Deadliness of attempted suicide has been dramatically underestimated

July 15, 2017

Over a lifetime, about 1 in 80 Americans will kill themselves. Suicide is the 10th-leading U.S. cause of death, and a history of having made a suicide attempt is considered a robust indicator of future risk of completed suicide. Yet, only a small portion of attempts come to medical attention, says J. Michael Bostwick, M.D., a psychiatrist at Mayo Clinic's Rochester, Minnesota, campus.

Moreover, much of what is known about suicide attempts derives from survey data, rather than community studies in which subjects have made medical contact and been followed over time.

Novel study design and findings

According to Dr. Bostwick, previous studies of attempted suicide as a risk factor for completed suicide suffer from the following limitations:

  • If individuals have killed themselves on first attempts coming to medical attention, they have not been included in the studies.
  • Most studies have been based on convenience samples, such as patients admitted to the hospital after an attempt or individuals who overdosed.

Convinced such studies underestimated suicide risk, Dr. Bostwick and his team set out to prove it with a unique study design. Using the Rochester Epidemiology Project, they identified 1,490 Olmsted County residents making an index attempt — a first attempt coming to medical attention — between 1986 and 2007, with follow-up through 2010. They defined "medical attention" to include deceased individuals whose first stop was the coroner's slab rather than the emergency department.

The study, published in The American Journal of Psychiatry's November 2016 issue, found 81, or 5.4 percent, of the sample killed themselves. Of these, 48, or 59.3 percent, perished on index attempt. Of 33 index attempt survivors, 27, or 81.8 percent, completed suicide within one year.

Marked gender differences appeared among suicides: males represented 62 of 81 deaths, or 76.5 percent, while females represented 19 of 81 deaths, or 23.5 percent.

Key physician takeaways

"My reaction to the findings is they are quite stunning," Dr. Bostwick says. "This is scary from a population standpoint, because 60 percent die before we ever see them, most with no psychiatric history."

The following study implications are important for physicians to consider, notes Dr. Bostwick:

  • The deadliness of suicide attempts has been dramatically underestimated. The finding of 5.4 percent of individuals who attempt suicide dying by suicide was nearly 60 percent higher than suicide prevalence reported in previous studies. Moreover, by including index attempt deaths, suicide prevalence more than doubled.
  • The year after a suicide attempt is crucial for potential recurrence risk. Over 80 percent of subsequent completed suicides occurred within one year of index attempts.
  • Completed suicides were disproportionately male. Overall, 1 in 9 men and 1 in 50 women enrolled in the study died by suicide either on index or subsequent attempt.
  • Firearms far outstrip all other methods in their lethality. Individuals who attempt suicide using guns had a dramatically disproportionate odds ratio of 140 for succeeding, as compared with all other methods. Of the deceased, 72.9 percent used firearms, including 75 percent of men. Although women used guns less frequently, they were as likely as men to die if they used firearms.
  • Scheduling follow-up appointments for individuals who attempt suicide matters. Having follow-up appointments on the books at emergency department or inpatient service discharge — regardless of whether they are kept — significantly reduced the risk of subsequent suicide.

Practice applications

This study not only demonstrates that suicide prevention efforts should begin before a first suicide attempt, but also supports prevention as being the responsibility of all medical providers, not just mental health practitioners.

Additionally, the study shows that prevention efforts beginning after index attempt would be too late for the nearly two-thirds dying on first attempt. Given the lack of attempt history for individuals with an index attempt, their suicidality would need to be detected during primary care as well as mental health visits.

Due to the astronomically high odds ratio of death for attempters using firearms, guns are an important focus, states Dr. Bostwick. "We've got to do something to prevent people from making a first attempt, particularly with a firearm," says Dr. Bostwick.

A role physicians can play in gun control, he indicates, is the asking of all patients: Do you have guns? Are they locked up? Are you leaving them where kids can get ahold of them?

Mustering preventive resources to thwart repeat — and lethal — attempts is another key clinical application of this study's findings, notes Dr. Bostwick.

Next steps

Dr. Bostwick indicates that further research on this topic should focus on identifying risk factors for populations vulnerable to making first attempts and target risk reduction in those groups.

For more information

Bostwick JM, et al. Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. The American Journal of Psychiatry. 2016;173:1094.