Multiple Suicide Attempts a Marker for Impaired Functionality

Megan Brooks

May 26, 2016

ATLANTA ― Depressed patients who attempt suicide four or more times have a higher risk of eventually dying by suicide compared with their depressed peers who have never attempted suicide or who have done so fewer times, new research suggests.

"Multiple suicide attempts may be a behavioral marker for particularly impaired functionality," Leo Sher, MD, associate professor of psychiatry, Icahn School of Medicine at Mount Sinai, in New York City, told Medscape Medical News.

Yet in clinical practice, persons who attempt suicide multiple times are often regarded as not being "serious" about wanting to die, added Dr Sher. But his study shows that persons who attempt suicide multiple times are a high-risk group and that such patients need careful evaluation and follow-up.

These findings were presented here at the American Psychiatric Association (APA) 2016 Annual Meeting.

Distinct Phenotype

Multiple lines of evidence suggest that suicide attempts are one of the most robust predictors of suicide or future suicide attempts, said Dr Sher. It has been suggested that those who make multiple suicide attempts may represent a distinct phenotype of suicidal behavior.

To investigate, the researchers studied 683 depressed patients who had a history of major depressive or bipolar disorder. They compared demographic and clinical features of three groups: depressed patients without a history of suicide attempts ("nonattempters," n = 458), depressed patients with a history of one to three suicide attempts ("attempters," n = 178) and depressed patients with a history of four or more suicide attempts ("multiple attempters," n = 47).

They found that attempters and multiple attempters had higher levels of depression, hopelessness, aggression, hostility, and impulsivity compared with nonattempters, but they did not differ between each other on these measures.

Both attempters and multiple attempters had higher levels of suicidal ideation when they entered the study compared with nonattempters. Multiple attempters also had a higher degree of suicide intent at the time of the most medically serious suicide attempt and more serious medical consequences during their most medically serious suicide attempt compared with attempters, Dr Sher reported.

"The effect of multiple suicide attempts on suicide risk is often underestimated. But patients with multiple past suicide attempts are at significantly elevated risk of future lethal attempts," he noted.

Dr Sher also emphasized that the concept of suicide "gesture" is rarely useful, overlaps greatly with that of "attempt," and can easily distract clinicians from the seriousness of associated psychopathology and suicide risk.

"The fact that most attempters do not later die by suicide should not distract psychiatrists and other mental and non–mental health professionals from the substantial increase in risk associated with a suicide attempt, and especially with multiple suicide attempts. Clinicians should not be misled by the folk saying, 'Those who try rarely die.' "

On the contrary, "multiple suicide attempters need monitoring for suicide risk by both mental health care professionals and the larger health care community," said Dr Sher.

Attitude Adjustment

APA president and study coauthor Maria Oquendo, MD, said one of the things that has "been very problematic in psychiatric practice is this notion that if the person were serious, they would have killed themselves already. But it's important to consider that in the United States, many people make suicide attempts by overdose, and emergency response systems and hospitals are very good at intervening and reversing the situation."

But the situation in many other countries is quite different. For instance, said Dr Oquendo, in China, many people use pesticides as a method of suicide, and almost all of them always die, not only because the pesticides are extremely lethal but also because the individuals often do not receive any kind of care, Dr Oquendo noted.

She believes physicians need to "readjust their view of the multiple suicide attempter as someone who is just trying to get attention. One of the things I tell my students is, you really shouldn't use the term 'suicide gesture' because it trivializes the behavior of that individual, and if you can help get them through their rough patch, you might just save a life," Dr Oquendo said.

When it comes to suicide risk and suicide risk assessment, "we've been turning a bit of a blind eye on the level of training that people do or don't have," Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention, told Medscape Medical News.

"Even just the step one ― how to have an open, genuine conversation with a patient at risk. It is not a core part of the curriculum in medical school in general, nor is it in most residency training programs. Maybe psychiatry is the exception," Dr Moutier noted.

She said it is "very easy to develop a sense of cynicism that multiple attempters are being willful and attention-seeking and manipulative. But when you review all the research on who ends up dying by suicide, it's people who've had an attempt or multiple attempts and certain psychopathology that goes along with that."

The study had no commercial funding and the authors report no relevant financial relationships.

American Psychiatric Association (APA) 2016 Annual Meeting: SCR-Suicide, No. 2, presented May 15, 2016.


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