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
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
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
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