Recurrent Suicidal Behaviours: Psychopathology and Prevention
M. De Vanna, A. Padovan Lang, D. Carlino, E. Aguglia.
Department of Clinical, Morphological and Technological Science
University of Trieste
Recent data suggest that multiple attempters may differ from single attempters in a number
of clinical and sociodemographic peculiarities. Traditionally, however, features associated
with suicidal behviour, such as impulsivity and mood regulation remain relatively
unexplored among repeaters. It is very interesting to elucidate the relationship between high
impulsivity and low lethality in multiple attempters.
It is possible that the difficulties in studying repetition of suicide depends on the
A systematic program of contact and telephone intervention appears to exert a significant
This program can be promoted by activation of a network of welfare and health assistance,
constituted by general practitioners, socio-health districts and Mental Heatlth Departement.
Key Words: suicidal repetitive behaviour, impulsivity, prevention, repeaters.
In the last 30 years both the absolute number and relative number of people who have been
treated or admitted to hospital after a suicide attempt or parasuicide have greatly increased.
Evidence shows this phenomenon in many Western European and North American countries
and perhaps also in other parts of the world.
A large percentage of people treated in hospital after a suicide attempt are ―repeaters‖, who
have received hospital treatment for the same reason previously.
It is estimated that 20-40% of these people are repeaters. Follow-up studies have
demonstrated that the risk of repetition is particularly high in the months following th eir
release from the hospital.
Approximately 10% make another suicide attempt in the first three months.
The percentage rises to 15% after a year and to 30-40% after 10-15 years. The repeaters
constitute a particularly high suicide risk group (up to 250 times more than the general
Therefore many future suicides come from this group. This raises the question about the
possibility of preventing suicide with specific treatment aimed at reducing the risk of
successive attempt by repeaters who are in contect with health services.
The recurrence of suicide attempt constitutes a great problem for clinicians as these
represent 16-20% of all suicide attempters.
At this moment unequivocal categorization of suicide behviour based on psychopathological
aspect of vulnerability and other risk factors doesn’t exist, nor it is possible to describve a
Sociodemographic Aspects of Repetition of Suicide Attempts
Kreitman & Casey work (1988) had already pointed out the sociodemographic diff erencies
on the basis of anamnestic data of the previous suicide attempts.
The two repeater subgroup values exceed the first-ever rates between the age of 25 and 54,
but do not do so for yuonger subjects nor, importantly, for those aged 55 and over.
Rates by marital status were highest in the divorced group in both sexes.
The number of suicide attempts is furthermore related to the lowest social classes.
Five of the social variables studied had a positive association with repetition in both sexes.
Hirschfeld and Davidson in a review of 11 studies, found that those who completed suicide
more often were men, while suicide attempters more often were women, and under the age
of 39 years.
The analysis of the time interval between the first and the last episode sh ows that 50% of
the male repeaters has its last attempt during the first six months, whereas the same
percentage of female repeaters has its last attempt during a period of 12 months.
All repeaters have assumed some drugs at least once in their ―suicidal c areer‖.
In the past, five studies indicated that the importance of the history of a previous suicide
attempt may be limited by the lethality of a next suicide attempt. The percentage of
completed suicide at the first attempt ranged from 58% to 79% (Carney et al., 1994; Cheng
et al., 1995; Conwell et al., 1998; Maris, 1981 Robins et al., 1959). In this connection, the
switching in the choice of suicide methods is important.
Among the 40 repeaters investigated by Isometsa et al. (1998), 82% utilized at least two
different suicidal methods.
Approximately 1% of suicide attempters die from suicide within a year of their attempt, and
approximately 3% die from suicide within 3-8 years of an attempt.
In these studies, 20-40% of the subjects repeated suicide attempts during the follow-up
period, and 6-8% commited suicide.
A high proportion of the patients who reattempted were alcohol abusers, and about one third
was treated for a psychiatric illness.
A large proportion of subjects that undertook a ―suicidal career‖ at tended a psychiatric
In comparison to the non-repeaters group, they were estimated as unstable people with
limited resources for coping with social and mental stress, and they had difficulties in the
area of personal relations and partnership.
Although repetition is less frequent in older people, De Leo et al.’s study (2002) is
interesting: the longitudinal design indicated that coping strategies are fundamental to
define suicide as a distinct behavioural pattern from completed suicide.
The aim of this study was to assess which factors may predict suicide and repetition of the
act in a sample of elderly European attempters.
At the time of follow-up, eight subjects (12.7%) had died by suicide and seven (11,1%) had
repeated at least one attempt.
Bereavement of the father during childhood was more frequent among older repeaters (chi
sq= 11.7, p<0.001) which were able to cope with difficulties in youth and adulthood, old age
and the ensuring dependence seem to present an insurmontable obstacle (Clark 199 3;
Furthermore, the mean Suicidal Intent Score was higher for the suicide compleaters group
than for non-repeaters group.
Similarly, Oquendo et al. (2000) found that attempters among bipolar patients reported more
suicidal ideation immediately prior to admission, and fewer reasons for living even when
the most recent suicide attempt preceded the index hospitalization by more than six months.
Descriptive psychopathology and methodological problems.
Suicidal behaviour, according to psychiatric practice and literature, is typically seen as a
symptom of some underlying psychiatric disorder, particularly depression and personality
Suicidal behviour spans a spectrum that ranges from the feeling that life is not worth living
and a tiredness of life to thoughts of suicide and suicidal acts.
According to Ahrens et al (2000), unanswered questions pertain to whether the different
motivations for dying represent a unique dimension or, rather, some distinct phenomena.
Although the literature supports a close relationship between suicidality and mental
disorders, they also show that suicidality is not an essential criterion for any of these
disorders, as respective diagnoses can also be made in the absence of suicidal behaviour,
and there is obviously no nosological specificity. This suggests that suicidality is not just a
symptom secondary to other mental disorders, but is in part also a separate problem (Scocco
et al., 2000).
This is supported by empirical data showing that there is a psychopat hological ―suicidal
syndrome independent of major psychiatric disorders‖, which can be partially characterized
by suicidal thoughts and by hopelessness, impulsivity and social withdrawal.
Mann et al. (1999) proposed a stress-diathesis model in which the risk for suicidal acts is
determined not merely by a psychiatric illness (the stressor) but also by a diathesis.
This diathesis may be reflected in tendencies to experience more suicidal ideation and to be
more impulsive and, therefore, more likely to act on suicidal feelings (Mann et al., 1999;
Malone et al., 2000).
Probably, the difficulties inherent in studying suicide result from the fact that the early
studies were retrospective (Bush et al., 2003). The retrospective nature of these studies
could distort the significance of recall of certain data. It also limits the possibility of
estimating the symptom severity as a relevant correlate.
The second problem with the retrospective method is the difficulty in relating various
observations or events accurately with respect to the time of the suicide.
The third major problem with most of the available studies of suicide correlates is that no
comparison groups were used to determine whether a correlation found in a suicide case was
truly associated with the suicidal outcome or whether it was simply a feature of an
underlying clinical disorder.
From a phenomenological and processual point of view, these methodological difficulties
make the definition of suicidality or parasuicidality syndrome very difficult.
Fawcett et al. (2000) study suggests five dimensional aspects of suicidality (anxiety,
agitation, hopelessness, anhedonia and impulsivity as personality traits associated with
serotoninergic function). Recently, impulsivity has been recognized as a maj or risk factor in
suicidal behviour, especially in repetitive suicidal behaviour (Evans et al., 1996).
However, after reviewing epidemiologic studies of suicide, Klerman paradoxically
suggested that impulsivity may be a feature of less serious suicidal att empts.
In the National Comorbidity Survey, Kessler et al. did not find a significant relationship
between lethality of intent and the presence of a plan of attempt after the onset of ideation.
These results are in according to the conclusions of Michaelis et al. (2003) study in a sample
of bipolar patients.
If the inverse relationship between impulsivity and lethality is replicated in other large and
representative samples, new studies will be needed to clarify the complex interactions
between the clinical dimensions and the biological correlates (particularly serotoninergic
function) of suicidal behviour.
Postcrisis Suicide Prevention
One major concern in suicide prevention efforts is how to provide assistance to high -risk
patients after they are discharged from a psychiatric inpatient setting.
The problem of patients refusing follow-up care is widespread, ranging from 11% to 50% of
patients in various studies. Van Heeringen et al. (1990) used a program of home visits to
provide ―additional motivation‖ for 318 non-compliant patients who had attempted suicide
so that they would accept outpatient treatment after discharge from the hospital. This
program was associated with an increase in compliance from 43% to 53%, although the
difference in the rate of repeated suicidal behaviours in one year was not significantly
different from that of a control group. Similar findings were reported by Torhorst et al.
(1987) in a sample of 226 patients.
Bronish and Hecht (1990) reported that 40% of the 72 patients in the ir sample who
attempted suicide did not accept any treatment program after discharge.
De Vanna et al. (1990) found that 57% of 60 patients in their study had no contact with the
medical staff after leaving the hospital. This finding was attributed to the p atients’
resistance to any program of regular and frequent meeetings with a care provider, to their
focus on somatic treatment during hospitalization, and their patients’ resistance to being
considered ―psychiatric cases‖. Kreitman (1977) reported comparab le results, finding that
among patients who attempted suicide and were referred to day hospitals, only half kept in
touch with the health care system. Moller (1989) provided an excellent review of
noncompliance as a central problem in the postdischarge car e of suicidal patients.
Linehan et al. (1993) examined the literature on treatments to prevent suicide. She
included in her review all controlled trials of treatments designed to reduce suicidal
behavior among these patients compared with a control group.
Linehan found no conclusive evidence that any treatment reduced suicide rates.
A review by Gunnell and Frankel (1994) also concluded that no single intervention has been
shown to reduce suicide in a well-conducted, randomized, controlled trial.
However, a more recently published study by Motto and Bostrom (2001) found significantly
lower suicide rates when high risk individuals who refused further treatment were
randomized to receive nondemanding letters or phone calls in which ―contact was limited to
expressing interest in the person’s well-being‖; the control group received no further
These results may be related to the sample being large enough (N=843) for a low -frequency
behavior such as completed suicide to be detected.
Nevertheless, these results suggest that further study of this innovative contact intervention
along with comparably sized treatment trials is needed.
Four treatments have shown significant effects in reducing the rate of repetition of
parasuicide (Comtois et al., 2002).
Among the four psychosocial treatments, two have a problem -solving focus. Two of the
four—dialectical behavior therapy and home visits—include active attempts to address
The other two were provided in the patient’s home.
Several other treatment trials showed that the experimental treatments were no better than
the usual interventions in reducing rates of parasuicide after admission to treatment.
Hawton and colleagues (1998), Linehan and coauthors (1997), and van der Sande and
colleagues (1997) have reviewed these trials. These findings may indicate that the
treatments are ineffective, but the studies were also marked by small samples, which may
have led to insufficient power of statistical significance. In addition, Linehan has suggested
that a key factor largely unnoticed is the inclusion or the exclusion of high -risk patients in
outcome studies of parasuicide. The one study that did not follow this trend did not control
for the type of behavioral intervention provided. It may be that current treatments are more
effective for high-risk individuals; however, this conclusion is tenuous, because these
individuals are usually excluded from research studies and because small samples of lower -
risk individuals may not have power to show smaller effect sizes. Thus certain treatments
may be more effective, but current research designs lack power. New treatment designs
should include high-risk patients.
Only a few studies have examined service utilization before completed suicide. In
Denmark, Andersen and colleagues (2000) examined all suicides in a county area, finding
that 13 percent of the suicide completers had been admitted to inpatient psychiatry in the
previous month and 15 percent in the previous three months; 42 percent had an admission a t
least once in their life. Most patients had seen their primary care physician in the previous
month (64 percent), and almost all in the previous year (92 percent). However, only 1
percent of individuals who committed suicide had seen a psychiatrist in th e previous month
and 5 percent in the previous year.
King and Barraclough conducted a comparable study in a county in England and found that
5 percent of individuals who committed suicide were hospitalized at the time of suicide and
that 38 percent had been hospitalized in the previous year.
Outpatient psychiatric services were more common than in Denmark; 15 percent of those
who committed suicide were enrolled in the National Health Service at the time of death,
and 22 percent had been enrolled during their lifetime.
Studies of service utilization before and after parasuicide show wide variation depending on
the country, date of study, and age group. For instance, some outpatient service was used by
19 to 57 percent of patients in the month before parasui cide (26 to 81 percent lifetime).
It is likely that the severity of the problem varies widely, and more intensive or longer
treatments would not be necessary for all parasuicidal individuals. In addition, the usual
care may not reflect these differing intensities. That is, there may be inefficiencies in the
system in which patients receiving the most intensive services and those needing such
services are not the same.
Although usual care for parasuicide per se has not been studied, depression, a common
diagnosis among parasuicidal individuals, has been examined.
It has been shown that usual care for depressed primary care patients does not generally
follow the Agency for Health Care Policy and Research recommendations about the
frequency of contact, dosages, or duration of antidepressant medications or specific
evidence-based psychotherapies such as cognitive-behavioral therapy.
Two studies in Finland have used a quality-of-care model to evaluate treatment provided
immediately before and after a parasuicide based on their own quality standards for the
pharmacotherapy of depression.
Suominen and colleagues (1999) examined the treatment of two groups of people who
attempted suicide (N=114), one affected by major depression and one affected by
alcoholism, in the month before and the month after the index parasuicide. The definition of
suicide attempt was the same as the definition of parasuicide used in this paper. In the
month before the parasuicide, 65 percent of the depressed patients and 51 percent of the
alcoholic patients received some medical or psychiatric care; 88 percent of the depressed
patients and 64 percent of the alcoholic patients received care after the parasuicide. The
authors concluded from a review of treatment received for depression that the vast majority
of patients did not receive adequate treatment for depression either before or after the
parasuicide. No treatment specific to parasuicide was reported.
Noncompliance cannot explain this result, because 93 percent of suicide attempters were
referred to inpatient or outpatient aftercare treatment, and only one referred patient did not
attend aftercare. Although the quality of care was not evaluated for the alcoholic patients,
the authors concluded that there was little change in the frequency or quantity of treatment
provided after the parasuicide. Compliance with aftercare was lower for alcoholic suicide
attempters. Only 74 percent of patients received an inpatient or outpatient aftercare referral,
of whom 82 percent attended that referral.
Clearly more research is needed on treatments for suicide prevention. Fortunately, many
strategies in the health services literature can be applied to planning services to prevent
suicide. Eight practical steps based on the suicide treatment and healt h services literature
are possible end-points for this research:
Establish case registries.
Evaluate quality of care.
Evaluate fidelity to treatment models.
Evaluate local programs.
Provide infrastructural supports.
Implement quality improvement.
An Epidemiological Unit to study suicidal behaviours has also been instituted in Trieste,
thanks to a cooperation between the Psychiatric Clinic of the University of Trieste and the
Mental Health Department of Trieste, in order to guarantee a secondary and tertiary
Furthermore, the implementation of the so called ―Amalia Project‖ confirms the importance
of a global assistential service which is operative night and day and allows an immediate
and integrated approach to reduce the suicidal risk.
The special call center (Loperfido et al., 2001), integrated in yhis program, received 4771
calls from January 1999 to February 2001 (Loperfido et al., 2001).
The majority of users are women (67%).
The average age is 44; 46 for women and 41 for men.
47% of the users declared that they were already followed by the psychiatric services.
63% of these outpatients confirmed that they were affected by a mental disorder, especiallly
mood disorders (69%) and still showed a suicidal ideation and intention, whereas 13%
reported a previous suicide.
It is more and more necessary to directly involve all the structures which make up the
social and health services.
Particularly, primary care physicians complain not that they are not imm ediately and
suitably informed about the suicide attempts of their patients.
Social-welfare workers, nurses, professional educators, psychologists, physicians and
psychiatrists can make specific projects to improve the quality of life thus relieving bo th the
somatic and the mental suffering.
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