Are predictors of future suicide attempts and the transition from suicidal ideation to suicide attempts shared or distinct: A 12-month prospective study among patients with depressive disorders
Introduction
Suicide is a leading cause of death worldwide (Mathers et al., 2006). Morbidity due to self-harm including suicide attempts has increased dramatically by 136% within the past decade (Institute for Health Metrics and Evaluation, 2013). One of the key processes in the prevention of suicidal behaviour involves the accurate identification of those who are at the highest risk of suicidal acts (attempted or completed suicide). Such high-risk populations have been identified among inpatients with depressive disorders (Bostwick and Pankratz, 2000). Prospective studies in patients with unipolar and bipolar depression have demonstrated the following predictive risk factors for future suicidal acts: past suicide attempts, duration spent in major depressive episodes, lack of a partner (Sokero et al., 2005); severity of subjective rating of depression, cigarette smoking (Oquendo et al., 2004), alcohol use disorders (Oquendo et al., 2006); younger onset of illness, bipolar diagnosis and psychiatric hospitalizations (Tondo et al., 2007).
The role of suicidal ideation as a risk factor for more serious suicidal acts has been somewhat mixed in the literature. Busch et al.׳s (2003) retrospective chart review found that only 39% of patients, mostly depressed, who eventually committed suicide had endorsed suicidal ideation a week before committing suicide (8). A more recent review by Mendez-Bustos et al. (2013) found that greater suicidal ideation was significantly associated with re-attempted suicide. The evaluation of suicidal ideation is crucial in suicidal risk assessment as it can be viewed as the gateway to more serious suicidal acts. Large and Nielssen (2013) highlighted the challenge of predicting who among those with suicidal ideation will eventually complete suicide, partly due to the non-specificity of well-established risk factors of suicidal behaviour. Although there is a growing body of literature that has examined the differences between suicidal ideators and attempters cross-sectionally (Klonsky and May, 2014), an important knowledge gap still exists with regards to understanding the critical transition from suicidal ideation to attempts. Retrospective, population-based studies have shown that prior suicidal behaviours i.e. previous plans, earlier onset of ideation onset (ten Have et al., 2013) and psychiatric disorders such as substance, bipolar, conduct and post-traumatic stress disorders predicted the transition from ideation to plans and attempts (Nock et al., 2010). Yang et al.׳s (2014) prospective study among Chinese medical students demonstrated the following transition risk factors: history of suicidal behaviour in first-degree relatives, severe anxiety symptoms, impulsivity, physical abuse and parental divorce.
The conundrum that most clinicians face is to identify which suicidal ideator will eventually attempt suicide. Such a decision carries important implications on the intensiveness of management and utilization of resources in mental health services i.e. outpatient versus inpatient treatment. May et al.׳s (2012) prospective study among 49 patients with depressive disorders demonstrated that cluster B personality disorders independently predicted future suicide attempts from ideators after accounting for the most robust predictor from existing literature, a history of past attempt. Apart from that study, the evidence-base for risk assessment of depressed patients progressing from suicidal ideation to attempts is still scarce, more so among non-Western populations. Another crucial clinical question that needs to be addressed is whether predictors of future attempts are distinct or overlap with predictors of the transition from ideation to attempts.
Our aim in this study was to examine the interplay between clinical and social predictors of (i) future suicide attempt and (ii) the transition from suicidal ideation to suicide attempt among patients with depressive disorders in a Malaysian sample.
Section snippets
Participants and procedures
In this paper, we report the prospective data from a 1-year longitudinal naturalistic cohort of patients admitted to the psychiatric wards of the National University of Malaysia Medical Centre (UKMMC), a tertiary-level, teaching hospital in Kuala Lumpur, the capital city situated in Peninsular Malaysia. Malaysia is an upper middle income South East Asian nation with an ethnic composition (Peninsular Malaysia) of Malays (63.1%), Chinese (24.6%), Indians (7.3%), indigenous groups (4.3%) and
Description of suicidal behaviour
Twelve out of 66 patients (18.2%) had made at least one suicide attempt during the 1-year follow-up period, all of which had baseline suicidal ideation. Thirty per cent (9/30) of patients with a past suicide attempt prior to baseline, and 28.8% (5/19) with an index suicide attempt at baseline reattempted suicide within a year. Twenty four per cent of baseline suicidal ideators (12/50) subsequently attempted suicide. Seventeen per cent (2/12) of future suicide attempters did not have any history
Discussion
We found that 24% of suicidal ideators progressed to attempted suicide among inpatients with depressive disorders. This finding was comparable to May et al.׳s (2012) figure of 26.5%. Our finding that the rate of suicide attempts, including the transition from ideation to attempt was the highest within the 5-month post-discharge period concurs with Oquendo et al. (2004) which showed that the period of highest risk for future suicidal acts was within the first year after discharge.
Acknowledgements
This study was funded by the National University of Malaysia Medical Centre (UKMMC) Fundamental Research Grant (Project code FF-095-2007). The authors would like to thank Ms. Nur Ahlina Abdullah for her administrative assistance in the preparation of this manuscript.
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