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Risk factors for fatal and nonfatal repetition

of suicide attempts: a literature review

This article was published in the following Dove Press journal:

Neuropsychiatric Disease and Treatment
7 November 2013
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Massimiliano Beghi 1,2 Objectives: This review aimed to identify the evidence for predictors of repetition of suicide
Jerrold F Rosenbaum 3 attempts, and more specifically for subsequent completed suicide.
Cesare Cerri 1,4 Methods: We conducted a literature search of PubMed and Embase between January 1, 1991
Cesare M Cornaggia 1,5 and December 31, 2009, and we excluded studies investigating only special populations (eg,
male and female only, children and adolescents, elderly, a specific psychiatric disorder) and
1
Psychiatry Clinic, University
of Milano Bicocca, Milan, Italy; studies with sample size fewer than 50 patients.
2
Department of Psychiatry, Salvini Results: The strongest predictor of a repeated attempt is a previous attempt, followed by
Hospital, Rho, Italy; 3Massachusetts
being a victim of sexual abuse, poor global functioning, having a psychiatric disorder, being
General Hospital, Harvard
Medical School, Boston, MA, USA; on psychiatric treatment, depression, anxiety, and alcohol abuse or dependence. For other
4
Department of Rehabilitation variables examined (Caucasian ethnicity, having a criminal record, having any mood disor-
Medicine, Zucchi Clinical Institute,
Carate Brianza, Italy; 5Forensic
ders, bad family environment, and impulsivity) there are indications for a putative correlation
Psychiatric Hospital, Castiglione delle as well. For completed suicide, the strongest predictors are older age, suicide ideation, and
Stiviere, Mantua, Italy history of suicide attempt. Living alone, male sex, and alcohol abuse are weakly predictive
with a positive correlation (but sustained by very scarce data) for poor impulsivity and a
somatic diagnosis.
Conclusion: It is difficult to find predictors for repetition of nonfatal suicide attempts, and
even more difficult to identify predictors of completed suicide. Suicide ideation and alcohol or
substance abuse/dependence, which are, along with depression, the most consistent predictors
for initial nonfatal attempt and suicide, are not consistently reported to be very strong predic-
tors for nonfatal repetition.
Keywords: suicide, deliberate self-harm, suicide attempt, repetition, predictors

Introduction
In recent years, suicide-attempt (SA) rates have been widely studied. A World Health
Organization community survey reported the lifetime prevalence of SAs at 0.4%–4.2%.1
Female sex, young age, marital status (divorced or widowed), and having a personality
disorder have been associated with an increased risk of attempting suicide.
The incidence rate for completed suicide (S) is 11.2/100,000,2 increases with age,
and is three times higher in males than in females.3 Suicide accounts for about 1%
of all deaths and is the ninth-leading cause of death in the US and the third in ages
15–24 years.3,4 Rates in Caucasians are twice those of non-Caucasian populations, and
Correspondence: Massimiliano Beghi
Psychosocial Center, married people are less likely than single, divorced, or widowed to commit suicide.2
28 Via Beatrice d’Este, Rho, Milan, Italy For those in bereavement, the risk is higher in the first year after loss. Rates are higher
Tel +39 02 9943 03919
Fax +39 02 9318 2492
in Protestants (31.4/100,000) than in Catholics (10.9/100,000) or Jews (15.5/100,000).
Email [email protected] Unemployment increases the rate of suicide by 50%.3

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The suicide risk is higher in psychiatric patients compared attempt” or “SA,” any nonfatal act in which the patient causes
to nonpsychiatric populations. More specifically, lifetime self-harm (self-mutilation, poisoning, jumping from high
risk of suicide has been reported as high as 15% for affective places, firearm shots, hanging, asphyxiation) was ­considered.
disorders, 10% for schizophrenia, and 2%–3% for alcohol The nomenclature has been taken from Silverman et al; we
abuse.4 With respect to affective disorders, the risk is higher considered all suicidal acts, despite the degree of suicidal
with increasing severity of depression. Suicides occur more intent. With the term “SA” we mean a not-completed suicide
often in patients with a family history of suicide, mood dis- (with or without injuries), while with the term “S” we mean
orders, and alcohol abuse.4 Suicidality tends to emerge early a completed suicide.9,10
in the course of a mood disorder, and increases in association For the aim of this study, we included cohort studies,
with melancholia and agitation.4 case-control studies, and cross-sectional studies. Since our
Despite these many variables having been associated review focused on environmental risk factors and not on
with suicidal behavior, their usefulness in predicting future management, we excluded studies investigating self-harm
suicidal behavior remains undemonstrated. The prospective management and/or care. Moreover, some of these studies
prediction of later suicide remains difficult.5,6 A need exists, investigated selected populations at risk, and others had
as underlined by Hughes and Owens,6 for more effective very small samples. Thus, we decided to exclude studies
monitoring of people who contact hospitals because of SAs, investigating selected populations (childhood/adolescence,
and for more information on patients who carry out SAs but elderly, males/females only, minorities only, patients with
do not attend hospital. The likelihood of a repeated attempt a specific personality disorder), studies with small samples
after a first SA has been investigated less extensively. An (fewer than 50), or prospective studies with a follow-up
episode of self-harm is a strong predictor of later suicide, shorter than 6 months. We decided to exclude special popu-
with the risk peaking in the first 6 months after a self-harming lations because the aim of the review was the prospective
episode, but risk persists for many decades. prediction of later suicide in the whole population referring
A recent review estimated the 1-year incidence of repeti- to the emergency room.
tion at 16% and fatal repetition at 2% of attempters.7 After Studies on self-poisoning only were included because
9 years, the suicide-fatality rate increased to more than the self-poisoning method encompasses 80% of females’
5%. Both fatal and nonfatal repetition rates were reported and 64% of males’ SAs.8 For the same reason, we decided
to be lower in Mediterranean than in Northern European to include studies on adults only.
countries.8
However, despite the potential importance of studies Data extraction
investigating the risk factors involved in repetition of SA, After a first screening, 211 papers satisfied our inclusion
no systematic reviews of the issue have been reported. ­criteria. Six were useful for the introduction and for the
­Accordingly, the aim of this review was to identify the evi- ­discussion. The majority of them were carried out in Europe.
dence for predictors of repetition of SA, and more specifically Since designs, the variables studied, and the length of follow-up
for subsequent S. were different among these studies, a formal meta-analysis or
direct comparison was not possible. After excluding 53 studies
Methods for not fulfilling the scope of the review, five studies for small
One of the authors (MB) searched both PubMed and Embase sample size, 72 studies for a selected sample (37 childhood/
systematically for studies carried out between January 1, adolescence, ten elderly, three females only, one males only,
1991 and 31 December, 2009 in English, using the keywords 19 patients with a psychiatric diagnosis, two minorities), we
repetition/repeated suicide attempt, repetition/repeated self- were left with 76 studies: 13 (17%) with a cohort analysis,
harm, recurrence/recurrent self-harm, recurrence/recurrent 45 (59%) with a case-control analysis, and 18 (24%) with a
suicide attempt, repetition/repeated self-poisoning, and cross-sectional analysis (Figure 1).
recurrence/recurrent self-poisoning. Suicides in most pri- Sixty of them (79%) were carried out in Europe, more
mary studies included those that were definite (by verdict of specifically, 24 in the UK, 20 in Scandinavian countries, five
a coroner or equivalent authority) or probable (open verdict in Ireland, two in France, one in Spain, one in the ­Netherlands,
or equivalent judgment); definitions were too variable for us one in Belgium, and six in three or more ­countries. The
to discriminate further, and we have included them all and other studies were done in the US (five), Australia (four),
used this broad definition of suicide. With the terms “suicide Canada (two), the People’s Republic of China (two), Iran (one),

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Dovepress Risk factors for fatal and nonfatal suicide attempts

Brazil (one), and Uganda (one). SA was investigated in 64, of 4,800 consecutive patients would commit suicide. On the
while S was investigated in 18 studies. basis of 21 risk factors, they identified 803 patients having
All the risk factors investigated in the studies were increased risk of suicide. Thirty of 803 (3.7%) committed
inserted and then selected by a consensus-based process suicide in a 5-year follow-up. None of these risk factors was
(by all the authors). detected in 37/67 suicides. These results are confirmed by
a review of twelve studies conducted by Diekstra in 1985.85
Results About 50% of suicidal people had committed at least one
Nonfatal repetition previous attempt. Also in this review, it is shown that it is
The strongest predictor for nonfatal repetition was a history easier to detect a nonfatal SA than a fatal one. This means
of SA, a finding reported as significant in 13 of 16 multi- that S is multifactorial, and involves not only medical but also
variate analyses and 13 of 14 univariate analyses (Table 1). philosophical aspects, eg, life is or is not worth living, and
Also significant were being a victim of a sexual abuse it is often a difficult but aware choice. The goal of a suicide
(multivariate 5/9, univariate 4/5), poor global ­functioning assessment is not to predict suicide, but to place a person
(multivariate 3/4, univariate 4/4), having a psychiatric along a putative risk continuum to evaluate suicidality, espe-
­disorder (multivariate 5/11, univariate 6/11), undergoing cially in the period immediately following the attempt, and
psychiatric treatment (multivariate 2/7, univariate 7/8), allow for a more informed intervention. In fact, according to
depression (multivariate 3/10, univariate 8/12), anxiety (mul- Reulbach and Bleich,86 up to 45% of people who deliberately
tivariate 2/6, univariate 4/5), or alcohol abuse or dependence harm themselves leave accident and emergency departments
(multivariate 4/10, univariate 4/8). There were weaker asso- without receiving an adequate psychiatric assessment; after
ciations for having a personality disorder, repetition for young the discharge, the patients should not be lost in aftercare,
adult age, unmarried status, alcohol abuse or dependence, especially if they suffer from depression, bipolar disorder,
psychiatric morbidity or treatment, and unemployment status. or schizophrenia.86
For many variables (Caucasian ethnicity, having a criminal In fact, after adjustment for baseline demographic and
record, having any mood disorders, bad family environment, clinical characteristics and hospital differences, being
and ­impulsivity) there are indications for a correlation, but referred for specialist follow-up was associated with reduc-
data are very scarce. The results of analyses are in Table 1. tion in repetition rate.87

Completed suicide Synthesis of the available results

The strongest predictors of S are older age (multivariate 9/16, It is difficult to identify risk factors for repetition of nonfatal
univariate 2/5), a high suicide ideation (multivariate 5/9, SA, and even more for repetition ending in S. The studies
univariate 1/2), a history of SA (multivariate 7/11, univariate evaluated in this review had different designs and follow-
1/5). Living alone, male sex, and alcohol abuse are weaker up, so they are not comparable for a systematic review with
predictors. There is a correlation (but supported by very scarce meta-analysis of the available data. However, some intriguing
data) for poor impulsivity and having a somatic diagnosis. results are available. Alcohol/substance abuse or dependence
There are no data available for sexual and physical abuse dur- and suicide ideation, which are, along with depressed mood,
ing childhood or for the family ­environment. The syntheses of the most consistent predictors for self-harm and suicide,4
the available results are in Table 2. do not seem as strong for nonfatal repetition. The presence
of a previous SA is a more consistent finding for nonfatal
Discussion repetition than for S, but it is the best risk factor for both
At present, there is no psychological test, clinical technique, and persists for many decades. The presence of a personal-
or biological marker sensitive and specific enough to predict ity disorder, depression, sexual abuse in childhood, alcohol
either short-term suicide or repetition. In line with Appleby dependence, or unemployed or unmarried status are more
et al,3 there is a north–south gradient in the repetition rate consistently significant in nonfatal than in fatal SAs, while
of suicide. A study by Pokorny5 illustrates how a method in nonrepeated SA, having a personality disorder increased
to predict suicide based on recognized risk factors will not rates among both fatal and nonfatal attempts.4 Impulsivity
only lead to a better identification of individuals at risk but seems to be correlated with SA and inversely correlated
also to a higher number of lost-to-follow-up or undetected with suicide completion. On the other hand, having a sui-
cases. In this study, the authors attempted to identify which cide ideation, (older) age, and (male) sex are thought to be

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Beghi et al Dovepress

more consistently found in fatal repetition, although the 9 years. However, as most prospective studies lasted 1 year,
role of sex is not very clear. Female sex and younger age, in the risk factors for S in subsequent years may differ from
contrast with data on nonfatal SA, are not likely to predict those detected at early follow-up.
repetition. This means that once a first SA has been made
(an event more frequent in females and younger people), the Future perspectives
risk for a second attempt does not appear increased in these Further studies would ideally examine a well-defined incep-
two categories. tion cohort (ie, patients at time of first SA) identified and
Other variables, such as family environment, problem- followed prospectively. A long-term follow-up (at least
solving, and global functioning, have a positive correlation 4 years) is recommended. Standard definitions of risk and
with fatal and/or nonfatal SA repetition, but data available are prognostic factors should be determined when planning
not sufficient to identify them as “predictors” of repetition. the study. Interacting factors such as previous attempts or
Further studies are needed to confirm this correlation. selected samples should be controlled for at the planning
or the analysis stage. Some variables, like sexual child
Methodological pitfalls abuse, family environment, problem-solving, and global
Many other variables have been studied, eg, Caucasians ­functioning, should be included, to evaluate their role for a
­commit suicide twice as frequently as other races, and Prot- repeated episode. Ideally, a study would compare different
estants are more likely to commit suicide than Catholics or ethnicities and religions and investigate the differences in
Jews.4 A nonheterosexual orientation carries an increased risk suicide repetition between immigrants and nonimmigrants.
for attempted but not for completed SAs.4 In all these cases, Sexual orientation should be investigated as well.
data on SA repetition are inconsistently reported.
Moreover, since a previous SA is the best risk factor Conclusion
for both fatal and nonfatal repetition, most findings pre- SA repetition (whether fatal or nonfatal) is a common event
sented here might not be specific to repetition. Only three in developed countries. Prediction of recurrent SA in a
studies in our group investigated the risk factors in first patient who committed a first SA is an important task for the
attempters for future attempts,38,45,78 and only one45 studied ­psychiatrist. However, it is hard to find independent predic-
it prospectively. tors out of all the many variables associated with repeated
According to Owens et  al,7 the median proportion of and especially with S. Based on the available evidence, only
patients repeating nonfatal SA is 16% at 1 year and 23% in a previous SA, depression, sexual abuse in childhood, and
studies lasting longer than 4 years. For a subsequent suicide, personality disorders have been found to predict nonfatal SA,
after a longer follow-up, the suicide rate increases from less while previous SA and older age were found to predict fatal
than 2% at 1 year to more than 5% in studies lasting over SA. Suicidal ideation, which is one of the most consistent

211 studies

53 did not fulfill the scope

of the review

72 studies with selected sample

(adolescents, elderly, army,
5 studies with small 76 studies included in the
males only, females only,
sample (fewer than 50) review
schizophrenic inpatient studies,
homeless)

Figure 1 Literature review.

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 Table 1 Summary of available factors correlated with suicidality
Variable Number of risk-factor-significant Number of risk-factor-significant Number of risk-factor-significant Number of risk-factor-significant
references in multivariate analysis references in multivariate analysis references in univariate analysis references in univariate analysis
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(significant/total) (S) (significant/total) (SA) (significant/total) (S) (significant/total) (SA)

Age 9 older/16 3 medium age/23 2 older/5 3 older/28
3 young/23 7 young-medium age/28
Sex 4 M/15 4 F/22 1 M/5 4 F/26
3 M/22 1 M/26
Ethnicity 0/1 1 Caucasian/3 0/1 2 Caucasian/4
Marital status 1 married or widowed/5 2 not married/182 divorced/18 1 not married/2 2 divorced/22
4 not married/22
2 married/22
Employment status 3 not employed/7 3 not employed/14 0/4 9 unemployed/18

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1 not student/18
1 retired/18
Social class 0/2 0/5 0/1 1 low/4
Education 0/2 1 low/10 2 low/9
Housing status 2 alone/4 0/8 1 alone/2 3 alone/7
Psychiatric morbidity 2/7 5/11 1/4 6/11
Psychiatric treatment 1/3 2/7 0/2 7/8
Psychosis 2/7 2/7 1/2 2/7
1/7 rev
Mood disorders 2/3 3/4 0/1
Depression 0/5 3/10 1/2 8/12
Anxiety 0/3 2/6 0/1 4/5
Alcohol misuse 2/9 4/10 1/4 4/8
Substance misuse 1/7 0/7 0/3 2/8
Somatic diagnosis 3/4 1/41 rev/4 1/2 1/3
Family history of S 0/1 1/2 2/4
Personality disorders 0/7 2/6 3/6
5/9 4/5
History of sexual abuse 7/11 13/16 1/5 13/14
1 rev/11
Method 1 less poison/4 2 penetrating/9 0/2 2 more poison/8
Suicidal ideation 5/9 1/13 1/2 6/14
1 rev/13
Hopelessness 0/2 2/8 5/6
Circumstances 0/3 0/6 0/2 2/8
Family environment 1 bad/1 2 bad/3
Criminal record 1/4 2/3

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Global functioning 1 low/2 3 low/4 1 low/1 4 low/4
Impulsivity 1 rev/1 1/1 1 rev/1 2/2
Abbreviations: F, female; M, male; SA, suicide attempt(s); rev, reverse correlation; S, completed suicide.

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Risk factors for fatal and nonfatal suicide attempts
 Table 2 Factors correlated with suicide attempts (SAs) and completed suicide (S)

1730
Study Year Design Number of patients Factors significantly associated with SA
Beghi et al

3
Appleby et al 1999 Case-control (S) 149 P, 149 C Care reduced, history of SA, suicidal thoughts during aftercare, most recent
admission at first illness
Asnis et al11 1993 Cross-sectional 74 repeaters, 90 first attempters No variables associated

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Batt et al12 1998 Cross-sectional 158 multirepeaters, 164 first Married status, not a student, not living alone, alcohol dependence, anxiety
repeaters, 310 first attempters
Bille-Brahe and 1994 Case-control 773 Self-poisoning, living alone, less hanging/cutting, divorced, unemployment
Jessen13
Boyes14 1994 5-year follow-up, 1,597 No differences
retrospective cohort
(male, female)

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Brådvik15 2003 Case-control (S) 98 S, 89 C No differences
Brezo et al16 2008 Case-control (previous SA) Not known History of SA, compulsivity, anxiety
Carter et al17 1999 Case-control 1,238 Female sex, single or divorced/widowed/separated, retired, age classes 25–34 or
35–44 years, length of stay
Carter et al18 2002 Case-control 1,317 History of SA, personality disorders, low social class
Carter et al19 2005 Case-control (S) 31 P, 93 C Increased number of drugs ingested, increased dose ingested, drug/alcohol
abuse/dependence
Cedereke and 2005 Case-control 178 History of SA, history of psychiatric treatment, lower global functioning,
Ojehagen20 suicide ideation
Chandrasekaran 2008 Case-control 293 (67 repeated) Hopelessness, history of psychiatric treatment, major depression, lower
and Gnanaselane21 global functioning
Christiansen and 2007 Case-control (S and SA) 2,614 P, 39,210 C SA method (self-poisoning), age class 15–24 years, psychiatric morbidity, S,
Jensen22 history of SA, method (jumping from high places), ages 15–24 and 25–59 years
Coakley et al23 1994 Cross-sectional 122 repeaters, 179 first attempters Older age, history of depression, schizophrenia, or alcohol dependence
Colman et al24 2004 Case-control 369 (92 repeaters) History of SA, history of depression, history of schizophrenia, and poor
physical health
Conner et al25 2007 Case-control 277 P Depression, acute stress, poor quality of life
277 C
Cooper et al26 2005 Case-control (S) 7,968 S: not living with a close relative, avoiding discovery, alcohol abuse/dependence,
method (cutting), history of psychiatric treatment, physical health problem, high
risk management at ER, history of SA
Cooper et al27 2006 5-year follow-up, prospective 299 South Asians, 6,884 Caucasians Caucasian ethnicity
cohort (ethnicity)
Corcoran et al28 2004 Case-control 1,256 History of SA, age class 45–49 years
Crane et al29 2007 Cross-sectional 323 repeaters, 285 first attempters Suicidal ideation, male sex, depression, hopelessness
da Silva Cais et al30 2009 Cross-sectional 101 repeaters, 102 first attempters Female sex, suicide ideation, unemployment status or being a housewife, history of
emotional, physical, or sexual abuse, criminal record, hopelessness, depression
De Moore and 1996 Case-control (S) 223 History of SA, planned attempt, narcotic overdose, mental illness
Robertson31 (dementia, depression, psychosis)
Ekeberg et al32 1991 Case-control (S) 934 Older age, suicide ideation
Evans et al33 1996 Cross-sectional 185 Impulsiveness

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 Evans et al34 2000 Cross-sectional 421 No differences
Forman et al35 2004 Cross-sectional 114 repeaters, 39 first attempters Unemployment, child emotional abuse, family mental illness, family suicide attempt,
depression, hopelessness, psychosis, substance abuse, less problem-solving
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Gilbody et al36 1997 Case-control 1,576 P (36% previous SA) History of SA

Harriss et al37 2005 2–6 years’ follow-up, prospective 2,489 S: suicidal ideation
cohort study (suicidal ideation) SA: no correlation
(S and SA)
Haukka et al38 2008 Case-control (S and SA) 18,199 S: psychosis, mood disorders
SA: female sex, age-group 30–40 years, any psychiatric disorder,
alcohol abuse/dependence
Haw et al39 2003 12–16 months’ prospective 118 No correlation
cohort (suicidal ideation)
Haw et al40 2007 Cross-sectional 4,167 (3 groups: first attempters, M with $4 episodes more aged 25–34 years, history of SA, current psychiatric
,4 episodes repeaters, $4 disorders, personality disorders, psychiatric treatment, alcohol/drug abuse, being a

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repeaters; M and F calculated victim of violence, criminal record, history of SA less in nonrepeaters
separately)
Hawton et al41 2003 Case-control 150 Psychiatric disorders
Henriques et al42 2005 5–10 years’ follow-up, 393 Suicidal ideation
prospective cohort
(suicidal ideation) (S)
Heyerdhal et al43 2009 Case-control 2,032 Deep coma, age class 30–49 years, use of sedative drugs and opiate agents
Hjelmeland et al44 1998 Case-control (S and SA) 654 S: older age class
SA: history of SA, lower suicidal intent
Hjelmeland 1996 Case-control 1,012 (507 first attempters, In first attempters: history of sexual abuse, psychiatric disorder
and Polit45 509 repeaters) In repeaters: alcohol abuse and suicide among relatives
Johnston et al46 2006 Case-control 4,743 History of SA, history of psychiatric treatment, employment status, unmarried,
Caucasian ethnicity
Kapur et al47 2006 Case-control (S and SA) 7,723 S: longer period since the first act, male sex, older age, single status
SA: age class 25–54 years, single status, Caucasian ethnicity, unemployed
status, current or previous psychiatric treatment, history of SA, alcohol abuse/
dependence, psychiatric diagnosis
Keeley et al48 2003 Case-control 2,287 Male sex, history of SA, dysfunctional family of origin, history of sexual abuse,
criminal record
Kinyanda et al49 2005 Cross-sectional 25 repeaters, 75 first attempters Single status, have children, live alone or with parents, sexual problems as major
precipitant for SA, had more negative life events in childhood and fewer negative
life events in the past year
Kiankhooy et al50 2009 Case-control 156 Self-inflicted injury, penetrating mechanism of injury, length of stay, male sex
Lilley et al51 2008 18-month prospective 7,344 Self-poisoning
cohort (method)
McAuliffe et al52 2006 Case-control 836 Repeaters scored higher on the passive avoidance factor and on the negative
expression factor and lower on the active handling factor on Utrecht coping list

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McAuliffe et al53 2007 Cross-sectional (suicide ideation) 84 repeaters, 52 first attempters No differences
McAuliffe et al54 2008 Case-control 152 Older age, history of SA

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Risk factors for fatal and nonfatal suicide attempts

(Continued)
 Table 2 (Continued)

1732
Study Year Design Number of patients Factors significantly associated with SA
Beghi et al

55
McEvedy 1997 Case-control 628 Married status, older age
Neeleman et al56 1998 Cross-sectional 120 natural-cause death, Adolescent emotional instability, conduct problems
36 accidental death,

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11 suicide death
Nordentoft et al57 1993 Case-control (S) 974 Older age, living alone, history of SA, no respirator treatment
Nordstrom et al58 1995 5-year follow-up, 1,573 Male sex, older age female
prospective cohort
Ojehagen et al59 1991 Cross-sectional 46 repeaters, 33 first attempters Unemployed status, disability pension, psychiatric disorder, psychiatric treatment,
psychiatric inpatient
Ostamo and 2001 Case-control (S) 2,782 Male sex, married, widowed or divorced status, older age class

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Lönnqvist60
Osváth et al61 2003 Cross-sectional 549 first attempters, 609 repeaters Psychiatric disorders (personality disorders, mood disorders, and alcohol abuse),
divorced status, unemployed status, low education status, age-groups 20–35 and
35–44 years
Owens et al62 1991 1-year follow-up, prospective 687 admitted to a ward, No differences
cohort (admission) 305 discharged from ER
Owens et al63 1994 Case-control 992 Ingestion of more than one drug, history of SA, age class 25–54 years, psychiatric
disorder, unemployed status, psychiatric admission, expression of a threat to
another person or written a note
Owens et al64 2005 Case-control (S) 1,091 Older age, male sex, impairment of consciousness, psychiatric disorders, admission
during the daytime, discharge from accident and emergency after psychiatric
assessment, no history of SA
Pettit et al65 2004 Case-control 123 Suicidal ideation, presuicidal crisis
Platt et al66 1992 Case-control Not specified Age class 15–34, female sex
Schmidtke et al8 1996 Cross-sectional 16,394 (repeaters 42% Divorced
of M and 45% of F)
Scoliers et al67 2009 Case-control 361 History of SA, female sex, age classes 20–29, 30–39, and 40–49 years, education,
suicide ideation, medium Buglass and Horton risk, anxiety, depression, psychiatric
disorder
Sheikholeslami 2008 Cross-sectional 35 repeaters, 49 first attempters Not married status, psychiatric disorder, personality disorder, depression,
et al68 hopeless, suicide ideation, impulsiveness, less satisfaction, negative events
Sidley et al69 1999 Case-control 66 History of SA, hopelessness
Sinclair et al70 2007 Case-control 68 Sexual abuse, mood disorder
Stenager et al71 1994 Case-control (S and SA) 139 S: older age
SA: no somatic diseases
Suokas et al72 2001 5-year follow-up, prospective 1,018 P SA
cohort (history of SA) (S)
Suominen et al73 2000 Retrospective cohort 114 with personality disorders, Personality disorder
(personality disorders) 65 without
Suominen et al74 2004 Case-control 224 Suicide ideation
Taylor et al75 1994 Cross-sectional 53 repeaters, 47 first attempters Panic disorder, psychiatric disorder, history of SA, history of sexual abuse, PTSD

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Dovepress Risk factors for fatal and nonfatal suicide attempts

predictors for SA and S, does not seem as strong for repeated

S: psychosis, mood disorder, depressive disorder, anxiety disorder, alcohol abuse/

SA, while it remains consistent for S. In several cases, no
apparent risk factor was detected, and it makes it difficult to

Age class ,40 years, being a newcomer, alcohol influence, suicide letter
prevent fatal and nonfatal attempts.
A large multicenter prospective investigation of first
SAs should be undertaken comparing different countries
and differing social and cultural backgrounds and settings
within each country.

History of sexual abuse, history of physical abuse

Acknowledgments

Abbreviations: M, male; F, female; PTSD, posttraumatic stress disorder; CSF, cerebrospinal fluid; S, completed suicide; SA, suicide attempt(s); P, patients; C, controls; ER, emergency room.
Jennifer Covino, PhD and Countney Clabby, PhD, for their
SA: history of SA, low global functioning

help on the data collection, and Ettore Beghi, MD, for criti-
dependence, personality disorder

cally reviewing the study proposal.

SA: psychosis, mood disorder

SA: younger age, female sex Disclosure

Serotonergic parameters
S: low global functioning

The authors report no conflicts of interest in this work.

Family history of S
Single drug used

S: history of SA
No differences

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