How do repeat suicide attempters differ from first timers? An exploratory record based analysis

Introduction

Suicide is a major social and public health issue worldwide.[12] A prior suicide attempt is one of the strongest predictors of eventual suicide.[34] However, there are difficulties in accurately identifying individuals who are likely to repeat from a sample of 1^st time suicide attempters. Traditionally, clinicians and researchers viewed all suicide attempters together regardless of their number of attempts. However, emerging evidence suggests that there are robust differences between 1^st time and multiple suicide attempters.[5] Multiple attempters tend to be single young subjects,[6] with a positive family history of suicide,[78] having poor adaptive functioning,[9] poor coping resources,[6] and various psychiatric co-morbidities including schizophrenia, depression, substance use, and personality disorders.[67910] Rudd et al. compared three groups: A group of young adult suicide ideators, 1^st time suicide attempters, and multiple suicide attempters and they showed that last group had elevated levels of depression, hopelessness, perceived stress, and poor coping.[11] Similar findings were also reported by investigators who studied people with more number of lifetime attempts[12] and adolescents.[13] From a clinical standpoint, characterization of repeat attempters is important as they are at a greater risk of eventually killing themselves.[14] From a suicide prevention perspective, this group merits closer attention as identifying repeat suicide attempters is a simple, convenient way of risk stratification for management.[9] Notwithstanding these obvious gains, studies trying to delineate repeat attempters are rare from Asian countries. This is important to know as the characteristics of repeat attempters may differ as a function of culture and ethnicity. The present study aims to support the existing literature by trying to identify the clinical and demographic variables that differentiate repeat suicide attempters from 1^st time attempters in South India. To remove the possible interaction of risk factors, we also aimed to identify independent predictors of repeat attempts using a regression model.

Methods

Results

A total of 439 patients were registered in the CIC during the study period. Of them, a suicidal attempt could be established in 423 patients (96.4 of the sample). Sixty-one (14.4%) were repeat attempters while remaining 362 (85.6%) were first ever attempters. The differences in demographic characteristics of 1^st time attempters and repeat suicide attempters are shown in Table 1. The two groups did not differ significantly across any of the demographic variables.

Table 1 Comparison of sociodemographic factors between 1^st time and repeat attempters

The methods and the reasons of suicidal attempt are depicted in Table 2. Overall, use of pesticide was the most common method for a suicide attempt. Interpersonal relationship issues were the most common reason of suicide attempt. A larger proportion of repeat suicide attempters had given hint prior to a suicide attempt. Otherwise, the two groups did not significantly differ between each other on the attempt being made under intoxication, having a family history of suicide, having a physical illness, visit to a health professional in past 3 months, or substance use. Adjustment disorder was the most common clinical diagnosis in both the groups.

Table 2 Comparison of attempt characteristics between 1^st time and repeat attempters

The number of stressors [Table 3] reported by the two groups did not significantly differ. Furthermore, the coping sub-scale scores, inpatient stay durations and functioning in the past 1-year scores did not significantly differ between the groups. Significant differences were noted in the BHS scores, with repeat attempters having greater levels of hopelessness.

Table 3 Comparison of clinical variables between groups

Logistic regression analysis was conducted to find the independent predictors of repeat attempts. Those variables which showed at least a trend level significance on univariate analysis (P < 0.10) were entered into backward Wald regression. It was seen that higher BHS score was the only variable that independently predicted repeat suicide attempts (P = 0.020) [Table 4]. Each point increase in BHS scores was associated with increase in the chance of making a repeat suicide attempt by 6.4% (95% confidence intervals [CIs] of 1.0% to 11.5%) (odds ratio - 1.064, 95% CIs of 1.010–1.115). The Nagelkerke R² of the model was 0.23 and the correct classification rate was 85.9%.

Table 4 Regression analysis for predictors of repeat attempters

Discussion

The present hospital record based study tried to compare the sociodemographic and clinical characteristics between 1^st time (n = 362) and repeat (n = 61) suicide attempters. We found that the two groups did not differ on any of the demographic characteristics. This is broadly similar to previous reports from India[10] and the West[923] and suggests that the demographics of repeat attempters tend to remain uniform across various ethno-cultural settings. Only a few studies have reported a female preponderance among multiple attempters.[24]

Repeat attempters did not differ from single attempters when compared on the preferred mode and reasons for the current attempt. This is consistent with prior reports that failed to show any incremental lethality with subsequent attempts among multiple lifetime attempters.[25] Further, no differences were found on their health care seeking patterns as both the groups had sought the help of a health-care professional in the preceding 3 months. However, we noted that repeat attempters were more likely to have dropped verbal or other hints prior to their attempts. This raises important questions about the availability of a window period for intervention in this group that may reduce the possibility of suicidal acts and is worth exploring further.

No significant differences emerged between 1^st time and repeat suicide attempters in terms of psychiatric morbidity, coping styles, levels of stress, and overall functioning. Our findings differ with the conclusions drawn by Forman et al. who showed that multiple suicide attempters displayed poorer problem solving skills and experienced greater relationship difficulties.[9] A 2 years follow-up study showed higher rates of major depression among repeat attempters.[10] However, a recent report extending the follow-up to 10 years did not suggest any differences in rates of axis-I co-morbidity between 1^st time and multiple attempters similar to our findings.[26]

The major finding of the present study was that levels of hopelessness distinguished 1^st time attempters from repeat attempters. Similar findings have been noted earlier by Rudd et al. though their sample composed of only young adults enlisted for military duty.[11] Increased concurrent expression of depression and hopelessness has been consistently reported among multiple attempters by previous investigators who compared this group with first ever attempters.[6910] According to many classic, as well as recent papers, depression, and hopelessness are closely linked and hopelessness mediates the relationship between depression and intent in attempted suicide.[27282930] However, few studies have shown an association of hopelessness with repeat attempts, independent of depression as we have done. Our findings are probably of clinical and theoretical relevance because it tells us that hopelessness could be an independent predictor of multiple suicide attempts even in the absence of clinical depression. We propose an amalgamation of the strain theory of suicide[31] with Beck's theory of modes[32] which may provide a generic cognitive model for multiple suicidal behaviors. The strain theory postulates that psychological strain, brought on by contradictory and competing pressures in an individual's life, precedes suicidal behavior.[33] As this strain gets too overwhelming, his or her coping repertoire may get exhausted, and hopelessness may occur prior to the contemplation of suicide. Over a period of time, this organization of schemas relevant to negative expectancies, memories, and self-evaluations, referred to as modes by Beck,[34] may get established and prone to activation by minimal triggers.[3235] To sum up, the suicidal mode preceded by cognitive hopelessness becomes easily accessible to the individual when it is repeatedly engaged in and requires minimal triggering stimuli for its subsequent activation as it is fresh in memory. A closer evaluation of the relationship between hopelessness and multiple suicide attempts through prospectively designed studies may help to further our theoretical understanding of how hopelessness may be causally related to attempt status or vice versa.

Our findings need to be interpreted in the context of certain limitations. This was a record based study, and hence, carries some design limitations including recall bias. The findings are drawn from a single Tertiary Care Center, and hence, needs wider replication for generalizability. No structured instrument was used to assess psychiatric co-morbidity. Furthermore, the two groups (repeat suicide attempters and first timers) were unbalanced in terms of the distribution of the number of cases, necessitating use of nonparametric tests. The strengths of this study include studying a well-defined sample of suicide attempters using internationally accepted nomenclature and comparison of 1^st time and repeat attempters on a broad set of variables to generate information. For the same reason, there was no admixture of parasuicides in our sample, otherwise a limitation in many studies on suicide. We also included certain novel variables such as health care seeking patterns not often seen in the literature. The measures used in this study are popular and validated across cultural settings, and hence, our results can be meaningfully when compared with global findings.

To conclude, the presence of hopelessness, irrespective of depression, may be a clinically useful marker to identify individuals at risk for making repeat suicidal attempts. This finding may have special significance for low and middle income countries where, consistently, lower rates of axis-I co-morbidity have been documented among suicide attempters[3637] as opposed to data from developed nations.[38] Other factors such as age, gender, stress, coping, and functioning did not distinguish these groups. Based on this, we propose that repeat suicide attempters as a group are different, at least in terms of cognitive schemas and may need different management approaches including case conceptualizations and treatment interventions. Hence, clinicians need to pay enhanced attention to the evaluation of hopelessness during a routine evaluation of attempted suicide. Further research questions that may be best addressed through longitudinal data in this group include whether and how hopelessness is causally related to the attempt status. The relationship of hopelessness with other factors that may predict multiple attempts also needs to be explored in order to come up with a coherent theoretical model for multiple suicidal attempts.