According to SUPRE, the World Health Organization’s worldwide initiative for the prevention of suicide, by 2020 over 1.5 million people will die from suicide every year— one death every 20 seconds. 1 Informed estimates suggest that the number of people who attempt suicide annually may be 10 to 20 times that number, 2 and some researchers estimate that there may be as many as 40 attempts for every completed suicide. 3 In the United States an average of 538,000 suicide attempts was reported annually between 2005 and 2008. 4 Many individuals will attempt suicide once or several times in their lifetimes without completing suicide; it is well known, however, that individuals who have attempted suicide are at an increased risk for recurrence 5–7 and are more likely to be completers. 8,9 In fact, a meta-analysis of psychological autopsy studies found that about 40% of suicides had been preceded by at least one previous, nonfatal attempt. 10
Repetition rates vary greatly as time passes from the initial attempt. In addition, the rates are dependent on the type of population being analyzed. Ruengorn, 7 Spirito, 11 and their colleagues found that nearly 40% of suicide attempters made a new attempt within 90 days of leaving hospitalized care. In the 1–2 years following discharge, the repetition rate of patients treated at medical emergency units varied from 14% to 25%. 12–15 When longer follow-ups were considered (4–10 years), the rate of suicide reattempts ranged from 20% to 55%. 16–20 Owens and colleagues, 21 in a systematic review of 90 studies analyzing the repetition of nonfatal self-harm in inpatient units and emergency departments, found that the repetition rate was 16% during the first year of follow-up, 21% from the second to the fourth year, and 23% after the fourth year. The evolution of repetition rates in suicide reattempters (SRs) could reflect a persistent vulnerability, which is in accordance with the stress-diathesis model of suicidal behavior. 22 This vulnerability could be increased during suicidal crises, coinciding with adverse life events or psychopathological changes.
Although in recent years research on SRs has grown, further studies on this specific population are needed 23–25 since much of the literature makes no distinction between single (that is, one time only) suicide attempters (SAs) and SRs. 26,27 Some authors have suggested that SRs are a clinically distinct group with greater levels of pathology and risk for future suicide attempts and death by suicide. 26,28 If unique characteristics can distinguish SRs from SAs, an increased understanding of these factors will help clinicians and researchers to identify high-risk groups. In addition, a better understanding of SRs could lead to interventions specifically tailored to prevent repetitive suicidal behavior and future suicides. Therefore, given the possibility that SRs and SAs may be differentiated as two clinically distinct groups, this review seeks to identify key demographic, psychological, and clinical variables associated with SRs and discern the operational definitions of repeated suicide attempts that have been proposed in the literature.
Literature Search Strategy
Searches for articles were carried out in the electronic databases PubMed, PsycINFO, and Web of Science. The core set of keywords to identify articles was as follows: multiple suicide attempters; recurrent suicide attempts; repeated suicide attempt; repetition suicide attempt; reattempts AND suicide; suicide attempts AND multiple, several, frequent, repeaters, reattempts, OR recurrent. The keywords were limited to the title and abstracts. The abstracts of the retrieved articles were then checked by applying the eligibility criteria. In cases of doubt, full articles were read.
Inclusion Criteria and Reviewed Articles
Research on suicide has greatly increased over the last few decades, though the operational definitions for the different types of suicidal behaviors have been established only in the last few years. 29,30 Therefore, to limit the number of articles to review, and to avoid large methodological differences between the studies, we decided to limit our search to articles published in English, Spanish, and French from 1 January 2000 to 30 June 2012. The initial electronic search identified 1480 documents. After evaluating the abstracts of all these documents, we selected 86 articles that met the following criteria: (1) they were original articles examining the characteristics of SRs, and (2) the definition of suicide attempt was compatible with the one proposed by Silverman and colleagues (2007): 29 “self-inflicted, potentially injurious behavior with a nonfatal outcome for which there is evidence (either explicit or implicit) of trying to die,” which is now used by the National Institute of Mental Health. 31 In addition, some articles examining the characteristics of self-harm were included in this review if the definition of self-harm explicitly involved at least some intent to die and therefore agreed with the cited definition of suicide attempt. 29 Selected studies are summarized in Table 1.
Most articles were retrospective in design (n = 49; 57.0%) and included adult subjects of both genders (n = 61; 70.9%). Several studies (n = 5; 5.8%) included only women, and one study (1.2%) included only men. Some studies focused specifically on adolescents (n = 20; 23.3%), and only one on the elderly (n = 1; 1.2%). Other researchers considered criminal (n = 2; 2.3%) or military (n = 3; 3.5%) populations. Regarding the study design, we found that the literature could be classified as follows: comparison with single suicide attempters (n = 36; 41.9%), comparison with suicide attempters not having reattempted after an in dex attempt (n = 27; 31.4%), and other methodologies (n = 23; 26.7%).
The assessment instruments most frequently used were the Beck Depression Inventory (n = 23; 26.8%), Beck Hopelessness Scale (n = 18; 20.9%), Scale for Suicide Ideation (n = 17; 19.8%), Suicide Intent Scale (n = 17; 19.8%), Barratt Impulsivity Scale (n = 9; 10.5%), and Hamilton Depression Rating Scale (n = 8; 9.3%). The clinical diagnostic tools mainly used were the Diagnostic and Statistical Manual of Mental Disorders (DSM) (n = 41; 47.7%) and International Classification of Diseases (ICD) (n = 17; 19.8%). A large majority of studies were performed in Europe or the United States (n = 75; 87.2%), whereas only 11.6% were performed in Asia and Oceania (n = 10) and one in South America (1.2%). No studies were conducted in Africa.
Definition of Suicide Reattempters
The various operational definitions of SRs used in the literature show the lack of consensus in this area of study. The inconsistency can lead to erroneous estimations of the burden and prevalence of suicide. 24,41,98 Most of the studies reviewed recruited the patients in emergency rooms after what was considered the “index” suicide attempt. In some studies, this index attempt served as a baseline to quantify the number of attempts. Repeaters were thus defined as those who made a subsequent attempt after their index attempts. In other studies, the number of lifetime attempts as reported by the patients or registered in clinical databases was used to define SRs.
A large majority of studies defined SRs as those who made more than one suicide attempt (n = 71; 82.5%). Other authors defined SRs as those who made three or more attempts (n = 4; 4.7%), and several studies did not specify a definition for SRs (n = 11; 12.8%). In summary, the following are the operational definitions of SRs that have been adopted:
1. SRs defined by an “index” suicide attempt 5,33,74 or as subjects who made two or more suicide attempts. 26,41,67
2. SRs defined as having made three or more attempts. 35,58,99
3. Based on the typology originally proposed by Goldston, 24,100 five types of suicide attempters defined, depending on the history of suicidal behavior: (a) a recent first suicide attempt, (b) a recent second or subsequent suicide attempt, (c) no recent attempts, (d) no suicide attempts, and (e) repetition of a suicide attempt at least one year before the interview.
4. Based on the work of Hengeveld, 101 one study examined the characteristics of “grand repeaters”: subjects who had made more than four attempts. 102
Comparison with Single Attempters
Female sex 20 and young age (18–29 years) 87 have been linked with SRs, but a majority of articles did not find significant differences in age or gender when comparing SRs to single attempters. Other sociodemographic differences, however, were repeatedly reported. Compared to SAs, SRs were more often unmarried or living alone, 20,71,87 and had lower education levels 27,62 and higher levels of unemployment. 61,68
Regarding clinical features, the main differences between SRs and SAs are detailed in Table 2. To summarize the probabilities of factors associated with SRs versus SAs, we have selected the median value of odds ratios (ORs) and their ranges throughout the literature.
SRs were more likely to meet criteria for affective disorders, such as major depression or bipolar disorder, 23,62,74,81 alcohol and substance use disorders, 27,61,71 anxiety disorders, 27,62,64,87 psychotic disorders, 26,61,68 and personality disorders. 61,96 Other clinical variables associated with SRs were greater suicidal ideation and lethality scores, 26,39,40,71 family history of psychiatric disorders or suicidal behaviors, 26,67,68 greater number of hospitalizations, more frequent current or prior psychiatric treatment, and comorbidity of three or more mental disorders. 20,27,67 Additionally, SRs were associated with psychological factors, such as higher motor impulsivity, hopelessness, and poor conflict-resolution skills, 26,62,67 and environmental stressors, such as negative or stressful life events, lifetime history of aggression, 28,62 and traumatic experiences during childhood and adolescence. 26,27,71 Of note, the intensity of negative life events may be associated with longer psychological crises but not with the severity of suicidal ideation among SRs. 28
Studies of adolescent samples showed distinctive differences between SRs and SAs. Apart from most of the above-mentioned clinical factors, adolescent SRs are more likely to present with attention-deficit/hyperactivity disorder, disruptive or dissocial behaviors, nonsuicidal self-harm, and greater desire to die. 6,42,59,77,88 Adolescent SRs are also less likely to be living with both biological parents and more likely to have had stressful life events, low social support, and early age of onset of mental illnesses. 51,92 Regarding psychological factors, adolescent SRs were more likely than SAs to present with low self-esteem, insecure attachment, emotional dysregulation, impulsivity, and thought problems. 59,77,88,90
Comparison with Subjects Not Reattempting After an Index Attempt
The studies reviewed in this section examined suicide attempters after an index attempt, regardless of previous history of suicidal behavior; that is, subjects who reattempted suicide during the study period (SRs) were compared to those that did not reattempt (NRs).
Studies that compared SR and NR populations found differences that were similar to those reported between SRs and SAs (Table 1). Unemployment, low social support, and life stress were more common in SRs than is NRs. 14,41 They also reported more psychiatric disorders (mood, anxiety, psychotic, and substance use disorders), more frequent history of psychiatric treatments, more psychiatric comorbidity, and higher scores in measures of suicidal ideation. 9,16,19,34 In addition, SRs had lower global functioning, and psychological factors, such as low sense of general self-efficacy, increased hopelessness, impulsivity, and low self-appraised problem-solving capacity, were more common in SRs than in NRs. 12,13,18,33 In one study, elderly SRs had more negative perceptions of their mental health and of the social assistance that they received, and were also more likely, during childhood, to have had a parent who died. 32 A study investigating sleep problems in SRs reported an association with frequent nightmares. 43
Other Study Designs
The studies included in this section are methodologically diverse. Some of them reported the characteristics of SRs as secondary findings in samples of those affected by a particular mental disorder, whereas others analyzed factors associated with the number of suicide attempts without specifying a definition of SRs.
Several studies confirmed the association of SRs with many of the above-mentioned factors (Table 1). 35,70,86 Comorbidity with depression increased the risk of repeated suicide attempts in patients with borderline personality disorder 73 and eating disorders. 38,75 One repeated finding was the association of SRs with stressful life events, 48,65,85 particularly childhood abuse. 66,95,97 Lizardi and colleagues 84 found that the number of suicide attempts was associated with a family history of suicidal behavior and fewer reasons for living. Other studies also linked family history of suicidal behavior with SRs, 10 especially when combined with childhood abuse. 97 Interestingly, post-mortem studies noticed that repeated suicide attempts during advanced age in women or during episodes of depression later in life were more often associated with suicide than with any other causes of death. 8,46
A few studies have examined biological factors in relation to SRs. Genetic vulnerability may, it appears, contribute to the repetition of suicide attempts. 85 Some authors have reported that certain variants of the tryptophan hydroxylase 1 gene (TPH1 A218C) and the serotonin transporter gene (5-HTTLPR) increase the risk for repeated suicide attempts. In addition, individuals carrying at least one S allele of 5-HTTLPR may be more prone to repeated attempts. 37,85,103 Alterations of the hypothalamic-pituitary-adrenal axis—a system closely linked to stress regulation—may also be associated with an increased risk of suicide attempt repetition. 78,104 Arling and colleagues 82 found no association between Toxoplasma gondii seropositivity and the number of suicide attempts in patients with recurrent mood disorders—though they did find an association between Toxoplasma gondii antibody titers and suicide attempts.
Risk of Completing Suicide
The probability of completing suicide is proportional to the number of attempts 52 and has been estimated to increase 32% with each attempt. 105 Nock and Kessler 106 emphasized a strong link between repeated attempts and suicide completion. In follow-up studies conducted between one and five years after a suicide attempt, median proportion varied from 2% to 10%, 16,21,72 These rates were four times higher in a follow-up study over nine years. 21 By contrast, the reported incidence of completed suicide among control groups is 0.04%. 16 Bradvik and Berglund 8 found that 46% of the subjects included in their group of completed suicides had attempted suicide previously. It has been suggested that attempters are approximately 66 times more likely to complete suicide than people with no history of attempts. 107 Michaelis and colleagues 60 suggested that the first attempt of future SRs might be less severe than those of SAs.
The economic and social consequences of suicide attempts have led to an increase of research on this type of behavior. 24,25,108 Suicide attempters frequently repeat. It is estimated that for every suicide, there are 5 hospitalizations and 22 emergency room visits due to nonfatal suicide-related behaviors. 31 Indeed, according to most studies, 16% to 34% of the subjects repeat within the first 1–2 years after a suicide attempt. 7,12,13,15,18 Moreover, a European study found that over 50% of the attempters repeated during the first year of follow-up. 109 Many authors have suggested that classifying the large number of attempters into SAs and SRs could help to predict future suicidal behaviors and improve suicide-prevention strategies. 27,33,110 Specifically, the identification of the particular profile of SRs could differentiate this population and avoid an overestimation of the number of suicide attempters. The economic costs associated with the use of health care systems, as well as the medical and emotional burden for individuals themselves and for their families, 15,111,112 support the need for specific research on SRs.
This systematic review shows the importance of SRs as a high-risk clinical subgroup and may help to differentiate SRs from SAs by the identification of specific clinical and sociodemographic variables. The reviewed studies have identified numerous characteristics associated with SRs in three graded levels: compared to SAs, compared to NRs, and using other methodological designs.
From a clinical standpoint the differences between SRs and SAs are the most relevant (Table 2). When compared to SAs, SRs were excessively associated with demographic risk factors for suicide, such as unemployment, mental disorders (including mood, anxiety, psychotic, and substance use disorders), and psychiatric comorbidity. Even though young age and female sex have been repeatedly associated with a greater risk of nonfatal suicidal behaviors, 52 the review of the literature did not provide a profile of SRs based on age or gender. Regarding psychological features, SRs were more likely than SAs to be diagnosed with personality disorders (particularly borderline personality disorder), and they presented with greater levels of impulsiveness, hopelessness, and anger, and with inadequate conflict-resolution strategies. Adverse life events, such as childhood abuse, also seem to be particularly associated with SRs. Regarding other factors related to suicidal risk, and in relation to SAs, SRs reported greater suicidal ideation, longer psychological crises, and more frequent history of suicidal behavior in their families. Importantly, most of the differences between SRs and SAs were replicated in studies that used other methodological designs. It should also be noted that many of the differential features of SRs are well-known risk factors for suicide. Overall, this systematic review corroborates that subjects making repeated suicide attempts are an especially vulnerable population.
Methodological changes are needed to improve the characterization of SRs. 110 For example, the use of larger sample sizes would avoid major imbalances in the distribution of sociodemographic variables such as age and sex. In addition, a greater consensus on the use of data-collection instruments could improve the external validity of the results achieved. Apart from these changes, it is essential to achieve greater consensus on both the conceptual and operational definitions of SRs. The lack of consistent definitions of suicidal behavior across studies has led to confusion in the field of suicidology. 30 Definitional clarification would help to avoid confusion with terms like self-harm or self-injury without intent of death. Additionally, the geographical distribution of the studies illustrates the importance of studying this topic outside Europe and North America in order to avoid cultural biases in interpreting results; in this context, cross-national studies would be useful, too. And though the repetition of suicide attempts may differ significantly across age groups, only adolescents have been distinctly analyzed regarding such repetition: adolescent SRs, versus SAs, are more likely to have psychiatric disorders, environmental stressors, and personality traits that are generally associated with suicidal behavior.
Since the designs, sample sizes, and populations for the 86 selected studies are diverse, they cannot be compared directly, especially in the continuing absence of a consensual definition of SRs. Moreover, many studies did not use adequate comparison groups to investigate the specific characteristics of SRs. For instance, many authors did not consider whether the subjects had made attempts prior to their inclusion in the studies after an index attempt. Those studies lack sufficient validity to assess the specific characteristics of SRs. Moreover, the study periods often lasted less than two years and may therefore fail to reflect the actual prevalence of repeat suicide attempts. To increase the validity of our findings, we have thus tried to focus our review on studies specifically comparing SRs with SAs, which were mostly retrospective in design and often limited by a memory bias. In addition, under-declaration of suicidal behaviors might hamper the identification of repeated suicide attempts. 17
Although it is possible to create a profile of the high-risk population of SRs by analyzing previous scientific literature, further research is needed to compare results and obtain more reliable information on their characteristics. Furthermore, future studies should focus on the comparison between SRs and SAs to delineate the particular features of each group. These efforts could lead to the division and reclassification of reattempters into clinically meaningful subgroups. For instance, the triggering effect of external events and the distribution of suicide attempts could be examined in relation to the repetition of suicide attempts. 84 In fact, the probability of repeating a suicide attempt seems to be higher in the immediate aftermath of a previous attempt, 94 but a history of multiple attempts may affect the long-term course of post-crisis suicidality. 113 Examining the distribution of these acts and their relation to external events could help to differentiate subjects with permanent vulnerability traits for suicidal behavior from “grand repeaters” who may use suicidal acts as a communication strategy.
Due to variations in the risk of relapse and suicide completion, separate consideration of SRs and SAs may have clinical implications for both prevention and treatment. More effective recognition and treatment of the underlying psychiatric and social conditions of suicide attempters have special importance in efforts to prevent future suicidal behavior.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
The authors thank Rosa Nunes for editorial assistance.
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