Serious Intent

One Million & Counting
cALL 800-273-8255 or
text "sos" to 741741

Teen Suicide Prevention
Talk to someone today
Words matter.


Access to methods of suicide: what impact?
A cross-national study on gender differences in suicide intent
A history of major depressive disorder influences intent to die in violent suicide attempters
A machine learning approach for predicting suicidal thoughts and behaviours among college students
Americans Who Become a New Versus a Former Gun Owner: Implications for Youth Suicide and Unintentional Firearm Injury
An analysis of child deaths by suicide in Queensland Australia, 2004-2012. What are we missing from a preventative health services perspective?
An evaluation of suicidal intent in suicide attempts
Annual Research Review: A meta-analytic review of worldwide suicide rates in adolescents.
A pilot randomized clinical trial of a lethal means safety intervention for young adults with firearm familiarity at risk for suicide
A Risk Algorithm for the Persistence of Suicidal Thoughts and Behaviors During College
Association between youth-focused firearm laws and youth suicides
Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings.
Beck's Suicide Intent Scale - Shortened Version
Borderline personality disorder, self-mutilation and suicide: literature review
Changing times: a longitudinal analysis of international firearm suicide data.
Characteristics of adult male and female firearm suicide decedents: findings from the National Violent Death Reporting System.of persons who die on their first suicide attempt: results from the National Violent Death
Characteristics of persons who die on their first suicide attempt: results from the National Violent Death Reporting System
Child Access Prevention Laws and Juvenile Firearm-Related Homicides
Child suicides in Sweden, 2000-2023.
Clinical strategies for reducing firearm suicide.
Comparing gun-owning vs non-owning households in terms of firearm and non-firearm suicide and suicide attempts.
Cost effectiveness of a community-based crisis intervention program for people bereaved by suicide
Decoding Suicide Decedent Profiles and Signs of Suicidal Intent Using Latent Class Analysis - 3/20/24

People Facing Health Challenges Make Up Largest Group of Suicide Decedents - 3/20/24

Development of a Suicide Prediction Model for the Elderly Using Health Screening Data.
Differences in Suicide Among Men and Women - 2/11/22

Differentiating suicide decedents who died using firearms from those who died using other methods.
Discussing Firearm Ownership and Access as Part of Suicide Risk Assessment and Prevention: "Means Safety" versus "Means Restriction"
Evolution of suicide attempts in a Tunisian clinical population between 2005 and 2015: New modalities for young people to commit suicide?
Excerpt: Fatal and non-fatal repetition of self-harm: systematic review. British Journal of Psychiatry
Factors associated with serious intent to die among suicide attempters in Hungary
Features for medically serious suicide attempters who do not have a strong intent to die: a cross-sectional study in rural China
Firearm access and adolescent suicide risk: toward a clearer understanding of effect size
Firearm availability and suicide, homicide, and unintentional firearm deaths among women
Firearms and suicide: The role of misinformation in storage practices and openness to means safety measures.
Firearms, firearms injury, and gun control: a critical survey of the literature.
Firearms injuries and deaths: a critical public health issue. American Medical Association Council on Scientific Affairs.
Firearms legislation and reductions in firearm-related suicide deaths in New Zealand.
Firearm Purchasing During the COVID-19 Pandemic: Results From the 2021 National Firearms Survey
Firearm suicide: pathways to risk and methods of prevention
Firearm suicides and homicides in the United States: regional variations and patterns of gun ownership
Gender and Suicide Method: Do Women Avoid Facial Disfiguration? - Trigger Warning
Gender differences in deliberate self-poisoning in Hungary: analyzing the effect of precipitating factors and their relation to depression.
Gender differentiation in methods of suicide attempts - NCBI
Gender Differences in Suicide - Wikipedia
Gun storage practices and risk of youth suicide and unintentional firearm injuries.
Hopelessness, Depression, and Suicide Intent - JAMA - 9/76
Jumping the gun: firearms and the mental health of Australians.
Lethal Means
Level of suicidal intent predicts overall mortality and suicide after attempted suicide: a 12-year follow-up study - NCIB
Male Gender Role Stress and PTSD - 5/28/21
Method Choice and Intent
Method choice, intent, and gender in completed suicide - NIH
Physical Health Problems as a Late-Life Suicide Precipitant: Examination of Coroner/Medical Examiner and Law Enforcement Reports
Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: Importance of the first depressive episodes and of bipolar II diagnoses. Journal of Affective Disorders
Prevalence of subthreshold forms of psychiatric disorders in persons making suicide attempts in Hungary. European Psychiatry
Prevention of Firearm Suicide in the United States: What Works and What Is Possible
Prevention of suicide and attempted suicide in Denmark. Epidemiological studies of suicide and intervention studies in selected risk groups.
Prior suicide attempts are less common in suicide decedents who died by firearms relative to those who died by other means
Public Opinion Regarding Whether Speaking With Patients About Firearms Is Appropriate: Results of a National Survey
Relationship Between Firearm Availability and Suicide - 3/2/18
Resilience among students at risk of dropout: Expanding perspectives on youth suicidality in a non-clinical setting.
Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research
Risk of re-attempts and suicide death after a suicide attempt: A survival analysis
Safer storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample
Scale for assessment of lethality of suicide attempt - India Oct-Dec, 2014
Severity of intent
Storing guns safely in homes with children and adolescents
Suicide - 2020 - NIH
Suicide Attempts and Dying by Suicide - SPRC - 3/10/17
Suicide by Cop: Fact Sheet - AAS
Suicide by gunshot in the United Kingdom: a review of the literature.
Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements.
Suicide in Older Adults With and Without Known Mental Illness: Resulaviors: A meta-analysis of 50 years of researchts From the National Violent Death Reporting System, 2003-2023.
Suicide prevention and mood disorders: Self-exclusion agreements for firearms as a suicide prevention strategy
Suicide Risk Assessment and Prevention: Challenges and Opportunities.
Suicidal Ideation
Surveillance for Violent Deaths - National Violent Death Reporting System, 32 States, 2016.
Surveillance for Violent Deaths - National Violent Death Reporting System, 34 States, Four California Counties, the District of Columbia, and Puerto Rico, 2017.
Surveillance for Violent Deaths - National Violent Death Reporting System, 17 States, 2013.
Surveillance for violent deaths - National Violent Death Reporting System, 16 states, 2010.
The gender paradox in Suicide.
The Gender Paradox of Suicide: How Suicide Differs Between Men, Women, and Transgender/Gender Diverse Individuals
The gender paradox in Suicide. Suicide and Life-Threatening Behavior
The Role of Reason for Firearm Ownership in Beliefs about Firearms and Suicide, Openness to Means Safety, and Current Firearm Storage
Trajectories in suicide attempt method lethality over a five-year period: Associations with suicide attempt repetition, all-cause, and suicide mortality - Australia
Understanding Suicide Among Men - 12/10/20
What Do We Know About the Association Between Firearm Legislation and Firearm-Related Injuries?
"What Will Happen If I Say Yes?" Perspectives on a Standardized Firearm Access Question Among Adults With Depressive Symptoms

Severity of intent

Suicide gestures - have no intent to die, who tend to manipulate others in their act and to enforce a close bond with the object of their action. seek to compel help from others

Ambivalent - vacilitate and confused in intent but in taking a risk of death they too may test the affection and care of others. Act out fantasies of a dangerous ordeal followed by rescue.

Serious Attempt -similar to the completed suicide group in their depression, hopelessness, and lack of social interation. Leave little room for help but a disguised plea for hellp can be heard in their frequent communications of their intent to die

An evaluation of suicidal intent in suicide attempts


Many significant differences exist between populations who attempt suicide and who succeed in killing themselves. Variations in intent account for these differences. This study describes a method of measuring intent to die in suicide attempts in which the intent is inferred from the degree of risk taken by the subject.

Using a five-point ordinal scale of suicidal intent, a group of judges made independent judgments of suicidal intent in a series of 121 unselected, consecutive attempted suicides. The judgments showed a high degree of agreement. Comparisons were made between this group and a group of 114 completed suicides. Severity of intent increased with age. Women tended to make less serious attempts. Over one-third of those who completed suicide were psychotic whereas the most frequent diagnoses in those who attempted suicide were personality disturbances.

Three subgroups are distinguished.(1) Those who make suicide gestures are individuals who have no intent to die, (2) who tend to manipulate others in their act and (3) to enforce a close bond with the object of their action. The ambivalent group are vacillating and confused in intent, but in taking a risk of death they too may test the affection and care of others. The serious attempt group are similar to the completed suicide group in their depression, hopelessness, and lack of social interaction.

The gesture group seek to compel help from others. The ambivalent group act out fantasies of a dangerous ordeal followed by rescue. The serious group leave little room for help, but a disguised plea for help can be heard in their frequent communications of their intent to die.

Excerpt: Fatal and non-fatal repetition of self-harm: systematic review. British Journal of Psychiatry

Nine out of ten people who attempt suicide and survive will not go on to die by suicide at a later date. This has been well-established in the suicidology literature. A literature review (Owens 2002) summarized 90 studies that have followed over time people who have made suicide attempts that resulted in medical care. Approximately 7% (range: 5-11%) of attempters eventually died by suicide, approximately 23% reattempted nonfatally, and 70% had no further attempts.
Source: Owens D, Horrocks J, and House A. Fatal and non-fatal repetition of self-harm: systematic review. British Journal of Psychiatry. 2002;181:193-199.

Gender and Suicide Method: Do Women Avoid Facial Disfiguration?


This study hypothesizes that women are less likely than men to use suicide methods that disfigure the face. Gender differences in the use of suicide methods that disfigure the face were examined using medical examiner’s files of 621 suicides covering a 10-year period from Summit County, Ohio in the U.S. Results showed that while firearms are the preferred method for both women and men, women were less likely to shoot themselves in the head. A series of logistic regression analyses revealed that gender, age, stressful life events and prior suicide attempts were predictors of methods that disfigure the face/head. Significant differences between men and women in correlates of suicide method emerged when the sample was split by gender. The results support the position that women who commit suicide are more likely than men who commit suicide to avoid facial disfiguration.

Factors associated with serious intent to die among suicide attempters in Hungary


As suicide attempts pose major risk for future suicide death, understanding the underlying factors of suicide attempts and suicidal behaviour is an important mental health imperative. The aim of this study was to examine suicide attempts with a special focus on the intention. A total of 2540 discharge summaries were collected between 2009 and 2011 in Miskolc, Hungary, and a content analysis was conducted. Data regarding the method, the reason for suicide attempts, the amount, the source, and the type of the medication taken were examined. Deliberate self-poisoning was the most frequent method (73.8%) committed with more than 200 different types of drugs. 40.5% of the patients attempted suicide with an intent to die, whilst 35.6% of the patients wanted to escape from an unbearable situation. Older age groups, greater amount of taken pills, and affective disorders were associated with self-reported serious intention to die. Our findings should be taken into consideration when monitoring drugs for older patients with depressive disorders.

A cross-national study on gender differences in suicide intent



Suicide accounts for over 58,000 deaths in Europe per annum, where suicide attempts are estimated to be 20 times higher. Males have been found to have a disproportionately lower rate of suicide attempts and an excessively higher rate of suicides compared to females. The gender difference in suicide intent is postulated to contribute towards this gender imbalance. The aim of this study is to explore gender differences in suicide intent in a cross-national study of suicide attempts. The secondary aims are to investigate the gender differences in suicide attempt across age and country.


Data on suicide attempts (acquired from the EU-funded OSPI-Europe project) was obtained from eight regions in Germany, Hungary, Ireland and Portugal. Suicide intent data was categorized into ‘Non-habitual Deliberate Self-Harm’ (DSH), ‘Parasuicidal Pause’ (SP), ‘Parasuicidal Gesture’ (SG), and ‘Serious Suicide Attempt’ (SSA), applying the Feuerlein scale. Gender differences in intent were explored for significance by using 2-tests, odds ratios, and regression analyses.


Suicide intent data from 5212 participants was included in the analysis. A significant association between suicide intent and gender was found, where ‘Serious Suicide Attempts’ (SSA) were rated significantly more frequently in males than females (p < .001). There was a statistically significant gender difference in intent and age groups (p < .001) and between countries (p < .001). Furthermore, within the most utilised method, intentional drug overdose, ‘Serious Suicide Attempt’ (SSA) was rated significantly more often for males than females (p < .005).


Considering the differences in suicidal intent between males and females highlighted by the current study, gender targeted prevention and intervention strategies would be recommended.

Peer Review reports


Suicidal behaviour is a significant public health problem. Suicide is the 13th leading cause of death globally [1] and accounts for over 58,000 deaths in Europe a year [2]. Suicide appears to be a male phenomenon, as death rates from suicide are four-to-five times higher for men than for women across the European Union [3].

For suicide attempts, for which the rate is estimated to be 20 times higher than that of suicides [4], the gender gap is less pronounced, with females demonstrating a disproportionately higher rate of suicide attempts compared to males [5]. The Male:Female ratio of age-standardized suicide rates globally is 1.9 [4]. This phenomenon of men completing suicide more frequently than females, while females engage significantly more frequently in suicide attempts, is known as the gender paradox of suicidal behaviour [6, 7].

Many studies have sought to explain the gender gap in suicidal behaviour by addressing lethality, suggesting that females survive suicide attempts more often than males because they use less lethal means [8, 9], and their outcomes are less lethal compared to males even when using the same method [8]. Major Depression (which is approximately twice as common in females, and is known to underlie more than half of all suicides) has also been proposed to account for a higher incidence of suicidal behaviours in females [10, 11]. This could be a contributing factor to the lower rates of suicidal behaviour in males overall, however, this does not account for the excessive rate of completed male suicides compared to female suicides. Psychosocial risk factors have also been found to contribute to the discrepancy of rates between male and female suicidal behaviour, where unemployment, retirement and being single were all significant risk factors for suicide in males, whereas no significant risk factors other than mental illness were reported for females [11, 12]. So far, studies aimed to disentangle the gender gap have reported inconsistent findings; therefore, suicide intent has been at the forefront of suicide research in order to contribute to the explanation of this gender imbalance.

Suicide intent in this context is characterised as “an individual’s desire to bring about his or her own death” [13], which specifically excludes motives for attempting suicide. Studies exploring intent have found that the type of suicide intent at the time of a suicide attempt is associated with an elevated risk of completed suicide [14, 15], which is particularly prudent within the female population, where the association between the type of suicidal intent and completed suicide is markedly higher [15].

To date, there have been some studies that have investigated this relationship between suicidal intent and gender. Theorists investigating suicide intent argue that the excess rate of attempted suicide in females, plus the stronger association between suicide attempts and death in males, is indicative of a stronger degree of intent to die in males than females [16, 17]. Some studies addressing gender differences in intent have reported no significant differences between males and females [6, 18,19,20] while others revealed significant associations between suicide intent and gender [15, 21, 22]. Although previous studies have documented gender differences in suicide intent, the findings need to be interpreted in light of methodological issues such as small sample sizes, absence of consistent operational terms of suicide intent and the assessment of intent and motives as a single concept. In order to fully comprehend the gender paradox in suicidal behaviour, further research to explicate this gender gap in suicide intent remains to be explored. The present study aims to overcome the methodological issues from previous research by utilising both standardised definitions and a large database retrieved cross-nationally for increased validity and effect.

Study aims

The main aim of the current study is to bring clarity to previous studies in this space, and to shed more light on the role of gender differences in suicide intent. The secondary aims are to investigate the gender differences in suicide attempt across age and country. Our main hypothesis is that male suicide attempts will be rated more frequently as a serious suicide attempt overall than female ones. Additionally, we expect that within each age group, country, and most utilised suicide method, males will be rated more frequently in the serious suicide attempt group compared to females.


Data collection

Data on suicide attempts was obtained from the EU-funded OSPI-Europe project (“Optimising Suicide Prevention Programmes and their Implementation in Europe”) [23] from eight model regions in Europe (Ireland, Hungary, Germany and Portugal). This project was conducted from 2008 to 2013, and its aim was to develop and evaluate an optimised version of the 4-level intervention programme of the EAAD (European Alliance Against Depression) [24, 25] targeting depression and suicidal behaviour. Attempted and completed suicides were assessed as the primary outcome parameter, where adults who attempted suicide were included in the study, and those who engaged in habitual self-harm were excluded. Project results have been reported elsewhere [9, 26, 27].

The data for the current study were obtained from the eight regions in the four participating countries, where each region adhered to the following standardised definition of Suicide Attempt: “an act with a non-fatal outcome in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause a self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired, via the actual or expected physical consequences” [28]. Suicidal behaviour elsewhere referred to as parasuicide [29] is included, while habitual intentional self-harm is excluded from this definition. A standardised questionnaire for the registration of suicide attempts and a codebook listing the associated variables (e.g. gender [in this context, defined as ‘the state of being male or female], age and country of suicide attempter, intent and method of suicide attempt) was employed by all eight regions to ensure comparability and consistency in the standardisation of data collection. The specific time and method of data collection was dependant on the local circumstances of the participating centres (see Table 1).

Table 1 The data collection procedures of the participating countries

Full size table

Table 1 summarises the data collection procedures in the participating countries.

Data on type of suicide intent (outlined below) were rated based on the judgement of the clinical staff. All personnel involved in the eight assessment regions were trained in administering the measurement and in how to proceed in unclear cases.

Definition of variables

Suicide intent was assessed as the dependent variable. The type of suicide intent was classified by a clinical staff member based on the nature of the suicide attempt using the Feuerlein Scale. The Feuerlein Scale [30] (see Fig. 1 for the format the scale had in the standardised questionnaire) is a categorical, non-ordinal based evaluation tool which was developed in order to classify different psychological intentions for suicidal acts based on the circumstances of the patients’ suicidal act, and has four categories: 1) (non-habitual) Deliberate Self-Harm (DSH); 2) Parasuicidal Pause (SP)- refers to suicidal behaviour carried out mainly to escape from an unbearable situation/from problems; 3) Parasuicidal Gesture (SG) – refers to an appellative or manipulative suicidal act (and excludes ideas or threats without any action performed); and 4) Serious Suicide Attempt (SSA) – refers to suicidal behaviour carried out with a clear intent to die [30].

Fig. 1

figure 1

Feuerline Scale

Full size image

The following independent variables were also addressed: gender, age, country and method of suicide attempt.

For age, means and standard deviations were computed, and age groups were aggregated in order to compare the younger age group as the reference category (< 30 years) with a middle (30–45 years) and higher age group (> 45 years).

Data analyses

Gender differences in the distribution of suicide intent were tested for significance by using the ?2-test for two-by-four tables. These analyses were repeated, using the factors “country” and “age group” as strata. Standardized residuals were computed in order to identify those cells in the cross tables which added the most to the statistically significant results of the corresponding ?2-tests. The effect of age group on suicide intent within each gender was also analysed using ?2-tests. In addtion, a ?2 analysis for suicide methods was calculated to identify types of suicide intent and their association with gender.

The hypothesis whether several independent variables (gender, age group, country) had a separate influence on the category of suicide intent regarding the frequency of suicide attempts was tested by running four stepwise binary logistic regressions. The binary dependent variable was each category of suicide intent (Deliberate self-harm: 1 = Yes; 0 = No; Parasuicidal Pause: 1 = Yes; 2 = No; Parasuicidal Gesture: 1 = Yes; 2 = No; Serious Suicide Attempt: 1 = Yes; 2 = No). For quantifying the strength of associations between the independent variables and gender, odds ratios (OR) and the corresponding 95% confidence intervals (CI) were applied.

Moreover, in order to answer the question whether gender differences in suicide intent were age-dependent or not, a multinomial regression analysis was used to investigate the interaction of the factors “gender” and “age group” regarding suicide intent as a dependent variable.

The statistical tests were two-tailed and performed using the statistical software package for IBM SPSS Statistics 20™ for Windows (IBM, New York, USA). The significance level was set at .05.


In total, 8189 suicide attempts were registered, however, the final sample consisted of 5212 subjects (63.65% of the complete OSPI-Europe sample), with 52.1% of the attempted suicides rated as a Serious Suicide Attempt (SSA), 20.6% as a Parasuidal Gesture (SG), 14.7% as a Parasuicidal Pause (SP) and 12.7% as Deliberate Self-Harm (DSH). 40.6% of the sample were males and 59.4% females, with a mean age of 39.16 years. Additionally, 25.0% of the sample were from Germany, 19.3% were recorded from Hungary, 29.5% from Ireland and 26.2% were from Portugal. 67.9% of the final sample attempted suicide by intentional drug overdose, 7.6% intentional self-poisoning by other means, and 3.5% by hanging.

Suicide intent and gender

The association between suicide intent and gender was statistically significant, X 2 (3, N = 5212) = 39.94; p < .001. According to the standardized residuals, SG and SSA contributed most to this significant difference: females were rated significantly more frequently in SP and SG than males, whereas SSA were rated significantly more often in males than females (see Table 2). There was no significant difference in the frequency of suicide attempts rated as DSH between males and females.

Table 2 Types of suicide intent and their association with gender, countries and age

Full size table

Suicide intent, gender and age

Overall, there were no significant gender differences in age (mean age (S.D.) in males: 38.77 (16.17) years; mean age (S.D.) in females: 39.42 (17.51) years; Z = -0.52; p = 0.60 (Mann-Whitney U test)). According to the Mann-Whitney U Tests, there was a significant difference in age between males and females in the DSH group, where the mean age for males was significantly higher than in females (39.93 > 36.99, p = 0.015).

Within the youngest age group (<30 years), there was a significant association between SG and SSA with gender. In this age group, male suicide attempts were rated as SSA significantly more often than female suicide attempts, while SG were rated significantly more times for females than males. In the middle age group (30–45 years), female suicide attempts were rated as SP and SG significantly more frequently than male suicide attempts, while male suicide attempts were rated as SSA significantly more than female suicide attempts. In the older age group (>45 years), female suicide attempts were rated as SG significantly more frequently than male suicide attempts, while male suicide attempts were rated as DSH significantly more than female suicide attempts.

A multinomial regression analysis was used to investigate the interaction of the variables “gender” and “age group”, with suicide intent as the dependent variable. A significant interaction effect was obtained, X 2 (6, n = 5212) = 15.96; p = .014. This finding represents an age-dependency of gender differences in suicide intent.

Suicide intent, gender and country

There was a statistically significant association between suicide intent and country both in males, X 2 (9, N = 5212) = 393.29; p < .001, and females, X 2 = (9, N = 5212) = 700.64; p < .001 [see Fig. 2]. Hungary, X 2 (3, N = 5212) = 14.66; p = .002, Ireland, X2 = (3, N = 5212) = 12.21; p = .007 and Portugal, X 2 (3, N = 5212) = 32.56; p < .001, all reported significant differences between males and females in suicide intent. There was no significant difference between the genders in suicide intent in Germany (p = .37). In Hungary, a significant difference between the genders was found in DSH and SP, where male suicide attempts were rated as DSH significantly more often than female suicide attempts, and female suicide attempts were rated as SP significantly more than male attempts. In Ireland and Portugal, significant differences in intent between males and females were reported, where female suicide attempts were rated significantly more frequently as SG and significantly less frequently as SSA than males.

Fig. 2

figure 2

Country differences in suicide intent

Full size image

Analyses for different suicide methods

In order to address the question of whether the method of suicide attempt plays a role in the association between suicide intent and gender, a Chi-square analysis was performed. In terms of the three most frequently used methods of suicide attempts (intentional drug overdose, intentional self-poisoning by other means, and hanging), there was only a significant difference in suicide intent and gender within the intentional drug overdose method (p = .0041). Of those who chose this method, males were rated as SSA significantly more frequently and as DSH and SG significantly less frequently than females (see Table 3).

Table 3 Results of a ?2 analysis for suicide methods identifying types of suicide intent and their association with gender

Full size table

Results of the binary logistic regression analyses

Table 4 displays the results of the binary logistic regression analyses which investigated the impact of age, gender and country on each category of suicide intent. The analyses explained between 7.1–16.5% of the total variance which suggests that there are other confounding variables that account for the variance in suicide intent and gender.

Table 4 Results for binary logistic regression analyses of variables influencing the type of suicide intent according to the Feuerlein Scale

Full size table

If a patient was male, the odds that he was rated as a SSA significantly increased (OR = 1.93; p < .001) while the odds for SP (OR = 0.55; p = .03) and SG (OR = 0.61; p = .009) significantly decreased. Compared to younger participants (< 30 years), the odds of people older than 45 years of age engaging in an act of DSH, or a SP significantly decreased (OR = 0.44; p < .001; OR = 0.7, p = .009) whereas corresponding odds for a SSA significantly increased (OR = 1.88; p < .001).

There was also a significant association between type of suicide intent and the variable “country” (p < .001)

Compared to Portugal, the odds of Germans, Hungarians and Irish suicide attempts being rated as a SSA (OR = 2.95; p < .001; OR = 1.32; p = .01; OR = 2.32; p < .001, respectively) significantly increased, while the odds for suicide attempts being rated as DSH (OR = 0.09; p < .001; OR = .35; p < .001; OR = .24; p < .001, respectively) significantly decreased.

Further to this, the analysis also revealed a significant interaction effect between gender and age group in the categories of DSH (p < .001) and SSA (p = .03), and also a significant interaction between gender and country in the SG (p = .009) and SSA (p = .02) category.


General findings

The main aim of the current study was to examine gender differences in suicide intent in a large European cross-national sample, and to explore whether gender differences exist across age, country and suicide method. The results support the hypothesis that males would demonstrate a higher frequency of Serious Suicide Attempts (SSA) than females. In line with our other hypotheses, our results showed a significant gender difference between age groups for suicide intent, where in all age groups male suicide attempts were rated significantly more frequently as SSA compared to females. However, in the oldest age group, male suicide attempts were rated as Deliberate Self-Harm (DSH) significantly more times than female attempts. The hypothesis that male attempts would be rated as SSA more frequently than females within each country was supported in Portugal and Ireland, however, there were no significant differences in Germany and Hungary. Finally, our results confirmed the prediction that within the most utilised method of attempted suicide, in our case - intentional drug overdose, male suicide attempts would be rated as SSA more frequently than females.

The regression analyses revealed that suicide attempts of older people (>45 years) were more likely to be rated as a SSA compared to younger people, and younger people were more likely to be rated in the DSH and SP group than older people.

Are there gender differences in intent?

The overall finding, that male attempts were rated as SSA more often than females, is in line with other studies that found females to have a less serious intent to die than males [15, 18, 31, 32] despite other findings illustrating no difference in suicide intent between males and females [6, 19, 33].

Are gender differences in intent dependent on age?

The association between suicide intent and age, which was found in previous studies [14, 15, 34] was not supported in the current study. In contrast with the results of previous studies that reported that young females had a significantly higher level of suicide intent than young males [35], in the present study, the proportion of young males (<30 years) rated as SSA was significantly higher than the young females. Further to this, previous studies have reported the lower age of females at the time of suicide attempt as a general trend [22, 36, 37] which was not confirmed in this study.

Are gender differences dependent on country?

In support of previous studies [38,39,40], a significant gender difference in suicidal intent across countries was revealed. Hungary, Ireland and Portugal reported significant differences between males and females in suicide intent, whereas no significant differences were reported for Germany. Current findings however contradict those of Hjelmeland et al. [31, 41] whose results of a cross-cultural study on suicide intent found that there were no gender differences in intent and country. Hjelmeland’s [41] findings however, support the current findings from Germany, which suggests that suicide intent is posited to be similar for both genders.

Are gender differences in intent dependent on method of suicide attempt?

In terms of the association between type of suicide intent and gender among different suicide methods, results illustrated that for suicide intent, SSA was rated significantly more frequently in males than females in the most frequently used method of attempted suicide (intentional drug overdose, N = 3542, 67.9% of patients). This finding propounds that even within the same method of attempted suicide, in this case, intentional drug overdose, males show a stronger intent to die than females. This finding is in line with a recent study of over four thousand self-harm cases, which reported a significant association between higher estimated median suicide intent scores with male gender, self-poisoning, multiple methods of self-harm, use of gas, use of alcohol and dangerous methods of self-harm [42]. Thus, it can be inferred that irrespective of the method of self-harm, male suicide attempts tend to be more serious than female suicide attempts.

Why are there gender differences in suicide intent?

The results presented above support previous evidence showing that males have a higher intent to die than females. This evokes questions as to why this would be the case. Some theorists contend that females attempt suicide earlier in the evolution of psychiatric morbidity than males, which might represent less of an intention to die, and more a desire to communicate distress or change their social environment [21, 22]. Another theory suggests that because males have a higher intent to die than females, females may be more reluctant to perform a SSA because it is considered ‘masculine’ [6]. These gender-specific beliefs and attitudes towards self-harm may contribute to the explanation of young men’s low rates of suicidal behaviour and their high rates of suicide mortality [43], however, more research needs to be conducted in this area in order to develop concrete theories to support prevention efforts.

The value of and barriers to measuring suicide intent

The concept of intent is a critical component in the clinical appraisal of suicide attempts, as it distinguishes between acts of deliberate and accidental self-harm. Many studies have assessed the value of measuring suicide intent for screening purposes and for its use in assessing future suicide risk, as the type of suicide intent has been associated with future suicide attempts [44, 45]. Therefore, the measurement of suicide intent may be particularly useful in the assessment of short-term suicide risk [46].

There are several measures to assess suicide intent, where Beck’s Suicide Intent Scale represents the most widely used one [47], however, the Feuerlein Scale [30], the five-point ordinal scale developed by Dorpat and Boswell [48] and other intent assessment instruments highlight the variability in the empirical measurement, nomenclature and analysis of suicide intent, and this lack of consistency and standardisation impedes future research related to the measurement of suicide risk and outcome [13]. Moreover, notwithstanding the clinical importance of assessing suicide intent, emergency department personnel often do not document suicide intent at all [49], despite national guidelines and policy initiatives recommending that psychosocial assessments (which include measuring suicide intent) must be undertaken after every self-harm presentation [50]. It is recommended that a standardised measurement for suicide intent is implemented in clinical settings in order to develop and effectively manage the treatment of patients at risk of suicide.

Strengths and weaknesses

Although care was taken in the systematic collection of the data in all participating countries, in some regions, data was collected by proxy as well as self-report. The judgement about the suicide intent of the presenting cases was made by clinical staff based on the available information on the suicide attempt, and therefore was not self-report, which is suggested to be a more reliable method of measurement. Furthermore, only part of the overall data on suicide attempts available from the OSPI-Europe database of suicide attempts contained information on suicide intent. This led to an overall reduced sample size when compared to the total number of cases. Finally, due to the complexity of suicide intent, categorizing suicide intent with the Feuerlein Scale may not be a sufficiently precise categorization to detect gender differences. A methodological strength of the current study is the sample size (n = 5212), which increased the validity and power of the findings. Furthermore, compared to other cross-national studies, there was no variation in the definition used for selecting the samples of patients to be included in the study and a standardised assessment instrument was also utilised.

Implications for future research and practice

In the current study, the previously reported gender differences between males and females in suicide intent were confirmed. However, remaining ambiguities call for further studies to include the variable ‘gender’ when conducting research on suicide. In order to reach a better understanding of the association between gender and suicide intent, cross-national studies to confirm or reject the transferability of the present findings and studies exploring the reasons for varying levels of suicide intent between males and females is needed. Nevertheless, in consideration of studies reporting gender differences in suicide intent, it seems reasonable to tailor prevention and intervention strategies to target gender-specific aspects. For instance, it would be justified to design an awareness campaign specifically targeting men, as our findings confirm that male suicide attempts are in general more serious than female attempts. Furthermore, given that female suicide attempts are more likely to be rated as Parasuicidal Pauses and Parasuicidal Gestures, it would be clinical valuable to specifically target at-risk females with low-level psychoeducational intervention, in order to help them communicate their distress more effectively.

In terms of the implications for age, the outcomes of the present study support the notion that age may impact on the level of suicide intent. Therefore, it is recommended that considering age in the assessment of suicide attempts is an important factor in the study of suicidal behaviour, as our findings show that specific ages for each gender are deemed to be more “vulnerable” to different levels of suicide intent and should be the focus of suicide prevention strategies.

The differences between countries regarding the association between gender and type of suicide intent that is presented here expose potential cross-cultural differences, which may have possible implications for the transferability of interventions. Further to this, the outcome that cultural influences play an important role in the gender paradox of suicidal behaviour has significant implications for research and for public policy makers.

The other finding from the current study which shows that even within the most frequently used method of attempted suicide, males report a higher level of suicide intent than females, also has significant implications for prevention efforts. Mental health promotion initiatives, such as public health strategies, should target “at-risk” groups, which may contribute to reducing suicide in general, but also to narrowing the gender imbalance in suicidal behaviours.


The findings presented here have clinical and practical implications which may guide future practice such as assisting national policy makers and health services in identifying vulnerable groups. In terms of assessment and intervention strategies, the use of a validated and reliable instrument to the assess level of suicide intent is likely to be beneficial to use in assessments in clinical practice to help guide and manage treatment strategies, and may also serve as a valuable basis to assess the future risk of the patient. Further insight into this area is the first step to understanding the meaning that these suicidal patients ascribe to their suicidal behaviour. Finally, our findings also shed some light on the gender paradox that exists in the incidence of suicide attempts and completed suicides by identifying the complex differences in suicide intent between males and females who attempt suicide. Considering the gender differences in suicidal intent highlighted by the study, targeted preventive interventions are warranted.


Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study. 2010. Lancet. 2012;380:2095–128.

2. Eurostat. Death due to suicide (1999–2010). Accessed 21 Sept 2014.

3. OECD iLibrary. Economic, Envieronmental and social statistics. Accessed 23 Sept 2014.

4. World Health Organisation. Preventing suicide. A global imperative. Geneva: World Health Organization. 2014;92.

5. O'Loughlin S, Sherwood J. A 20-year review of trends in deliberate self-harm in a British town, 1981-2000. Soc Psychiatry Psychiatr Epidemiol. 2005:446–53.

6.Canetto SS, Sakinofsky I. The Gender Paradox in Suicide. Suicide Life Threat Behav. 1998;28:1–23.

7. Schrijvers DL, Bollen J, Sabbe BGC. The gender paradox in suicidal behaviour and its impact on the suicidal process. J Affect Disord. 2012;138:19–26.

8. Cibis A, Mergl R, Bramesfeld A, Althaus D, Niklewski G, Schmidtke A, et al. Preference of lethal methods is not the only cause for higher suicide rates in males. J Affect Disord. 2012;136:9–6.

9. Värnik A, Kõlves K, Feltz-Cornelis CM, Marusic A, Oskarsson H, Palmer A, et al. Suicide methods in Europe: a gender-specific analysis of countries participating in the “European Alliance Against Depression”. J Epidemiol Community Health. 2008;62:545–51.

10. Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, et al. ESEMeD/MHEDEA 2000 Investigators, European Study of the Epidemiology of Mental Disorders [ESEMeD] project. Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders [ESEMeD] project. Acta Psychiatr Scand Suppl. 2004:21–7.

11. Qin P, Agerbo E, Westergard-Nielsen N, Eriksson T. Gender differences in risk factors for suicide in Denmark. Br J Psychiatry. 2000;177:546–50.

12. Tóth MD, Ádám S, Birkás E, Székely A, Stauder A, Purebl G. Gender differences in deliberate self-poisoning in Hungary analyzing the effect of precipitating factors and their relation to depression. Crisis. 2014;5(3):145–53.

13. Hasley JP, Ghosh B, Huggins J, Bell MR, Adler L, Shroyer LW. A review of “Suicide intent” within the existing suicide literature. Suicide Life Threat Behav. 2008;38(5):576–91.

14. Suominen K, Isometsä E, Ostamo A, Lönnqvist J. Level of suicide intent predicts overall mortality and suicide after attempted suicide: a 12-year follow-up study. BMC Psychiatry. 2004;4:1–7.

H15. arriss L, Hawton K, Zahl D. Value of measuring suicide intent in the assessment of people attending hospital following self-poisoning or self-injury. Br J Psychiatry. 2005;186:60–6.

16. Hawton K. Sex and suicide. gender differences in suicidal behaviour. Br J Psychiatry. 2000;144:484–5.

17. Hawton K, Fagg J. Suicide, and other causes of death, following attempted suicide. Br J Psychiatry. 1988;152:359–66.

18. Denning D, King D, Cox C. Method choice, intent, and gender in completed suicide. Suicide Life-Threat Behav. 2000;30:282–8.

19. Moscicki EK. Gender differences in completed and attempted suicides. Ann Epidemiol. 1994;4:152–8.

20. Strosahl K, Chiles JA, Linehan M. Prediction of suicide intent in hospitalized parasuicides: Reasons for living, hopelessness, and depression. Compr Psychiatry. 1992;33:366–73.

21. Kumar CTS, Mohan R, Ranjith G, Chandrasekaran R. Gender differences in medically serious suicide attempts. A study from South India. Psychiatry Res. 2006;144:79–86.

22. Aghanwa H. The determinants of attempted suicide in a general hospital setting in Fiji Islands: a gender-specific study. Gen Hosp Psychiat. 2004;1:63–9.

23. Hegerl U, Wittenburg L, Arensman E, Van Audenhove C, Coyne JC, McDaid D, et al. Optimizing suicide prevention programs and their implementation in Europe [OSPI Europe]: an evidence-based multi-level approach. BMC Pub Health. 2009;23:1–8.

24. Hegerl U, Wittman M, Arensman E, Audenhove C, Bouleau JH, Feltz-Cornelis C, et al. The European Alliance Against Depression [EAAD]: a multifaceted, community-based action programme against depression and suicidality. World J Biol Psychiatry. 2008;9:51–9.

25. Hegerl U, Rummel-Klue C, Värnik A, Arensman E, Koburger N. Alliances against depression - A community based approach to target depression and to prevent suicidal behaviour. Neurosci Biobehav Rev. 2013:2404–9.

26. Värnik P, Sisask M, Värnik A, Laido Z, Meise U, Ibelshäuser A, et al. Suicide registration in eight European countries: a qualitative analysis of procedures and practices. Forensic Sci Int. 2010;202(1–3):86–92.

27. van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, Volker D, Roskar S, Grum AT, et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. Crisis. 2011;32:319–33.

28. Maloney J, Pfuhlmann B, Arensman E, Coffey C, Gusmão R, Poštuvan V, et al. Media recommendations on reporting suicidal behaviour and suggestions for optimisation. Acta Psychiatr Scand. 2013;128:314–5.

29. Platt S, Bille-Brahe U, Kerkhof A, Schmidtke A, Bjerke T, Crepet P, et al. Parasuicide in Europe I. Introduction and preliminary analysis for 1989. Acta Psychiatr Scand. 1992;85:97–104.

30. Feuerlein W. Selbstmordversuch oder parasuizidale Handlung? Tendenzen suizidalen Verhaltens. Nevenartz. 1971;3:127–30.

31. Hjelmeland H, Nordvik H, Bille-Brahe U. A cross cultural study of suicide intent in parasuicide patients. Suicide Life-Threat Behav. 2000;30:295–303.

32. Nordentoft M, Branner J. Gender differences in suicide intent and choice of method among suicide attempters. Crisis. 2008;29:209–12.

33. Rapeli CB, Botega NJ. Clinical profiles of serious suicide attempters consecutively admitted to a university-based hospital: a cluster analysis study. Rev Bras Psiquiatr. 2005;27:285–9.

34. Dyer JA, Kreitman N. Hopelessness, depression and suicide intent in parasuicide. Br J Psychiatry. 1984;144:127–3.

35. Hamdi E, Amin Y, Mattar T. Clinical correlates of intent in attempted suicide. Acta Psychiatr Scand. 1991;83:406–11.

36. Lewinsohn PM, Rohde P, Seeley JR, Baldwin CL. Gender differences in suicide attempts from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry. 2001;40:427–34.

37. Wunderlich U, Bronisch T, Wittchen HU, Carter R. Gender differences in adolescents and young adults with suicidal behaviour. Acta Psychiatr Scand. 2001;104:332–9.

38. Michel K, Valach L, Waeber V. Understanding deliberate self-harm: the patients’ views. Crisis. 1994;15:172–8.

39. ames D, Hawton K. Overdoses: explanations and attitudes in self-poisoners and significant others. Br J Psychiatry. 1985;146:481–5.

40. Boergers J, Spirito A, Donaldson D. Reasons for adolescent suicide attempts. Associations with Psychological Functioning. J Am Acad Child Adolesc Psychiat. 1998;37:1287–3.

41. Hjelmeland H, Hawton K, Bille-Brahe U, De Leo D, Fekete S, Grad O, et al. Why people engage in parasuicide: a cross-cultural study of intentions. Suicide Life Threat Behav. 2002;32:380–93.

42. Haw C, Casey D, Holmes J, Hawton K. Suicidal intent and method of self-harm: a large-scale study of self-harmpatients presenting to a General Hospital. Suicide Life Threat Behav. 2015; [Epub ahead of print]

43. Möller-Leimkühler A. The gender gap in suicide and premature death or: why are men so vulnerable? Eur Arch Psychiatry Clin Neurosci. 2003;253:1–8.

44. Pallis DJ, Sainsbury P. The value of assessing intent in attempted suicide. Psychol Med. 1976;6:487–92.

45. Niméus A, Alsén M, Traskman-Bendz L. High suicidal intent scores indicate future suicide. Arch Suicide Res. 2002;66:211–9.

46. Haw C, Hawton K. Life problems and deliberate self-harm: associations with gender, age, suicide intent and psychiatric and personality disorder. J Affect Disord. 2008;109:139–48.

47. Beck AT, Schuyler D, Herman I. Development of suicidal intent scales. In: Beck AT, Resnik HLP, Lettieri DJ, editors. The prediction of suicide. Charles Press: Philadelphia; 1974. p. 45–56.

48. Dorpat T, Boswell J. An evaluation of suicide intent in suicide attempts. Compr Psychiatry. 1963;4:117–5.

49. Cooper J, Steeg S, Bennewith O, Lowe M, Gunnell D, House A, et al. Are hospital services for self-harm getting better? An observational study examining management, service provision and temporal trends in England. BMJ. 2013;3:1–9.

50. National Institute for Health and Clinical Excellence. The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. 2004. Clinical Guideline 16.


Gender differentiation in methods of suicide attempts



Suicide is an important public health problem worldwide, especially due to an increasing rate of suicides committed by violent methods. This study compared and assessed the methods used in suicide attempts (but no completed suicides) as undertaken by men and women and investigated the possible role of gender in the selection of suicide method.


The most prevalent methods of suicide attempts were pharmacological drugs abuse (42.31%) and exsanguination (25.64%), and the least frequent were poisoning and throwing oneself under a moving car (1.28%). The findings revealed that the female subjects tended to choose pharmacological drugs overdose and exsanguination as the suicide method, while males more frequently used hanging and asphyxia. Females also used a greater number of different suicide methods.


The study results indicate that women as a group more frequently attempted suicide rather than actually committing it, whereas men were more likely to complete suicides and choose more violent suicide methods; thus, women are the “attempters” and “survivors” of suicide attempts. The study findings may have implications for therapy and prevention of suicide, and suggest that psychotherapeutic activities should be tailored to the psychological and personality traits associated with gender identity.


Suicidal behaviours are a serious public health problem worldwide. In the individual perspective, suicide is a manifestation of the person’s suffering, and in the interpersonal and social perspective it is not only a tragedy and a loss for a family and close friends, but also a loss of a community member and of the possible benefits which the person could have brought to the society. Suicide is among the 5 major causes of death in young people [1]. Suicides in general are one of the leading causes of death worldwide, with suicide-related mortality approximating 2% and the attempted suicide being a major risk factor for suicide completion [2]. The number of suicides has been increasing around the world, especially among young persons and adult males. According to present estimates, suicide is the third cause of death among young people [3,4]. Moreover, violent methods of suicide such as hanging have been on the increase, suggesting that these more lethal methods contribute to the higher rate of suicide risk [5]. Some of the personality traits that were identified after suicide attempts included anger, aggression, and temperament/character [2]. The factors contributing to suicide attempts are feelings of helplessness and hopelessness [6], but also include alienation and being misunderstood by others [7]. A nonfatal suicide attempt is among the strongest clinical predictors of a completed suicide, which is reflected by the recurrence of suicide attempts [8].

Literature data suggest that suicide attempts are more frequently undertaken by women, whereas men are more often the performers of effective (lethal, fatal) suicides [3,4,9]. However, there are only a few reports on the methods applied by males and females in suicide attempts. In view of the scarcity of such data, the aim of the present study was to assess the differences in the methods used by Polish men and women who attempted suicides and were hospitalised thereafter.

Material and Methods

This study was conducted among persons who attempted suicide by various methods and were admitted to hospital for this reason. The study population comprised 147 participants (33 males and 114 females) aged between 14 and 33 years. The subjects received treatment (pharmacology and psychotherapy) at mental health centres (in- or out-patient clinics) due to suicide attempt. The hospitalization was voluntary. Neither of the subjects was diagnosed with psychotic disorders or mental retardation.

The examination was anonymous and the participation was voluntary. The study objectives formulated as an effective help for persons in difficult life situations as well as an important research problem for effective prevention were presented to the subjects, and they expressed consent to participate, according to the Helsinki Declaration, prior to the study. There were no refusals. Permission to carry out the examinations was obtained from the health centre management. The examinations were performed using a structured, self-reported questionnaire developed by the authors, as well as the medical records of the subjects. The researchers were present during the examination to help the respondents with the questionnaire items if necessary.

For the statistical analysis, the chi-square test (chi2, ?2) and Mann-Whitney “U” test were used. Values were expressed as mean ±SD, and p=0.05 was considered significant. The calculations were performed using Statistica PL 8.0 for Windows[10].


Table 1 shows the demographic characteristics of the study population. Table 2 and Figure 1 present the methods used by males and females in suicide attempts.

An external file that holds a picture, illustration, etc.

Object name is medscimonit-17-8-PH65-g001.jpg

Open in a separate window

Figure 1

Suicide attempt methods in the study population.

Table 1

Study population characteristics.

Variable n %

Gender Female 114 77.55

Male 33 22.45

Age x±SD 19.37 (5.40)

Range 14–33

Educational level (participants) Elementary 87 59.18

Vocational 3 2.04

Secondary 51 34.69

University 6 4.09

Educational level (parents) Elementary 50 20.58

Vocational 60 24.69

Secondary 98 40.33

University 35 14.40

Family socieconomic status High 45 30.61

Average 72 48.98

Low 30 20.41

Family structure Complete family 81 55.10

One-parent family 51 34.70

Reconstructed family 15 10.20

Residency Urban 93 63.27

Rural 54 37.73

Open in a separate window

Table 2

Suicide attempt methods in the study population.

Suicide attempt method Total Females Males

n % n % n %

1. Pharmacological drugs abuse 99 42.31 87 87.88 12 12.12

2. Exsanguination 60 25.64 54 90.00 6 10.00

3. Hanging 39 16.67 18 46.15 21 53.85

4. Jumping from a height 21 8.97 18 85.71 3 14.29

5. Asphyxia 9 3.85 3 33.33 6 66.66

6. Poisoning 3 1.28 3 100.00 0 0

7. Throwing oneself under a car 3 1.28 3 100.00 0 0

Total 234 100.00 186 79.49 48 20.51

Open in a separate window

(Females-Males) Chi-square=929.750, df=6, p<0.001

As revealed by the study results, the subjects used several different methods when attempting suicide. These included pharmacological drugs abuse, exsanguination, hanging, jumping from a height, asphyxia, poisoning and throwing oneself under a moving car.

The most prevalent suicide methods are pharmacological drugs abuse (42.31%) and exsanguination (25.64%), while the least frequent are poisoning and throwing oneself under a moving car (1.28%). As revealed the chi-square of 929.750 with 6 degrees of freedom (p<0.001), the proportions of observations in the contingency table vary. Asphyxia, poisoning, and throwing oneself under a car are infrequent. The predominant methods of committing suicide differ considerably from those reported in other studies, i.e. hanging or poisoning [11–15]. In the study population, the use of firearms as the suicide method was not found.

Table 3 displays the results of a comparative analysis of the methods used in suicide attempts by male and female subjects (Mann-Whitney U-test).

Table 3

Comparison of suicide methods as used by females and males.

Suicide attempt method Females Males Significance

Sum of ranks Mean rank Sum of ranks Mean rank U Z p

Pharmacological drugs abuse 9187.500 80.59 1690.500 51.23 1129.500 4.29524 p<0.001

Exsanguination 8985.000 78.82 1893.000 57.36 1332.000 2.99388 p<0.001

Hanging 7756.500 68.04 3121.500 94.59 1201.500 -4.12517 p<0.001

Jumping from a height 8562.000 75.11 2316.000 70.18 1755.000 0.96510 ns.

Asphyxia 8143.500 71.43 2734.500 82.86 1588.500 -3.27011 p<0.001

Poisoning 8485.500 74.43 2392.500 72.50 1831.500 0.93834 ns.

Throwing oneself under a car 8485.500 74.43 2392.500 72.50 1831.500 0.93834 ns.

Number of suicide attempt methods 8833.500 77.49 2044.500 61.95 1483.500 2.10427 p<0.05

Open in a separate window

Statistically significant differences refer to pharmacological drugs overdose and exsanguination (females) as well as to hanging and asphyxia (males) (Table 3, Figure 1). Furthermore, females obtained a significantly higher score with respect to the total number of suicide methods.

For comparison, it is worth reporting the data on suicide rates in Poland during the study period. In 2005, the total rate of completed suicides was 15.2 (per 100 000 population), the rate for males being 26.8 and for females 4.4 [16]. In 2008, the respective rates were 14.9, 26.4 and 4.1. [17]. These values point to males as the group more frequently committing suicides.


As evidenced by the study results, suicide attempts conducted by females are over 3 times as frequent as those pertaining to males. Females also show a higher creativity in selecting the modes of committing suicide. However, despite the considerably larger number of suicide attempts and the number of women making such attempts, the females are less frequently the victims of fatal suicides, which indicate that they tend to be the “attempters” and “survivors” rather than “performers” of suicides. This finding may be associated with many factors, amongst which the mode of suicide attempt seems to be important.

In the present study, the modes of committing suicide are distinctly different from those found in other reports, i.e. hanging or poisoning [11–15]. In the cases of suicidal death, the most prevalent suicide methods were hanging (36.90%) [18] and poisoning [15]. However, the studies mentioned above focused on completed suicides, not the suicide attempts. Furthermore, most of the methods reported in the present study are characterized by so-called softness, low effectiveness and “feminine” rather than “masculine” attributes. Some authors presume that women “prefer” the means of lower effectiveness, like exsanguinations or abuse of hypnotics, while men tend to use more violent methods like firearms or jumping from a height [11,19].

In the present study, the use of firearms in suicide attempt was not found, perhaps due to a severely restricted accessibility to the firearms in Poland, which may point to the role of cultural and legislative specificity [cf. 20]. Keeping firearms at home may be a suicide risk factor, e.g. suicide attempt within the preceding year was common among the participants from the US who reported that they currently lived in a home where firearms was kept [21,22].

Suicides: Males & females

World-wide, men commit 2–3 times more suicides than women do, but women make more suicide attempts, which is called the “gender paradox” in suicides [3,9,15,23,24]. This paradox was also seen in our study results.

The gender paradox does not depend on age, and more girls (10.4%) than boys (6.0%) reported a previous suicide attempt. Among girls, the higher level of risk factors may account for a higher level of self-reported nonfatal suicidal behaviour [25]. The completed suicide, i.e. suicidal death, is more common among males, but the attempted suicide is more common among females (3 times more for each gender) [26–28]. The study populations in almost all the studies on attempters consist of a greater number of women than men, and the female to male ratio is 3.1:1.0 [18,24]. In our study the ratio is similar: 3.45:1.0. Although 62% of women who committed suicide had made previous suicide attempts, 62% of men who committed suicide had not previously made such an attempt [28]; therefore, women are more likely to attempt suicide while men are more likely to commit it [15,29]. This is consistent with our findings – women reported undertaking more suicide attempts than men did. Thus, the recurrence of suicide attempts may be a predicting factor of suicide completion among women, but not among men. Some studies suggest the seasonality of suicide attempts in females, but not in males [30].

Suicide methods: Males & females

Some authors suggest that this “less effectiveness” of suicide attempts undertaken by women may be associated with the methods of these attempts. Suicide attempts made by males more frequently required intensive care and involved a higher risk of death [24], which reflects the more death-oriented intentions of the male attempters.

When analysing the gender differences in suicide attempts worldwide, we need to consider the factors related to the culture and tradition. For instance, in a study performed in India, the most favoured suicide method among males and females was hanging (36.9%) followed by poisoning (34.7%). Male dominance was apparent for each method of suicide except for self-immolation. Males were relatively more likely to use hanging (as in the present study) and poisoning, while females preferred drowning and self-immolation as the methods of suicide [18]. In India, the ritual self-immolation of widows (“sati”, which means “good wife” in Sanskrit) has a long tradition; therefore, it is not surprising that this suicide method was more frequently chosen by women.

The gender-related differences in the methods of suicide attempts were also noted among the patients with psychopathological conditions: male patients with psychotic or substance-related disorders preferred hanging, while female patients with similar conditions chose self-poisoning [31]. The results of our study are similar, although the participants were not diagnosed with psychotic disorders.

As mentioned above, the availability of the means is one of the most important factors for suicidal behaviour [27]. A retrospective study was conducted which analysed post-mortem data on 164 firearm-related casualties. The most common manner of death was suicide (60.4%) and most of the victims were males. The entry wounds were primarily located in the head (right temple) and chest (precordium) [32]. In our study, no suicide attempts by using firearms were found, probably because the accessibility to firearms in Poland is very restricted.

Worth mentioning is a neglected factor that contributes to the gender suicide ratio – the wound site or the area of the body that is wounded in firearm suicides. Males may have a higher rate of suicides by firearms partially due to their greater likelihood than women for shooting themselves in the head as opposed to the body. This has been related to gender differences in fear of facial disfigurement and suicide intent. Data from 807 suicides committed with firearms revealed that women were 47% less apt than men to shoot themselves in the head as well as use shotguns and rifles in their suicides (weapons that make head shooting awkward). The findings are consistent with the assumption that women are more concerned than men about facial disfigurement, and that women have a lower desire to die than men [33]. At this point one can see gender conditioning resulting not only from the psychopathology or suicidology, but also from psychology – women, even in the face of death (or only an attempt), are concerned with aesthetics and their own appearance.

The “Gender Paradox” Explained (?)

The finding that males have higher suicide rates than females is one of the best empirically documented social facts in suicidology, but the underlying reasons continue to be debated; maybe women have a lower desire to die than men do (cf. above) [33].

Major depression forms the background of more than half of all suicides. Women are twice as likely as men to experience major depression, yet women are one fourth as likely as men to take their own lives. One of the possible explanations to this paradox may be that men highly value independence and decisiveness, and they regard acknowledging a need for help as a weakness and avoid it. Women appreciate interdependence, and they consult friends and readily accept help. They consider decisions in the context of a relationship, take many things into consideration, and they feel freer to change their minds [34,35].

The explanation of the gender-related differences in suicide attempts is based on Breed’s 5 “components of a basic suicide syndrome”, which appears to be a satisfactory model for explaining male suicide. The same factors affect the sexes differently, but the content and structure of the roles are different. Failure is obvious for males, but the female role is diffuse and lacking in standards for both the success and failure [36].

Some theories try to explain the gender paradox in suicidal behaviour. The first one is related to the method: men tend to use violent methods that are more lethal. The second one is about the differences in the prevalence of depression and alcohol abuse between the genders. It also includes the fact that women more frequently seek treatment, and this may prevent suicide. The socialisation theory suggests that both genders tend to adopt self-destructive behaviours according to their cultural backgrounds; therefore, suicide attempts (but not necessarily the committed suicides) would be “more acceptable” among females [24,35,37].

The higher rate of suicide attempts among women is probably related to the fact that depression occurs more frequently in this group, whereas the higher rate of suicidal death among men is probably associated with the choice of the method. Women prefer less ultimate means, such as exsanguination and abuse of hypnotics, while men are apt to use firearms or jump from a height [19]. In other words, males prefer more lethal methods (e.g. hanging) while the methods favoured by females tend to be less lethal (e.g. overdose). Furthermore, women may intentionally use less lethal suicide methods to draw attention to their situation, and do not intend to die. Males are more prone to aggressive, antisocial and externalising behaviours – they are likely to make more impulsive, lethal, active and determined suicide attempts [29]. In addition, nonfatal suicidal behaviour (e.g. suicidal ideation and nonfatal attempts) is associated with “femininity” and that of killing oneself is considered “masculine” and “powerful” as a rational response to adversity. Therefore, due to social pressure, males may be protected against nonfatal suicidal behaviour, but are more likely to resort to more lethal means of suicide in order to reduce the likelihood of surviving [38].

The suicide attempts conducted by males more frequently needed intensive care and involved a higher risk of death. A possible explanation for this is that aggressive behaviour and alcohol abuse might mask the depression symptoms among men. A cultural bias should then be considered: men could have more difficulties admitting that they have problems that indicate “weakness” [24]. The inverse is also probable – alcohol abuse, especially alcohol addiction, may cause major depression episodes with lethal suicide attempts, often committed during alcohol intoxication.

Searching for treatment, among other things, may protect women from a fatal suicidal behaviour. They also tend to perceive problems as personal and seek help at health care institutions. The males usually see their distress as a result of economic or social problems, they deny that they have depression, and tend to abuse alcohol. One could also assume that they perceive survival after a suicidal attempt as a failure, since suicide seems to be a more “masculine” behaviour [24,35,38].


The implications of the findings in this work primarily apply to prevention and therapy.

When analysing the therapeutic aspect, it is essential to consider indirect self-destructive tendencies and behaviours, especially the passive ones (neglect) [20]. The evidence for this was provided by a 10-year follow-up of adolescents after suicide attempts – it was found that 70.50% of them stated that they were happy [39]. Moreover, optimistic reframing of negative life events for the patients may have therapeutic implications for the prevention of suicidal activity [40], since it is well known that pessimism is one of the suicide risk factors [41].

Thus, neither suicide attempt itself, nor suicide attempt method, erase the possibility of leading a happy life, and that is why it is worth offering such persons this kind of help and motivating them to take the chance. It seems to be important to tailor the (psycho) therapeutic activities to the psychological and personality traits associated with gender identity.

An answer to the question of how many of suicide attempts were desperate “crying for help”, especially among women, and how many of suicide attempts were actual suicide intensions, may be the subject of further research [cf. 20].


1. Omigdobun OO, Adejumo OA, Babalola OO. Suicide attempts by hanging in preadolescent children: a case series. West Afr J Med. 2008;27(4):259–62. [PubMed] [Google Scholar]

2. Giegling I, Olgiati P, Hartman AM, et al. Personality and attempted suicide. Analysis of anger, aggression and impulsivity. J Psychiatr Res. 2009;43(16):1262–71. [PubMed] [Google Scholar]

3. WHO. Figures and facts about suicide. Geneve: World Health Organisation; 1999. [Google Scholar]

4. WHO. Mental health and development Targeting people with mental health condition as a vulnerable group. Geneve: World Health Organisation; 2010. [Google Scholar]

5. Largey M, Kelly CB, Stevenson M. A study of suicide rates in Northern Ireland 1984–2002. Ulster Med J. 2009;78(1):16–20. [PMC free article] [PubMed] [Google Scholar]

6. Polewka A, Chrostek-Maj J, Kroch S, et al. Sense of coherence and risk of suicide attempt. Przeg Lek. 2001;4:335–39. [in Polish] [PubMed] [Google Scholar]

7. Pluzek Z. In: Czlowiek-Wartosci-Sens. Popielski K, editor. Lublin: KUL; 1996. pp. 371–80. [in Polish] [Google Scholar]

8. Tsirigotis K, Gruszczynski W, Kruszyna M. [Indirect self-destructiveness in persons after suicide attempts]. Suicydologia. 2008;IV:57–62. [in Polish] [Google Scholar]

9. Pietro D, Tavares M. Risk factors for suicide and suicide attempt: incidence, stressful events and mental disorders. J Bras Psiquitr. 2005;54(2):146–54. [Google Scholar]

10. StatSoft Polska. Statistica PL. Kraków: StatSoft; 2007. [Google Scholar]

11. Holyst B. [Suicide – Accident or necessity]. Warszawa: PWN; 1983. [in Polish] [Google Scholar]

12. Chambers D. Reach Out: Ireland’s National Strategy for Action on Suicide Prevention. Suicydologia. 2007;III:12–17. [Google Scholar]

13. Jarosz M. [Suicides in the 3rd Republic of Poland in the world perspective. Sociological analysis]. Suicydologia. 2005;1(1):1–13. [in Polish] [Google Scholar]

14. Araszkiewicz A, Pilecka E. [Extended suicides compared with general suicides cases in Poland in 1991–2005]. Suicydologia. 2006;2(1):69–75. [in Polish] [Google Scholar]

15. Runeson B, Tidemalm D, Dahlin M, et al. Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study. BMJ. 2010;340:c3222. [PMC free article] [PubMed] [Google Scholar]

16. WHO. Highlights on health in Poland 2005. World Health Organisation; 2006. [Google Scholar]

17. GUS-Central Statistical Office. Concise Statistical Yearbook of Poland. 2010. [Google Scholar]

18. Kanchan T, Menon A, Menezes RG. Methods of choice in completed suicides; gender differences and review of literature. J Forensic Sci. 2009;54(4):938–42. [PubMed] [Google Scholar]

19. Seligman MEP, Walker E, Rosenhan DL. Abnormal Psychology. 4th ed. New York: WW Norton; 2001. [Google Scholar]

20. Tsirigotis K, Gruszczynski W, Tsirigotis-Woloszczak M. Indirect (Chronic) Self-Destructiveness and Modes of Suicide Attempts. Archives of Medical Science. 2010;6(1):111–16. [PMC free article] [PubMed] [Google Scholar]

21. Miller M, Barber C, Azrael D, et al. Recent psychopathology, suicidal thoughts and suicide attempts in householdswith and without firearms: findings from the National Comorbidity Study Replication. Inj Prev. 2009;15(3):183–87. [PubMed] [Google Scholar]

22. Ohberg A, Lonnqvist J, Sarna S, et al. Violent methods associated with high suicide mortality among the young. J Am Acad Child Adolesc Psychiatry. 1996;35:144–53. [PubMed] [Google Scholar]

23. Canetto SS, Sakinofsky I. The gender paradox in suicide. Suicide Life Threat Behav. 1998;28(1):1–23. [PubMed] [Google Scholar]

24. Stefanello S, da Silva Cais CF, Mauro MLF, et al. Gender differentiation in suicide attempts: preliminary results of the multisite intervention study on suicidal behavior (SUPRE-MISS) from Campinos, Brasil. Rev Bras Psiquiatr. 2008;30(2):139–43. [PubMed] [Google Scholar]

25. Wichstrøm L, Rossow I. Explaining the gender difference in self-reported suicide attempts. A natonally representative study in Norwegian adolescents. Suicide Life Threat Beh. 2002;32(2):101–16. [PubMed] [Google Scholar]

26. Gould MS. Suicide risk among adolescents. In: Romer D, editor. Reducing Adolescent Risk: Toward an Integrated Approach. Thousand Oaks: Sage Publications; 2003. pp. 303–20. [Google Scholar]

27. Hawton K, van Heeringen K. Suicide. Lancet. 2009;373( 9672):1372–81. [PubMed] [Google Scholar]

28. Isometsa ET, Lonnqvist JK. Suicide attempts preceding completed suicide. Br J Psychiatry. 1998;173:531–35. [PubMed] [Google Scholar]

29. Beautrais AL. Gender issues in youth suicidal behavior. Emergency Medicine. 2002;14:35–42. [PubMed] [Google Scholar]

30. Mergl R, Havers I, Althaus D, et al. Seasonality of suicide attempts: association with gender. Eur Arch Psychiatry Clin Neurosci. 2010;260(5):393–400. [PubMed] [Google Scholar]

31. Huisman A, van Houwelingen CA, Kerkhof AJ. Psychopathology and suicide method in mental health care. J Affect Disord. 2010;121(1–2):94–99. [PubMed] [Google Scholar]

32. Verzeletti A, Astorri P, De Ferrari F. Firearm-related deaths in Brescia (Northern Italy) between 1994 and 2006: a retrospective study. J Forensic Leg Med. 2009;16(6):325–31. [PubMed] [Google Scholar]

33. Stack S, Wasserman J. Gender and suicide risk: the role of wound site. Suicide Life Threat Behav. 2009;39(1):13–20. [PubMed] [Google Scholar]

34. Murphy GE. Why women are less likely than men to commit suicide. Comprehensive psychiatry. 1998;39(4):165–75. [PubMed] [Google Scholar]

35. Tsirigotis K, Gruszczynski W. Psycho(patho)logical functioning of Adult Children of Alcoholics (ACoAs), outpatients of Mental Health Clinic. Clinical and Experimental Medical Letters. 2009;50(2):81–88. [Google Scholar]

36. Wilson M. Suicidal behavior: toward an explanation of differences in female and male rates. Suicide Life Threat Behav. 1981;11(3):131–40. [PubMed] [Google Scholar]

37. Canetto SS. Gender and suicidal behavior: Theories and evidence. In: Maris RW, Silverman MM, Canetto SS, editors. Review of suicidology. New York: Guilford; 1997. pp. 138–67. [Google Scholar]

38. Canetto SS. Meanings of gender and suicidal behavior during adolescence. Suicide Life Thraet Behav. 1997;27(4):339–51. [PubMed] [Google Scholar]

39. Géhin A, Kabuth B, Pichené C, Vidailhet C. Ten Year Follow-up Study of 65 Suicidal Adolescents. J Can Acad Child Adolsc Psychiatry. 2009;18(2):117–25. [PMC free article] [PubMed] [Google Scholar]

40. Hirsch JK, Woldorf K, Lalonde SM, et al. Optimistic explanatory style as a moderator of the association between negative life events and suicide ideation. Crisis. 2009;30(1):48–53. [PubMed] [Google Scholar]

41. Seligman MEP. What You Can Change and What You Cannot. New York: Knopf; 1994. [Google Scholar]


Characteristics of persons who die on their first suicide attempt: results from the National Violent Death Reporting System


Background: Much of suicide research focuses on suicide attempt (SA) survivors. Given that more than half of the suicide decedent population dies on their first attempt, this means a significant proportion of the population that dies by suicide is overlooked in research. Little is known about persons who die by suicide on their first attempt-and characterizing this understudied population may improve efforts to identify more individuals at risk for suicide.

Methods: Data were derived from the National Violent Death Reporting System, from 2005 to 2013. Suicide cases were included if they were 18-89 years old, with a known circumstance leading to their death based on law enforcement and/or medical examiner reports. Decedents with and without a history of SA were compared on demographic, clinical, and suicide characteristics, and circumstances that contributed to their suicide.

Results: A total of 73 490 cases met criteria, and 57 920 (79%) died on their first SA. First attempt decedents were more likely to be male, married, African-American, and over 64. Demographic-adjusted models showed that first attempt decedents were more likely to use highly lethal methods, less likely to have a known mental health problem or to have disclosed their intent to others, and more likely to die in the context of physical health or criminal/legal problem.

Conclusions: First attempt suicide decedents are demographically different from decedents with a history of SA, are more likely to use lethal methods and are more likely to die in the context of specific stressful life circumstances.

Keywords: First suicide attempt; suicide; violent death.

MeSH terms

  • Adolescent
  • Adult
  • Age Distribution
  • Aged
  • Aged, 80 and over
  • Cause of Death
  • Female
  • Firearms*
  • Health Status*
  • Humans
  • Law Enforcement*
  • Logistic Models
  • Male
  • Middle Aged
  • Population Surveillance*
  • Sex Distribution
  • Suicide / statistics & numerical data*
  • Suicide / trends
  • Suicide, Attempted / statistics & numerical data
  • Suicide, Attempted / trends
  • United States / epidemiology
  • Young Adult
  • Related information
  • MedGen


Method Choice and Intent

It is intuitive to think that those who attempt suicide and live were less intent on dying than those who died by suicide. While seriousness of intent plays a role in severity of attempt and choice of suicide method (means), the relationship is not a straight-forward one. Many studies (some described below) find little relationship between intent and medical severity or between intent and choice of method. Other studies, however, do find a relationship (e.g., Townsend 2001, Hamdi 1991, Harriss 2005). Dating back twenty years. One reason for the mixed results is that other factors also play a role, such as the availability and acceptability of methods and attempters’ knowledge of the likely lethality of a given method. Many people who attempt suicide have inflated expectations about the lethality of common methods like poisoning and cutting.

  • Thirty patients who attempted suicide with motor vehicle exhaust were interviewed (Skopek 1998). Reasons given for choosing the method included availability, painlessness, and lethality. Suicide intent scores were not high, which was inconsistent with most patients being aware that the method was highly lethal. Relationship problems were the most frequent precipitating circumstance. Most attempters regretted the attempt. Survival was due largely to failure of the method or unexpected discovery rather than to patient factors.
  • Sixty patients presenting to a large urban medical center for a suicide attempt completed questionnaires measuring the seriousness of their suicidal intent and other factors (Plutchik 1988). No relationship was found between level of intent and medical seriousness of the attempt.
  • Among 268 self-poisoning patients in rural Sri Lanka, 85% cited easy availability as the basis for their choice of poison (Eddelston 2006). Patients had little knowledge about the lethality of the poison they chose. There was no evidence that attempters who used highly toxic poisons were more serious or deliberative in their attempt than those using less toxic poisons.
  • Patients’ expectation of the lethality of their attempt (as measured by the Beck Suicidal Intent Scale item 11) was not associated with observed medical severity in a sample of 173 attempters treated in an urban emergency department (Brown 2004). Only 38% of the patients were accurate in their expectations regarding severity; 32% were inaccurate, and 29% did not know whether what they did was likely to be lethal.
  • A study of 33 people (mostly young men) who attempted suicide with a firearm and lived found that all used firearms obtained in their homes (Peterson 1985). When asked why a firearm was used, the answer given most often was, “Availability.
  • A Houston study compared nearly-lethal suicide attempts with less-lethal attempts and found that expectation of dying, planning, impulsivity, and taking precautions against discovery were not associated with the medical severity of the attempt (Swahn 2001).

Intent is a complex matter and falls along a continuum. While some attempters are probably at the low end of the spectrum with very little intent to die, and others are at the high end, many fall into an ambivalent middle ground. Still others have high intent but only during a very brief episode. Note: This is why assuming those who filed their attempt have the same level of intent as those who were successful on their first attempt question the assumption that both groups fit under the same MO. I contend that more people, especially men, who die on their first attempt have a higher level of serious intent in the moment and therefore (1) use more effective lethal means to insure the outcome In addition it is not unusual that someone who fails in their first attempt regrets having attempted and are glad they survived. Note survivors who jumped from the Golden Gate Bridge. All of them said they regretted jumping the second they left the bridge. This is not an option to learn from those who died on their first attempt. They don't have the option to reevaluate their decision and present their shift in research. It is these latter two groups for whom reducing easy access to highly lethal methods of suicide is likely to be most effective in saving lives.

More studies – (Intent, Lethality and Method Choice in Suicide Attempts)

  • Brown GK, Henriques GR, Sosdjan D, and Beck AT. Suicide intent and accurate expectations of lethality: predictors of medical lethality of suicide attempts. Journal of Consulting and Clinical Psychology. 2004;72(6):1170-74.
  • Eddleston M, Karunaratne A, Weerakoon M, Kumarasinghe S, Rajapakshe M, Sheriff MH, Buckley NA, Gunnell D.Choice of poison for intentional self-poisoning in rural Sri Lanka.Clin Toxicol (Phila). 2006;44(3):283-6.
  • Hamdi E, Amin Y, and Mattar T. Clinical correlates of intent in attempted suicide. Acta Psychiatr Scand. 1991;83(5):406-11.
  • Harriss L, Hawton K, Zahl D. Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. Brit J Psych. 2005;186:60-66.
  • Peterson L, Peterson M, O’Shanick G, and Swann A. Self-inflicted gunshot wounds: Lethality of method versus intent. American Journal of Psychiatry. 1985;142:228-231.
  • Plutchik R, van Praag HM, Picard S, Conte HR, and Korn M. Is there a relation between the seriousness of suicidal intent and the lethality of the suicide attempt? Psychiatry Resesarch. 1988; 27:71-79.
  • Skopek MA and Perkins R. Deliberate exposure to motor vehicle exhaust gas: the psychosocial profile of attempted suicide. Australian and New Zealand Journal of Psychiatry. 1998;32(6):830-38.
  • Swahn MH and Potter LB. Factors associated with the medical severity of suicide attempts in youths and young adults. Suicide and Life-Threatening Behavior. 2001;32:21-29.
  • Townsend E, Hawton K, Harriss L, Bale E, Bond A. Substances used in deliberate self-poisoning 1985-1997: trends and associations with age, gender, repetition and suicide intent. Soc Psychiatr Epidemiol. 2001;36(5):228-34.


Suicide Attempts and Dying by Suicide - SPRC - 3/10/17

A study found that 59.3 percent of people who died by suicide did so as a result of their first attempt (defined by the study as a first lifetime attempt that resulted in medical attention). If it required medical attention, then did they die, die from suicide, die from medical attention, what did they actually die from and what percent of people die by suicide without receiving any medical attention? The authors suggested that this finding reveals the importance of identifying people at risk before they attempt suicide for the first time. (Do those risk factors difference from the risk factors for people who die on the first attempt? How about by gender?) It also reveals a critical problem of using “prior suicide attempt(then it wouldn't be first aattempt) to identify people at risk of suicide—that is, this method fails to identify approximately 60 percent of the people who die by suicide, since they die as a result of their first attempt.

The study found that 5.4 percent of people who made a first-time suicide attempt requiring medical attention in Olmstead County, Minnesota between 1986 and 2007 died by suicide by 2010—either on their first attempt or on a subsequent attempt. Of the suicide attempters who survived their first attempt, but died as the result of a subsequent attempt, 81.8 percent died within 12 months of their first attempt. The authors suggested that this finding reveals that it is critical to ensure that people who survive a first attempt receive effective intervention immediately following that attempt.

Males made up 76.5 (compare to 59.3 percent in the first line.) percent of those who died by suicide. (Combining all attempts, not use first attempt?) Being male and being older were associated with dying on a subsequent attempt after surviving a first attempt. Among those who died on their first attempt, 72.9 percent used firearms. Very few (1.5 percent) of the people who used firearms on their first attempt survived that attempt. People who used firearms on their first suicide attempt had 140 times the risk of dying on their first attempt than people using other methods.

This research also found that “having a follow-up appointment scheduled on discharge from either the emergency department or an inpatient service, whether or not it was actually kept . . . significantly [reduced] the risk of dying on a subsequent attempt.” The authors noted that only 69.4 percent of people who survived a first attempt had a scheduled follow-up appointment. They suggested that the 30.6 percent of people treated for a suicide attempt and released without a follow-up appointment represents a lost opportunity for preventing suicides.

Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100.

Hopelessness, Depression, and Suicide Intent - JAMA - 9/76


One hundred fifty-four suicide attempters, threateners, and psychiatric controls were rated on suicide intent scales and given tests to assess hopelessness, depression, and self-rated suicide risk. Ninety-four subjects were retested one month later. Both hopelessness and depression were significantly greater in suicidal subjects. In threateners, hopelessness and depression scores differed significantly between high and low suicide intent subjects. In attempters ranked by suicide intent at time of testing, more and less suicidal subjects differed significantly in hopelessness and depression scores. Both depression and hopelessness were sensitive to changes in suicide risk during the one-month follow-up. In all analyses, hopelessness correlated more highly with suicide intent than did depression. The data were regarded as supporting the hypothesis that hopelessness is more closely related to suicide intent than is depression.

Decoding Suicide Decedent Profiles and Signs of Suicidal Intent Using Latent Class Analysis - 3/20/24

Key Points

Question Are there distinct suicide profiles linked to varying signs of suicidal intent and risks?

Findings This cross-sectional study including 306 800 US suicide decedents from 2003-2020 identified 5 suicide profiles or classes: comorbid mental health and substance use disorders; mental disorders alone; crisis, alcohol-related, and intimate partner problems; physical health problems; and polysubstance use. Class 4 (physical health problems) was the largest, exhibiting minimal explicit suicidal intent, rarely detected psychiatric diagnoses, and minimal psychotropic medication use.

Meaning Suicide prevention strategies may be more effective when tailored to different suicide profiles because integrated care enhances the detection and treatment of comorbid mental health conditions, substance and alcohol use disorders, and physical health problems.


Importance Suicide rates in the US increased by 35.6% from 2001 to 2021. Given that most individuals die on their first attempt, earlier detection and intervention are crucial. Understanding modifiable risk factors is key to effective prevention strategies.

Objective To identify distinct suicide profiles or classes, associated signs of suicidal intent, and patterns of modifiable risks for targeted prevention efforts.

Design, Setting, and Participants This cross-sectional study used data from the 2003-2020 National Violent Death Reporting System Restricted Access Database for 306 800 suicide decedents. Statistical analysis was performed from July 2022 to June 2023.

Exposures Suicide decedent profiles were determined using latent class analyses of available data on suicide circumstances, toxicology, and methods.

Main Outcomes and Measures Disclosure of recent intent, suicide note presence, and known psychotropic usage.

Results Among 306 800 suicide decedents (mean [SD] age, 46.3 [18.4] years; 239 627 males [78.1%] and 67 108 females [21.9%]), 5 profiles or classes were identified. The largest class, class 4 (97 175 [31.7%]), predominantly faced physical health challenges, followed by polysubstance problems in class 5 (58 803 [19.2%]), and crisis, alcohol-related, and intimate partner problems in class 3 (55 367 [18.0%]), mental health problems (class 2, 53 928 [17.6%]), and comorbid mental health and substance use disorders (class 1, 41 527 [13.5%]). Class 4 had the lowest rates of disclosing suicidal intent (13 952 [14.4%]) and leaving a suicide note (24 351 [25.1%]). Adjusting for covariates, compared with class 1, class 4 had the highest odds of not disclosing suicide intent (odds ratio [OR], 2.58; 95% CI, 2.51-2.66) and not leaving a suicide note (OR, 1.45; 95% CI, 1.41-1.49). Class 4 also had the lowest rates of all known psychiatric illnesses and psychotropic medications among all suicide profiles. Class 4 had more older adults (23 794 were aged 55-70 years [24.5%]; 20 100 aged =71 years [20.7%]), veterans (22 220 [22.9%]), widows (8633 [8.9%]), individuals with less than high school education (15 690 [16.1%]), and rural residents (23 966 [24.7%]).

Conclusions and Relevance This study identified 5 distinct suicide profiles, highlighting a need for tailored prevention strategies. Improving the detection and treatment of coexisting mental health conditions, substance and alcohol use disorders, and physical illnesses is paramount. The implementation of means restriction strategies plays a vital role in reducing suicide risks across most of the profiles, reinforcing the need for a multifaceted approach to suicide prevention.


Suicide rates in the United States increased by 35.6% from 10.4 to 14.1 per 100 000 per year between 2001 and 2021.1 This increase is particularly concerning given that up to 79% of suicide decedents die on their first attempt,2-4 underscoring the need for effective early detection and intervention.5

The multifaceted nature of suicide, as evidenced by the absence of a single profile,5,6 challenges traditional prevention efforts that predominantly focus on screening known mental disorders.7 Although psychological autopsy studies indicate 70% to 90% of suicides involved a mental disorder,8-12 only about 20% of suicide decedents with a psychiatric disorder before death had engaged with mental health services.13 This suggests a gap in prevention strategies: identifying individuals with mental disorders in mental health settings is insufficient,14 as that approach fails to reach most of those at risk. Among varying lethality of methods, self-inflicted gunshots have a survival rate of less than 10% compared with a 92% survival rate for drug overdoses, which adds complexity.15 Suicide decedents using high-lethality methods were less likely to seek psychiatric treatment or have a history of previous nonfatal suicide attempts.16 Thus, suicide prevention in this high-risk subgroup must begin before the first suicide attempt and outside mental health service settings.

To improve prevention, a better understanding of modifiable risk factors is imperative.2,5 One approach is identifying “suicide decedent profiles” with a broader spectrum of risk factors: seeking at-risk subgroups that may not manifest traditional warning signs,17 such as individuals with diagnosed mental health disorders, psychiatric medications, nonfatal suicide attempts, or disclosure of suicidal intent.17,18 Instead of a 1-size-fits-all approach, idenifying heterogeneous suicide decedent profiles may inform prevention strategies tailored for high-risk populationts who might die at their first attempt.19

Previous efforts using this approach have encountered limitations. First, our study, leveraging the National Violent Death Record System (NVDRS), addresses a critical gap in suicide research by focusing on data typically absent in clinical settings. This approach is necessary and innovative, because within 1 month of death, twice as many individuals (40%) had consulted general health care professionals20 compared with mental health professionals.13 Second, while it is labor intensive to use psychological autopsies to detect mental disorders, we used toxicology data from medical/legal examiners to assess psychotropic treatment adherence in suicide decedents.2,21 This information, coupled with suicide method details from autopsy records, offers a more comprehensive understanding of suicide decedent profiles than previous studies.22-24 Third, most US studies lacked national representation, with previous research using NVDRS datasets limited to 17 states.24 Fourth, despite evidence of disparities in suicide deaths and precipitating circumstances across age, race and ethnicity, sex, and geography,6,22 mapping these characteristics onto suicide profiles remains underexplored.

Our study addresses these gaps by discerning suicide profiles through a comprehensive analysis of variables, including circumstances of death, toxicology, and suicide methods. We analyzed all suicides from 2003 to 2020 in the NVDRS Restricted Access Database. Additionally, we associated suicides with suicide intent disclosure, suicide notes, and psychotropic use while examining sociodemographic differences. Our data-driven approach led us to hypothesize distinct suicide profiles that differ regarding potentially modifiable risk factors and would require different combinations of evidence-based prevention measures in nonpsychiatric and psychiatric clinical settings.


Study Design, Setting, and Population

The NVDRS is a national surveillance system for violent deaths,25 the largest dataset on US suicide decedents. Beginning in 2003 in 6 states and expanding to 50 states, the District of Columbia, and Puerto Rico by 2018,26 the NVDRS Restricted Access Database compiles information from death certificates, coroner and medical examiner records, and toxicology reports. Abstractors review data to ensure accuracy.27 The system is suitable for identifying suicide profiles (eMethods 1 in Supplement 1). We included all 306 800 suicide decedents at all ages from 2003 to 2020. Statistical analyses were performed from July 2022 to June 2023. Weill Cornell Medicine’s institutional review board exempted this study. We followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional designs.


Latent class analysis models included theory-informed28-31 and evidence-informed32,33 indicators: circumstances, toxicology-based substance indicators, and suicide-method indicators (see eTable 1 for data dictionary and recoding and eMethods 2 for indicator selection rationale in Supplement 1).

Circumstances included mental health problems, depressed mood, past/current mental illness treatment, suicide-attempt history, recent crisis, financial problems, job-related problems, friend/family member suicide/death, physical health problems, interpersonal violence perpetration/victimhood, criminal/civil legal problems, intimate partner/other relationship problems, alcohol, and other substance-use problems. Responses were binary (0 = no/not available/unknown; 1 = yes). See eMethods 3 and 4 in Supplement 1 for a discussion of no/not available/unknown responses and other recoding.

Toxicology screening included amphetamines, alcohol, opiates, marijuana, and cocaine. We recoded responses into binary variables (0 = no/not available/unknown/missing; 1 = yes) after assessing missing/misclassification (eMethods 4 in Supplement 1). We calculated polysubstance use (0 = none present/unknown/missing, 1 = 1, 2 = 2, 3 = 3, 4 = =4 substances).

We grouped suicide methods into 4 categories: 0 indicated firearms; 1, hanging, suffocation, or strangulation; 2, poisoning (suicide by prescription/illicit drugs, alcohol, carbon monoxide, gas, rat poison, or insecticides); and 3, other methods (eg, fire, drowning, hypothermia) or unknown/missing.13

Primary outcomes were the absence of suicide intent disclosure and suicide notes. Suicide intent disclosure indicated disclosing suicidal thoughts or plans within the last month to family members, health care workers, friends, intimate partners, neighbors, others, or on social media. Suicide note presence means the decedent left a suicide note or other communication indicating intent but too late for prevention. Additionally, we evaluated the presence of 4 psychotropic drug classes (antidepressant, anticonvulsant, antipsychotic, and benzodiazepine) from toxicology reports. Because not every drug was tested, a decision made by medical/legal examiners, we calculated new variables accounting for whether the drug was tested and the results (response categories: tested–present, tested–not present, not tested, and missing or unknown). We assessed missing values (eTable 1 in Supplement 1).

We included suicide-associated covariates: age, sex, race and ethnicity, education, marital status, military/veteran status, and urban/rural residence.5,6,34,35 Race and ethnicity descriptions included Hispanic, non-Hispanic American Indian or Alaska Native (hereafter American Indian or Alaska Native), non-Hispanic Asian or Other Pacific Islander (hereafter Asian or Other Pacific Islander), non-Hispanic Black (hereafter Black), non-Hispanic other/unspecified, non-Hispanic 2 or more races, non-Hispanic White (hereafter White), and unknown/missing.36

Statistical Analysis

We conducted latent class analysis using poLCA37 in R version 4.2.1 (R Foundation) to identify profiles. Latent class analysis is a finite mixture modeling approach to identify groups based on similar indicator responses.23,38,39 We estimated models ranging from 2 to 10 classes, determining the optimal model by fit (eg, Bayesian information criterion, entropy) and interpretability.

Individuals were assigned to classes based on probability,40 with class prevalence and membership differences analyzed using analysis of variance, Kruskal-Wallis, or ?2 tests. Logistic regression was used to associate class membership with primary outcomes.

There were no missing values for class indicators and outcome variables after recoding. We addressed missing covariate data (0.0%-19.3%) using multiple imputation (mice version 3.14.0)41 and validated findings against nonimputed data for robustness.


Among 306 800 suicide decedents, 239 627 (78.1%) were male, 67 108 were female (21.9%), 3918 (1.3%) were American Indian or Alaska Native, 7019 (2.3%) were Asian or Other Pacific Islander, 19 986 (6.5%) were Black, 19 354 (6.3%) were Hispanic, 251 861 (82.1%) were White, and 3428 (1.1%) reported more than 2 races (Table 1). There were 51 956 (16.9%) veterans. Regarding marital status, 109 151 (35.6%) were never married, and 99 532 (32.4%) were married or in a civil union or domestic partnership. Most completed at least high school (204 432 [66.6%]) and lived in metropolitan/urban areas (245 042 [79.9%]).

Latent Classes of

A 5-class model (Figure 1) provided the best fit (eTable 2 and eFigure 1 in Supplement 1) and interpretability (eTable 3 and eFigures 2-10 in Supplement 1). Class 1 (mental health and substance problems, n = 41 527; 13.5%) had high percentages of mental health problems (40 979 [98.7%]), depressed mood (16 981 [40.9%]), past (41 409 [99.7%]) and current (35 217 [84.8%]) mental health treatment, and prior suicide attempts (16 811 [40.5%]). Almost everyone (41 031 [98.8%]) in class 1 had illegal substances detected on toxicology, with 45.8% (n = 19 029) of these decedents exhibiting 4 or more substances. Class 1 had the highest suicide proportion by poisoning (20 829 [50.2%]).

Class 2 (mental health problems, 53 928 [17.6%]) had comparably high known prior mental health problems (53 305 [98.8%]) but fewer substance problems than class 1 (80.5% [43 390] of class 2 had no substances at death, and <1% [427] had =2 substances). Class 2 had the highest proportion of suicides by hanging (18 887 [35.0%]). Class 3 (crisis, alcohol-related, and intimate-partner problems, 55 367 [18.0%]) manifested the most recent crisis, alcohol-related, and/or intimate partner problems.

Class 4 (physical health problems, 97 175 [31.7%]) was the largest class of suicide decedents and was characterized by the most physical health problems (23 647 [24.3%]) and firearm suicide deaths (61 674 [63.5%]). Class 4 had the fewest known mental health problems (13 033 [13.4%]), depressed mood (20 710 [21.3%]), positive amphetamine test results (44 [0.05%]), positive alcohol test results (2755 [2.8%]), positive opiate test results (717 [0.7%]), positive marijuana test results (229 [0.2%]), positive cocaine test results (67 [0.1%]), and prior suicide attempts (5561 [5.7%]), and less than 1% had known history of (668 [0.7%]) or current (10 [0.01%]) mental illness treatment.

Class 5 (polysubstance problems, n = 58 803, 19.2%) reported the most substance misuse (43 578 [74.1%] with =2 substances at death) and alcohol misuse (23 298 [39.6%]). Classes 1 and 5 differed: class 1 had a higher frequency of known mental health issues and treatment (40 979 [98.7%] and 41 409 [99.7%], respectively) compared with lower rates in class 5 (14 421 [24.5%] and 1697 [2.9%], respectively). Class 1 primarily attempted suicide by poisoning (20 829 [50.2%]), while class 5 mostly used firearms (20 220 [34.4%]).

Shifts in class proportions were observed (Figure 2). Class 5 saw the largest increase, rising by 194% from 2010 to 2015 ([8.4%] to 5075 [24.7%]). Class 4 increased by 31.2% in 2016 to 2020 (7223 [27.9%] to 14 198 [36.6%]). In contrast, class 2 and class 3 decreased 49.8% (888 [24.5%] to 4769 [12.3%], 2003-2020) and 36.7% (800 [22.1%] to 5436 [14.0%], 2003-2020), respectively. Between 2011 and 2017, class 1 increased by 67.0%, from 1206 (9.7%) to 4821 (16.2%).

Associations With Signs of Suicide Intent

Known suicide intent disclosure and not leaving a suicide note varied across classes (Table 2). Class 1 (12 217 [29.4%]) and class 2 (15 708 [29.1%]) showed the highest rates of suicide intent disclosure, whereas class 4 (13 952 [14.4%]) had the lowest. Suicide notes ranged from the highest in class 1 (14 706 [35.4%]) and class 5 (18 445 [31.4%]) to the lowest in class 4 (24 351 [25.1%]). Psychotropic drugs detected via toxicology also varied, with class 1 showing the highest rates for antidepressants (17 551 [50.5%]), anticonvulsants (4366 [19.1%]), antipsychotics (3693 [16.2%]), and benzodiazepines (10 930 [41.5%]). In contrast, class 4 had the lowest rates of psychotropics detected: antidepressants (824 [2.3%]), antipsychotics (39 [0.3%]), and benzodiazepines (534 [3.5%]). Adjusting for covariates (Table 3), compared with class 1, the odds of not disclosing suicide intent were highest in class 4 (OR, 2.58; 95% CI, 2.51-2.66), and suicide note absence was more common in class 4 (OR, 1.45; 95% CI, 1.41-1.49).

Demographic Disparities

Compared with White individuals, Black individuals had higher odds of nondisclosure of intent (OR, 1.27; 95% CI, 1.22-1.32) and no note (OR, 1.88; 95% CI, 1.81-1.95). Females were less likely to disclose intent (OR, 1.08; 95% CI, 1.06-1.10) and more likely to leave a note (OR, 0.72; 95% CI, 0.71-0.74).


We identified 5 suicide profiles, each requiring tailored prevention strategies. Class 1 had comorbid mental and substance use disorders. Class 2 was dominated by mental disorders. Class 3 experienced crisis, alcohol-related, and intimate partner problems; Class 4 displayed physical health problems; and Class 5 displayed substance-use problems. We found Class 4 was least likely to disclose suicide intent, leave suicide notes as intent indicators, and have known mental illness or psychotropics detected by toxicology. (What was male/female breakdown? I would say primarily male.)

Class 4 emerged as the most concerning group: the largest (31.7%) and increasing the most (31.2% increase since 2016). With the strikingly lowest rate of diagnosed mental disorders and toxicology-detected psychotropic medications, class 4 comes the closest to having an “invisible suicide decedent risk profile.” Several factors may explain this. Men’s suicide rate is 4 times higher than women’s, and men are poorer at help-seeking. Physical illnesses can cause physical pain and psychological distress, which can lead to feelings of helplessness and heighten suicide risk that may be overlooked in medical settings.42 Suicidal patients may prioritize physical over mental health care because they consulted non–mental health care professionals twice as often as mental health professionals in the 30 days before death by suicide. Therefore, nonpsychiatric health care settings, especially primary care and emergency departments, are crucial for suicide risk screening.43

The composition of class 4 (predominantly older adults, non-Hispanic Asian American individuals, and veterans) reflects broader suicide trends in these populations.44 Systemic barriers such as stigma and social isolation may impede the recognition and treatment of mental health issues.10 Suicide decedents in class 4 were more likely to die on the first attempt because they mostly used firearms.5 The contrast in psychotropic medication usage between class 4 and class 1 is noteworthy. In class 4, only 2.3% of individuals were using antidepressants, compared with 50.5% in class 1. This discrepancy raises concerns about the potential undertreatment of major depression, given its link to nearly half of US suicide deaths.5 This highlights the urgent need to enhance the diagnosis and treatment of major depression in health care settings.5 Future research is needed to understand why class 4 has grown as a proportion of suicide decedents over time because that may identify other suicide prevention targets. (Maybe because a majority are members of the dominat class which are not the focus of the majority of the work being proposed and done to get to Zero Suicide.)

In contrast, while both classes 1 and 2 experienced high rates of mental health problems, they exhibited distinct challenges. Class 1 faced the additional challenge of comorbid substance use. A significant majority of class 1 members (84.8%-99.7%) had received or were receiving mental illness treatment.45 Notably, treatment rates escalated between 2011 and 2015, paralleling the increase in opioid-involved overdose deaths, which surged from 22 784 in 2011 to 68 630 in 2020.46 The increase in prescription and illegal opioids, particularly fentanyl, and its association with poisoning-related suicides in class 1 necessitates further investigation. Toxicology findings indicate that nearly half of the suicide decedents in class 1 were not taking psychotropic medications at the time of death, indicating possible nonadherence or cessation of treatment before suicide.47 In contrast, class 2, with minimal substance use disorders and less mental health treatment than class 1, experienced a significant decrease in suicide rates, suggesting improvements in mental health care, but limited resources for managing substance use disorders were underlying the trends in these 2 classes of suicide.

Class 5, marked by widespread polysubstance problems, grew the fastest. Toxicology reports revealed one-fifth of class 5 decedents had no current psychotropic medication at the time of death, and only 3% had a treatment history. This class also recorded the highest rates of positive test results for substances such as amphetamine (12.5%), alcohol (39.6%), marijuana (19.5%), and cocaine (7.9%). Challenges like stigma and health complications from multiple substance dependencies likely hinder recovery efforts, leading to lower treatment engagement and adherence and a hesitancy to reveal suicidal tendencies.48 As indicated by the trends in classes 1 and 2, systemic barriers49 to accessing substance abuse treatment, and potentially the absence of culturally tailored and gender-specific programs, may have contributed to the suicide risk in classes 1 and 5.

Following prior studies, we found class 3 represented younger males struggling with alcohol misuse amid economic challenges50 and separated or single males facing intimate partner relationship difficulties.51 Prevention should extend beyond immediate, visible aspects of these crises to comprehensively address less apparent but underlying causes often overlooked in research and intervention strategies.

Demographic Differences

The demographic characteristics of class 4, comprising an aging, rural, racial and ethnic minority, widowed, veteran, and less educated population, suggest that shared factors (eg, limited access to education/health care, social isolation, financial difficulties, trauma, low health literacy) may have contributed to neglected suicide risks and increase physical-illness–related suicide rates observed from 2016 to 2020.6,44 The post-2011 increase of class 5 may be partially explained by societal changes affecting this high school–educated, single/never-married, 25- to 54-year-old male demographic segment, including economic stress from uneven recovery after the Great Recession, increased substance availability,52 and absence of protective marriage.53 A higher proportion of divorced individuals (24.7%) and females (42.3%) in class 1 suggests that relationship breakdowns are significant stressors, as divorce is often associated with psychological and substance use problems.54 The observed greater reluctance among females to disclose suicidal intent was unexpected, presenting an area for further investigation. Class 3, with a notable majority of males (88.5%), aligns with previous findings linking males to heightened crisis, alcohol-related issues, and intimate partner problems.3,5,17

Research and Policy Implications to Improve Suicide Prevention

Our findings reinforce the need for tailored approaches that recognize the diverse needs of the suicide decedent profile. The 5 suicide profiles based on postmortem data can also inform clinicians to screen for each suicide risk subtype for personalized suicide prevention strategies. For class 4, integrated care coordinating physical and mental health services is crucial, especially in primary care/internal medicine settings,55 where a significant proportion of patients experience at least 1 (60%) or 2 (40%) chronic diseases,56 including diabetes (37.3 million people), Alzheimer disease (5.8 million people), and cancer (1.6 million people).

Class 1 is characterized by significant comorbid mental health and substance use problems, calling for a holistic approach that integrates psychiatric and substance abuse treatment,57 medication management,58 and community-based rehabilitation to foster recovery and social reintegration.59 Class 2 might benefit from comprehensive mental health services,60 including psychoeducation tailored to individuals and families.61 Improved medication adherence is potentially helpful but not the only option. Beyond medication, therapies such as cognitive-behavioral therapy62 and dialectical behavior therapy63 can be effective for suicidal behaviors, supporting risk reduction and enhanced coping mechanisms, particularly for those with depression and borderline personality disorder.62

For class 3, interventions like safety planning, crisis intervention,64 alcohol treatment programs,65 and family/relationship counseling are imperative.66 Class 5, characterized by polysubstance issues, could benefit from mental health screenings, substance use treatment,52 harm reduction,67 and peer support.68 Both classes 3 and 5 may also gain from treatments addressing the overlap of suicide risks and substance use, as well as firearm control measures.

Given the increasing diversity in the US, clinical interventions should be culturally relevant and sensitive, accommodating different racial and ethnic, sex, age, and educational backgrounds. Such inclusivity ensures that interventions are effective and resonate with diverse groups.6,22,26,69,70

Strengths and Limitations

This study harnessed comprehensive suicide data to identify 5 suicide profiles, each informing unique prevention strategies. This study has limitations. First, the NVDRS data revealed geographic variations due to decentralized coroner systems and diverse law enforcement practices. Combined with variable experience levels among data abstractors and reliance on second-hand information, these variations may introduce data incompleteness. To mitigate this, we applied fixed effects and county-year interactions to control for location and time-specific variations. Our conclusions remained robust.

Second, data coding, particularly in ambiguous categories like no/not available/unknown, may affect the accuracy of our findings. This is particularly true for toxicology data, where underreporting is common. We tackled this by examining drug testing details and cross-validating our findings through multiple imputations and direct data comparison.

Third, the potential for misclassifying suicide deaths and underreporting previous suicide attempts poses a risk of overestimating the incidence of first-attempt suicides. This challenge is amplified by reliance on medical examiner and law enforcement reports, which may not always capture the full history of attempts.1 Our high rate of first-attempt decedents (60%-94%) aligns with other NVDRS studies (79%)33 but contrasts with lower rates reported in some psychological autopsy studies (10%-40%).8,10,71,72

Fourth, the high frequency of firearm-related deaths in the US limits the generalizability of our findings to countries with lower firearm availability.5,6,73 With the highest per capita gun ownership (45%) in the developed world,74 the US presents a unique context for firearm suicide by making firearms accessible to many at-risk individuals.

Finally, there is a risk of biased screening related to demographics.75 For example, Black and Hispanic individuals may receive less comprehensive investigations than White individuals, affecting data reliability.75 Given possible unreliable data, we suggest interpreting our findings as part of a broader approach to guide suicide prevention.

Despite these limitations, the NVDRS remains the only national US dataset that comprehensively captures circumstances, toxicology, and suicide methods.13 We found internally consistent results, despite dataset weaknesses, offering a nuanced understanding of suicide.


This study identified 5 distinct suicide profiles, underscoring the complexity of suicide and illustrating its multifaceted nature. A notable finding is the rise of an invisible risk profile characterized by physical health problems, highlighting psychiatric underdiagnosis and subsequent undertreatment. These findings highlight the need for tailored suicide prevention strategies that address the specific needs of each profile to the extent they are identifiable, or prevent impulsive thoughts from being acted on, moving away from a 1-size-fits-all approach. Improving the detection and treatment of coexisting mental health conditions, substance and alcohol use disorders, and physical illnesses is paramount. Moreover, the implementation of means restriction strategies plays a vital role in reducing suicide risks across most of the profiles, reinforcing the need for a multifaceted approach to suicide prevention.

Article Information

Accepted for Publication: January 7, 2024.Published Online: March 20, 2024. doi:10.1001/jamapsychiatry.2024.0171 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Xiao Y et al. JAMA Psychiatry.

Supplemental Online Content:


1. Centers for Disease Control and Prevention. Suicide increases in 2021 after two years of decline. Published September 30, 2022. Accessed June 4, 2023.

2. Mann JJ?, Apter A?, Bertolote J?, et al. Suicide prevention strategies: a systematic review. ? JAMA. 2005;294(16):2064-2074. doi:10.1001/jama.294.16.2064

ArticlePubMedGoogle ScholarCrossref

3. Zalsman G?, Hawton K?, Wasserman D?, et al. Suicide prevention strategies revisited: 10-year systematic review. ? Lancet Psychiatry. 2016;3(7):646-659. doi:10.1016/S2215-0366(16)30030-XPubMedGoogle ScholarCrossref

4. Jordan JT?, McNiel DE?. Characteristics of persons who die on their first suicide attempt: results from the National Violent Death Reporting System. ? Psychol Med. 2020;50(8):1390-1397. doi:10.1017/S0033291719001375PubMedGoogle ScholarCrossref

5. Mann JJ?, Michel CA?, Auerbach RP?. Improving suicide prevention through evidence-based strategies: a systematic review. ? Am J Psychiatry. 2021;178(7):611-624. doi:10.1176/appi.ajp.2020.20060864PubMedGoogle ScholarCrossref

6. Xiao Y?, Cerel J?, Mann JJ?. Temporal trends in suicidal ideation and attempts among US adolescents by sex and race/ethnicity, 1991-2019. ? JAMA Netw Open. 2021;4(6):e2113513-e2113513. doi:10.1001/jamanetworkopen.2021.13513 ArticlePubMedGoogle ScholarCrossref

7. García de la Garza Á?, Blanco C?, Olfson M?, Wall MM?. Identification of suicide attempt risk factors in a national US survey using machine learning. ? JAMA Psychiatry. 2021;78(4):398-406. doi:10.1001/jamapsychiatry.2020.4165 ArticlePubMedGoogle ScholarCrossref

8. Favril L?, Yu R?, Uyar A?, Sharpe M?, Fazel S?. Risk factors for suicide in adults: systematic review and meta-analysis of psychological autopsy studies. ? Evid Based Ment Health. 2022;25(4):148-155. doi:10.1136/ebmental-2022-300549PubMedGoogle ScholarCrossref

9. Cavanagh JTO?, Carson AJ?, Sharpe M?, Lawrie SM?. Psychological autopsy studies of suicide: a systematic review. ? Psychol Med. 2003;33(3):395-405. doi:10.1017/S0033291702006943PubMedGoogle ScholarCrossref

10. Bostwick JM?, Pabbati C?, Geske JR?, McKean AJ?. Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. ? Am J Psychiatry. 2016;173(11):1094-1100. doi:10.1176/appi.ajp.2016.15070854PubMedGoogle ScholarCrossref

11. McMahon EM?, Greiner BA?, Corcoran P?, et al. Psychosocial and psychiatric factors preceding death by suicide: a case-control psychological autopsy study involving multiple data sources. ? Suicide Life Threat Behav. 2022;52(5):1037-1047. doi:10.1111/sltb.12900PubMedGoogle ScholarCrossref

12. Ross V?, Kõlves K?, De Leo D?. Beyond psychopathology: a case-control psychological autopsy study of young adult males. ? Int J Soc Psychiatry. 2017;63(2):151-160. doi:10.1177/0020764016688041PubMedGoogle ScholarCrossref

13. Liu GS?, Nguyen BL?, Lyons BH?, et al. Surveillance for violent deaths: National Violent Death Reporting System, 48 states, the District of Columbia, and Puerto Rico, 2020. ? MMWR Surveill Summ. 2023;72(5):1-38. doi:10.15585/mmwr.ss7205a1PubMedGoogle ScholarCrossref

14. Xiao Y?, Zhang Z?, Yip P?, Cerel J?, Mann JJ?. Trends in suicide deaths with and without warning from 2003-2019: identifying the missing link for effective suicide prevention. 2022 Annual meeting of American Public Health Association APHA. Accessed June 22, 2023.

15. Cai Z?, Junus A?, Chang Q?, Yip PSF?. The lethality of suicide methods: a systematic review and meta-analysis. ? J Affect Disord. 2022;300:121-129. doi:10.1016/j.jad.2021.12.054PubMedGoogle ScholarCrossref

16. Bond AE?, Bandel SL?, Rodriguez TR?, Anestis JC?, Anestis MD?. Mental health treatment seeking and history of suicidal thoughts among suicide decedents by mechanism, 2003-2018. ? JAMA Netw Open. 2022;5(3):e222101. doi:10.1001/jamanetworkopen.2022.2101 ArticlePubMedGoogle ScholarCrossref

17. Wang S?, Dang Y?, Sun Z?, et al. An NLP approach to identify SDoH-related circumstance and suicide crisis from death investigation narratives. ? J Am Med Inform Assoc. 2023;30(8):1408-1417. doi:10.1093/jamia/ocad068PubMedGoogle ScholarCrossref

18. Rodway C?, Tham SG?, Turnbull P?, Kapur N?, Appleby L?. Suicide in children and young people: can it happen without warning? ? J Affect Disord. 2020;275:307-310. doi:10.1016/j.jad.2020.06.069PubMedGoogle ScholarCrossref

19. Yip PSF?, Caine E?, Yousuf S?, Chang SS?, Wu KCC?, Chen YY?. Means restriction for suicide prevention. ? Lancet. 2012;379(9834):2393-2399. doi:10.1016/S0140-6736(12)60521-2PubMedGoogle ScholarCrossref

20. Hochman E?, Shelef L?, Mann JJ?, et al. Primary health care utilization prior to suicide: a retrospective case-control study among active-duty military personnel. ? J Clin Psychiatry. 2014;75(8):e817-e823. doi:10.4088/JCP.13m08823PubMedGoogle ScholarCrossref

21. Mann JJ?. Can knowledge of genetic and environmental causal factors of fatal and nonfatal suicidal behavior be translated into better prevention? ? Am J Psychiatry. 2021;178(11):994-997. doi:10.1176/appi.ajp.2021.21090913PubMedGoogle ScholarCrossref

22. Xiao Y?, Romanelli M?, Lindsey MA?. A latent class analysis of health lifestyles and suicidal behaviors among US adolescents. ? J Affect Disord. 2019;255:116-126. doi:10.1016/j.jad.2019.05.031PubMedGoogle ScholarCrossref

23. Grant RW?, McCloskey J?, Hatfield M?, et al. Use of latent class analysis and k-means clustering to identify complex patient profiles. ? JAMA Netw Open. 2020;3(12):e2029068-e2029068. doi:10.1001/jamanetworkopen.2020.29068 ArticlePubMedGoogle ScholarCrossref

24. Logan J?, Hall J?, Karch D?. Suicide categories by patterns of known risk factors: a latent class analysis. ? Arch Gen Psychiatry. 2011;68(9):935-941. doi:10.1001/archgenpsychiatry.2011.85 ArticlePubMedGoogle ScholarCrossref

25. Paulozzi LJ?, Mercy J?, Frazier L Jr?, Annest JL?; Centers for Disease Control and Prevention. CDC’s National Violent Death Reporting System: background and methodology. ? Inj Prev. 2004;10(1):47-52. doi:10.1136/ip.2003.003434PubMedGoogle ScholarCrossref

26. Wilson RF?, Liu G?, Lyons BH?, et al. Surveillance for Violent Deaths: National Violent Death Reporting System, 42 states, the District of Columbia, and Puerto Rico, 2019. ? MMWR Surveill Summ. 2022;71(6):1-40. doi:10.15585/mmwr.ss7106a1PubMedGoogle ScholarCrossref

27. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. National Violent Death Reporting System web coding manual version 6. Accessed February 13, 2024.

28. Lindsey MA?, Xiao Y?. Depression, trauma, and suicide among adolescent and young adult males. Men’s Health Equity. Accessed February 13, 2024.

29. Mann JJ?. Neurobiology of suicidal behaviour. ? Nat Rev Neurosci. 2003;4(10):819-828. doi:10.1038/nrn1220PubMedGoogle ScholarCrossref

30. Joiner T?. Why People Die by Suicide. Harvard University Press; 2009.

31. Klonsky ED?, May AM?. The three-step theory (3ST): a new theory of suicide rooted in the “ideation-to-action” framework. ? Int J Cogn Ther. 2015;8(2):114-129. doi:10.1521/ijct.2015.8.2.114Google ScholarCrossref

32. Xiao Y?, Hinrichs R?, Johnson N?, et al. Suicide prevention among college students before and during the COVID-19 pandemic: protocol for a systematic review and meta-analysis. ? JMIR Res Protoc. 2021;10(5):e26948. doi:10.2196/26948PubMedGoogle ScholarCrossref

33. Franklin JC?, Ribeiro JD?, Fox KR?, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. ? Psychol Bull. 2017;143(2):187-232. doi:10.1037/bul0000084PubMedGoogle ScholarCrossref

34. Kposowa AJ?. Marital status and suicide in the National Longitudinal Mortality Study. ? J Epidemiol Community Health. 2000;54(4):254-261. doi:10.1136/jech.54.4.254PubMedGoogle ScholarCrossref

35. Hawley JE?, Sun T?, Chism DD?, et al. Assessment of regional variability in COVID-19 outcomes among patients with cancer in the United States. ? JAMA Netw Open. 2022;5(1):e2142046. doi:10.1001/jamanetworkopen.2021.42046 ArticlePubMedGoogle ScholarCrossref

36. Management and Budget Office, Federal Register. Revisions to the standards for the classification of federal data on race and ethnicity. Published October 30, 1997. Accessed February 13, 2024.

37. Linzer DA?, Lewis JB?. poLCA: an R package for polytomous variable latent class analysis. ? J Stat Softw. 2011;42:1-29. doi:10.18637/jss.v042.i10Google ScholarCrossref

38. Laska MN?, Pasch KE?, Lust K?, Story M?, Ehlinger E?. Latent class analysis of lifestyle characteristics and health risk behaviors among college youth. ? Prev Sci. 2009;10(4):376-386. doi:10.1007/s11121-009-0140-2PubMedGoogle ScholarCrossref

39. Mori M?, Krumholz HM?, Allore HG?. Using latent class analysis to identify hidden clinical phenotypes. ? JAMA. 2020;324(7):700-701. doi:10.1001/jama.2020.2278 ArticlePubMedGoogle ScholarCrossref

40. Collins LM?, Lanza ST?. Latent Class and Latent Transition Analysis: With Applications in the Social, Behavioral, and Health Sciences. John Wiley & Sons; 2009. doi:10.1002/9780470567333

41. van Buuren S?, Groothuis-Oudshoorn K?. mice: multivariate imputation by chained equations in R. ? J Stat Softw. 2011;45(3). doi:10.18637/jss.v045.i03Google ScholarCrossref

42. Xiao Y?, Brown TT?. Moving suicide prevention upstream by understanding the effect of flourishing on suicidal ideation in midlife: an instrumental variable approach. ? Sci Rep. 2023;13(1):1320. doi:10.1038/s41598-023-28568-2PubMedGoogle ScholarCrossref

43. Geale K?, Henriksson M?, Jokinen J?, Schmitt-Egenolf M?. Association of skin psoriasis and somatic comorbidity with the development of psychiatric illness in a nationwide swedish study. ? JAMA Dermatol. 2020;156(7):795-804. doi:10.1001/jamadermatol.2020.1398 ArticlePubMedGoogle ScholarCrossref

44. Centers for Disease Control and Prevention. Disparities in suicide. Published May 9, 2023. Accessed November 6, 2023.

45. Gibbons RD?, Brown CH?, Hur K?, Davis J?, Mann JJ?. Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine. ? Arch Gen Psychiatry. 2012;69(6):580-587. doi:10.1001/archgenpsychiatry.2011.2048

ArticlePubMedGoogle ScholarCrossref

46. National Institute on Drug Abuse. Drug overdose death rates. Published June 30, 2023. Accessed November 6, 2023.

47. Miller M?, Swanson SA?, Azrael D?, Pate V?, Stürmer T?. Antidepressant dose, age, and the risk of deliberate self-harm. ? JAMA Intern Med. 2014;174(6):899-909. doi:10.1001/jamainternmed.2014.1053

ArticlePubMedGoogle ScholarCrossref

48. Clement S?, Schauman O?, Graham T?, et al. What is the impact of mental health-related stigma on help-seeking? a systematic review of quantitative and qualitative studies. ? Psychol Med. 2015;45(1):11-27. doi:10.1017/S0033291714000129PubMedGoogle ScholarCrossref

49. Priester MA?, Browne T?, Iachini A?, Clone S?, DeHart D?, Seay KD?. Treatment access barriers and disparities among individuals with co-occurring mental health and substance use disorders: an integrative literature review. ? J Subst Abuse Treat. 2016;61:47-59. doi:10.1016/j.jsat.2015.09.006PubMedGoogle ScholarCrossref

50. Abdou R?, Cassells D?, Berrill J?, Hanly J?. An empirical investigation of the relationship between business performance and suicide in the US. ? Soc Sci Med. 2020;264:113256. doi:10.1016/j.socscimed.2020.113256PubMedGoogle ScholarCrossref

51. Kazan D?, Calear AL?, Batterham PJ?. The impact of intimate partner relationships on suicidal thoughts and behaviours: a systematic review. ? J Affect Disord. 2016;190:585-598. doi:10.1016/j.jad.2015.11.003PubMedGoogle ScholarCrossref

52. Cicero TJ?, Ellis MS?, Kasper ZA?. Polysubstance use: a broader understanding of substance use during the opioid crisis. ? Am J Public Health. 2020;110(2):244-250. doi:10.2105/AJPH.2019.305412PubMedGoogle ScholarCrossref

53. Kyung-Sook W?, SangSoo S?, Sangjin S?, Young-Jeon S?. Marital status integration and suicide: a meta-analysis and meta-regression. ? Soc Sci Med. 2018;197:116-126. doi:10.1016/j.socscimed.2017.11.053PubMedGoogle ScholarCrossref

54. Yip PSF?, Yousuf S?, Chan CH?, Yung T?, Wu KCC?. The roles of culture and gender in the relationship between divorce and suicide risk: a meta-analysis. ? Soc Sci Med. 2015;128:87-94. doi:10.1016/j.socscimed.2014.12.034PubMedGoogle ScholarCrossref

55. Spottswood M?, Lim CT?, Davydow D?, Huang H?. Improving suicide prevention in primary care for differing levels of behavioral health integration: a review. ? Front Med (Lausanne). 2022;9:892205. doi:10.3389/fmed.2022.892205PubMedGoogle ScholarCrossref

56. Centers for Disease Control and Prevention. Chronic diseases in America. Published December 13, 2022. Accessed November 7, 2023.

57. Substance Abuse and Mental Health Services Administration (SAMHSA). Integrated treatment for co-occurring disorders evidence-based practices (EBP) kit. Published February 5, 2021. Accessed October 27, 2023.

58. Minkoff K?, Covell NH?. Recommendations for integrated systems and services for people with co-occurring mental health and substance use conditions. ? Psychiatr Serv. 2022;73(6):686-689. doi:10.1176/ ScholarCrossref

59. Treatment models and settings for people with co-occurring disorders. In: Substance Use Disorder Treatment for People With Co-Occurring Disorders. Substance Abuse and Mental Health Services Administration; 2020:chap 7.

60. Ee C?, Lake J?, Firth J?, et al. An integrative collaborative care model for people with mental illness and physical comorbidities. ? Int J Ment Health Syst. 2020;14(1):83. doi:10.1186/s13033-020-00410-6PubMedGoogle ScholarCrossref

61. Higgins A?, Murphy R?, Downes C?, et al. Factors impacting the implementation of a psychoeducation intervention within the mental health system: a multisite study using the consolidation framework for implementation research. ? BMC Health Serv Res. 2020;20(1):1023. doi:10.1186/s12913-020-05852-9PubMedGoogle ScholarCrossref

62. Brown GK?, Ten Have T?, Henriques GR?, Xie SX?, Hollander JE?, Beck AT?. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. ? JAMA. 2005;294(5):563-570. doi:10.1001/jama.294.5.563 ArticlePubMedGoogle ScholarCrossref

63. Mehlum L?, Tørmoen AJ?, Ramberg M?, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. ? J Am Acad Child Adolesc Psychiatry. 2014;53(10):1082-1091. doi:10.1016/j.jaac.2014.07.003PubMedGoogle ScholarCrossref

64. Gould MS?, Pisani A?, Gallo C?, et al. Crisis text-line interventions: evaluation of texters’ perceptions of effectiveness. ? Suicide Life Threat Behav. 2022;52(3):583-595. doi:10.1111/sltb.12873PubMedGoogle ScholarCrossref

65. Conner KR?, Bagge CL?, Goldston DB?, Ilgen MA?. Alcohol and suicidal behavior: what is known and what can be done. ? Am J Prev Med. 2014;47(3)(suppl 2):S204-S208. doi:10.1016/j.amepre.2014.06.007PubMedGoogle ScholarCrossref

66. Stanley AR?, Aguilar T?, Holland KM?, Orpinas P?. Precipitating circumstances associated with intimate partner problem-related suicides. ? Am J Prev Med. 2023;65(3):385-394. doi:10.1016/j.amepre.2023.03.011PubMedGoogle ScholarCrossref

67. National Institute on Drug Abuse. Priority Scientific Area No. 2: develop and test novel prevention, treatment, harm reduction, and recovery support strategies. Accessed October 27, 2023.

68. Connor JP?, Gullo MJ?, White A?, Kelly AB?. Polysubstance use: diagnostic challenges, patterns of use and health. ? Curr Opin Psychiatry. 2014;27(4):269-275. doi:10.1097/YCO.0000000000000069PubMedGoogle ScholarCrossref

69. Bridge JA?, Horowitz LM?, Fontanella CA?, et al. Age-related racial disparity in suicide rates among US youths from 2001 through 2015. ? JAMA Pediatr. 2018;172(7):697-699. doi:10.1001/jamapediatrics.2018.0399 ArticlePubMedGoogle ScholarCrossref

70. Ruch DA?, Heck KM?, Sheftall AH?, et al. Characteristics and precipitating circumstances of suicide among children aged 5 to 11 years in the United States, 2013-2017. ? JAMA Netw Open. 2021;4(7):e2115683. doi:10.1001/jamanetworkopen.2021.15683 ArticlePubMedGoogle ScholarCrossref

71. Innamorati M?, Pompili M?, Masotti V?, et al. Completed versus attempted suicide in psychiatric patients: a psychological autopsy study. ? J Psychiatr Pract. 2008;14(4):216-224. doi:10.1097/01.pra.0000327311.04153.01PubMedGoogle ScholarCrossref

72. Buchman-Schmitt JM?, Chu C?, Michaels MS?, et al. The role of stressful life events preceding death by suicide: evidence from two samples of suicide decedents. ? Psychiatry Res. 2017;256:345-352. doi:10.1016/j.psychres.2017.06.078PubMedGoogle ScholarCrossref

73. Mann JJ?, Michel CA?. Prevention of firearm suicide in the United States: what works and what is possible. ? Am J Psychiatry. 2016;173(10):969-979. doi:10.1176/appi.ajp.2016.16010069PubMedGoogle ScholarCrossref

74. Gallup. Guns. Published 2022. Accessed October 27, 2023.

75. Mezuk B?, Kalesnikava VA?, Kim J?, Ko TM?, Collins C?. Not discussed: inequalities in narrative text data for suicide deaths in the National Violent Death Reporting System. ? PLoS One. 2021;16(7):e0254417. doi:10.1371/journal.pone.0254417PubMedGoogle ScholarCrossref

People Facing Health Challenges Make Up Largest Group of Suicide Decedents - 3/20/24

More than 30% of suicide deaths were related to physical, not mental, health conditions

by Michael DePeau-Wilson, Enterprise & Investigative Writer, MedPage Today March 20, 2024

Five distinct suicide profiles that could improve detection and treatment of co-existing health conditions and bolster suicide prevention strategies were identified in a cross-sectional study.

In an analysis of 306,800 suicide deaths, individuals who faced physical health challenges comprised the largest profile class of the five (31.7%), according to Yunyu Xiao, PhD, of Weill Cornell Medicine/NewYork-Presbyterian in New York City, and colleagues.

Notably, decedents with this profile (Class 4) also had the lowest rates of disciosing suicidal intent (14.4%) or leaving a suicide note (25.1%), they reported in JAMA Psychiatry ( )

While physical health conditions made up the largest profile, the Class 1, 2,,3 and 5 profiles were comprised of individuals who predominantly faced mental health or substance abuse conditions:

Class 1: comorbid mental health and substance use problems (13.5%)
Class 2: mental health problems (17.6%)
Class 3: crisis, alcohol-related, and intimate-partner problems (18%)
Class 4: physical health challenges
Class 5: polysubstance problems (19.2%)

Identifying these profiles served to underscore "the complexity of suicide" and illustrated "its multifaceted nature," the researchers wrote, emphasizing the need for tailored suicide prevention strategies to address the specific needs of individuals struggling within each profile.

However, the most notable finding was the rise of "an invisible risk profile characterized by physical health problems," suggesting underdiagnosis and subsequent undertreatment of psychiatric conditions in this population, the researchers said.

"Traditionally, people have the belief that suicide is just a mental health problem," Xiao told MedPage Today. "We found that, in fact, [more than] 30% of suicide decedents are related to physical health."

"Physical illnesses can cause physical pain and psychological distress, which can lead to feelings of helplessness and heighten suicide risk that may be overlooked in medical settings," the researchers wrote.

The physical health problems class was roughly the same size as both the mental health and mental health with substance use problems groups combined, Xiao said. There could be multiple explanations for this, she said. One reason could be related to the association between chronic pain and suicide. Another could be the possibility that stigma around mental health may prevent people from seeking help, she added.

There's a need to continue "encouraging clinicians to screen suicide risk, even when the patients are not showing they have suicidal ideation," she said -- particularly in primary care and emergency department settings.

In addition to not disclosing suicidal intent, class 4 also had the lowest rates of psychiatric illnesses or use of psychotropic medications, making identification with standard screening practice more difficult, the researchers found.

"One of the important clinical implications is being able to ask about suicides, because [one] of the myths of suicide prevention is not to ask about suicide, because it might trigger people," Xiao said. "In the research, what we found is that it is actually more important that you ask."

To conduct this cross-sectional study, the researchers collected data from the 2003-2020 National Violent Death Reporting System Restricted Access Database. Of the more than 300,000 suicide deaths recorded, they noted that the decedents had a mean age of 46.3 years and the majority were male (78.1%) and lived in metropolitan or urban areas (79.9%).

Overall, 82.1% of decedents were white, 6.3% were Hispanic, and 6.5% were Black. Roughly 16% of decedents were veterans.

Class 4 had more older adults between ages 55 and 70 (24.5%) and those older than 71 years (20.7%). It also had more veterans (22.9%) and rural residents (24.7%).

The study was limited by some data collection approaches, including decentralized coroner systems and diverse law enforcement approaches, which may leave some data incomplete. There were also some issues with consistent data coding that could affect the accuracy of the analysis, including misclassified suicide deaths or underreported prior suicide attempts.

Source Reference: opens in a new tab or windowXiao Y, et al "Decoding suicide decedent profiles and signs of suicidal intent using latent class analysis" JAMA Psych 2024; DOI: 10.1001/jamapsychiatry.2024.0171.

©2017-2024,34 or