt deaths,” investigators affiliated with University of California, San Diego and Mayo Clinic in Rochester, Minnesota, wrote in their publication.
This population-based cohort study involved data collected by the Rochester Epidemiology Project which links together all medical records from private practitioners, as well as medical centers and affiliated hospitals, in Olmsted County. The suicide attempters were identified by the corresponding diagnosis code—Hospital International Classification of Disease, Adapted, or International Classification of Disease. Investigators excluded those individuals with evidence of prior suicide attempt, and the final sample consisted of 555 males and 935 females, or 1 490 individuals, total.
Investigators reported that 8% of individuals (n=130) died during the study period, and more than 60% of deaths (n=81) were due to suicide. Out of 81 persons who attempted suicide, 48 died from first suicide attempt (mean age=33.2; SD=15.2), and 33 died from subsequent attempts (mean age 41.6; SD=20.7).
When the whole sample is taken into account, persons between age 25 and 44, as well as those older than 65, had the highest rate of completed suicide from the first attempt. Older age was “marginally” associated with higher probability of death (odds ratio=1.6, P=0.091), but was significantly associated with death from first suicide attempt (odds ratio=1.02, P=0.009).
Male sex (P<0.0001) and method of attempt (P<0.0001) were significantly associated with death from first suicide attempt. More than 70% of those who died from first suicide attempt died after they shot themselves, compared to only 9% who died of hanging, 5% who died of non-medication poisoning, and 0.6% who died of medical overdose.
It is important to mention, that “neither older age nor sex retained significance after adjustment for gunshot as the method,” and “regardless of sex, those using firearms had 140 times the risk of dying [from the first suicide attempt] than those using other methods,” investigators wrote.
Less than 70% of survivors of first suicide attempt had received a scheduled psychiatry follow-up appointment, which is crucial, considering that these appointments “proved highly protective, regardless of whether or not survivors had been hospitalized.” More specifically, individuals without appointments were significantly more likely to commit suicide compared with those with appointments (odds ratio=0.212, 95% CI=0.089-0.507).
With regard to a timeline, more than 80% and 87% of males and females, respectively, who died from a subsequent suicide attempt did so within 12 months of their first attempt.
“The implication of these findings is that suicide prevention efforts that commence after [the first suicide] attempt are too late for the nearly 2/3 who die on the first attempt,” and focus should be on “identifying populations at risk of making a first attempt,” researchers concluded.
Bostwick JM, Pabbati C, Geske JR, McKean AJ. Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. Am J Psychiatry. 2016. doi: 10.1176/appi.ajp.2016.15070854.