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This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research
and educational use, including for instruction at the author’s institution and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are encouraged to visit:
http://www.elsevier.com/copyright
Journal of Affective Disorders 136 (2012) 35–43
Contents lists available at SciVerse ScienceDirect
Journal of Affective Disorders
j ourna l homepage: www.e lsev ie r .com/ locate / jad
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Research report
Sociodemographic and psychopathological risk factors in repeated suicideattempts: Gender differences in a prospective study
Julie Monnin a,b,c,⁎, Emilie Thiemard a,1, Pierre Vandel a,b,c,2, Magali Nicolier a,3, Gregory Tio a,3,Philippe Courtet d,e,4, Frank Bellivier f,g,5, Daniel Sechter a,b,c,6, Emmanuel Haffen a,b,c,7
a Service de Psychiatrie, Hôpital Universitaire de Besançon, 2 Place Saint Jacques, 25030 Besançon cedex, Franceb Université de Franche-Comté, Laboratoire de Neurosciences, EA 481, 1 Place du Maréchal Leclerc, 25030 Besançon cedex, Francec Centre d'investigation clinique, Inserm CIT 808, Hôpital Universitaire de Besançon, 2 place Saint Jacques, 25030 Besançon cedex, Franced Département d'Urgence et Post Urgence psychiatrique, Hôpital Lapeyronie, CHRU de Montpellier, Francee Université de Montpellier, Inserm U1061 Neuropsychiatrie : recherche épidémiologique et clinique, Hôpital La Colombière, Montpellier, Francef Pôle de Psychiatrie, Hôpital Albert-Chenevier, Créteil, Franceg Inserm U841, Equipe 15 (Psychiatrie génétique), Faculté Henri Mondor, Créteil, France
a r t i c l e i n f o
⁎ Corresponding author at: Service de Psychiatrie, CE-mail addresses: [email protected] (J. Mo
Article history:Received 21 March 2011Received in revised form 31 August 2011Accepted 1 September 2011Available online 4 October 2011
Background: The prevention of the repetition of suicide attempts is an important feature of thecare of attempters but current data fail to give actual predictors of repetition. The aim of thisstudy was to characterize sociodemographic and psychopathological features and risk factorsassociated with future repetition of suicide attempts in two years. The study focused on differ-ences between men and women.Methods: 273 participants selected in psychiatric emergency units after their admission for asuicide attempt (index) were included in the study. Subsequent suicide attempts occurringwithin a two year follow-up were identified from the regional observatory of suicide attempts.At inclusion, sociodemographic variables and psychopathological data were collected. In par-ticular, psychometric evaluations were performed using the following scales: BDI-SF, SIS, BISand BDHI. The lifetime history of suicide attempt was also noted.Results: Repetition of suicide attempt in 2 years was associated with current follow up andtreatment, a personal history of multiple suicide attempt, post traumatic stress disorder,current recurrent psychotic syndrome and substance misuse. Specific features of men andwomen repeaters have been identified. Men repeaters were characterized by substance usedisorders whereas the re-attempt in women was associated with current follow up and treat-ment, post traumatic stress disorder and higher BDI-SF score.Conclusions: Repeaters must be considered as a specific population among suicide attemptersand gender differences must be taken into account in this particular population in order to pro-mote more personalized prevention programs for suicidal recurrence and completed suicide.
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1. Introduction
Risk factors for suicide attempts have been studied inmany works, the main predictor identified being the personalhistory of suicide attempt. Indeed, in retrospective studies,40% to 55% of suicide attempters have a history of suicide at-tempt (Chastang et al., 1997; Rudd et al., 1996; Scoliers etal., 2009) and suicide attempts are at great risk of recur-rence (Bille-Brahe and Jessen, 1994; Groholt and Ekeberg,2009; Kapur et al., 2006; Owens et al., 2002; Scoliers et al.,2009; Wang and Mortensen, 2006). The history of suicideattempt is also considered as a great risk factor for com-pleted suicide, as 10–15% of attempters complete suicide(Cullberg et al., 1988; Rudd et al., 1996), and the risk ofcompleted suicide increases proportionally with the num-ber of suicide attempts (Leon et al., 1990; Scoliers et al.,2009). Despite the considerable significance of the historyof suicide attempts for predicting suicidal behavior, sui-cide repeaters have not often been studied as a specificpopulation but have mostly been included in the overallpopulation of suicide attempters.
Existing data suggest that multiple attempters may becharacterized by clinical and sociodemographic factors thatcould explain the recurrence of the suicidal behavior. Themain risk factors for repetition are female gender, youngage, socioeconomic status (e.g. unemployment), higher se-verity of psychiatric symptoms and comorbidity (Bille-Braheand Jessen, 1994; Brezo et al., 2008; Courtet and Thuile,2010; Groholt and Ekeberg, 2009; Mechri et al., 2005;Michaelis et al., 2003; Osvath et al., 2003; Rudd et al., 1996;Scoliers et al., 2009).
Current research raises some issues that could explain thelack of identification of significant characteristics for differen-tiating one-time attempters from multiple attempters. First,the clinical evaluation of patients is often based on medicalregisters and not on the evaluationwhen suicide is attempted.Secondly, most studies do not analyze male and female popu-lations separately, and yet they are known to have specificfeatures concerning suicidal behaviors. Indeed, women aremore likely to attempt suicide whereas men are more likelyto complete suicide (Links et al., 1999; Rudd et al., 1996).These different approaches to the suicidal act between menand women are associated with differences in suicidal intent,the methods used and sociodemographic characteristics(Oquendo et al., 2007; Qin et al., 2000). It is likely that somespecific characteristics could appear in male and female sub-populations of repeaters. The few existing data suggest thatin males, repeaters were mostly aged between 20 and 35whereas repetition in women was associated with the agegroup 35–44 year age group (Osvath et al., 2003), and it isalso suggested that repetition in men happened a short timeafter the index suicide attempt (Kapur et al., 2006). Concern-ing other sociodemographic and clinical data, results aremorediscrepant.
Finally, since most research is based on retrospective data,the opportunities to use results for preventing future attemptsare more limited.
The aim of our study was to determine the risk factorsassociated with the repetition of suicide attempts, focusing onspecific features of men and women, in a two year prospectivefollow-up study.
2. Methods
2.1. Participants and sampling procedure
This study is a two year follow-up prospective study ofsociodemographic and psychopathological factors associatedwith suicide re-attempts.
A total of 273 patients, admitted to the psychiatric emer-gency units of the University Hospital of Besançon and theHospital of Dole (France) for suicide attempt, were includedin the study between June 2004 and December 2007. Suicideattempters were seen by a psychologist straight after theiradmission to the emergency psychiatry unit and were askedto participate in the study. A suicide attempt was defined asself-inflicted and potentially dangerous behavior for whichthe intent to die has been proven, according to Silvermannet al. (Silverman et al., 2007).
After being properly informed of the study each participantgave his/her informed consent. Patients included were aged 18and over. This study complied with the principles laid down inthe Declaration of Helsinki. The research protocol was ap-proved by the clinical ethics committee of the University Hos-pital of Besançon and the Committee of the Protection ofPersons (CPP-Est II).
2.2. Measures
A standard assessment form created especially for theresearch was completed by a psychologist the day after thepatient's admission to the psychiatric emergency unit (T1,index).
The form included detailed sociodemographic data suchas gender, age, professional and marital status. Data on clini-cal aspects were also collected: index suicide attempt method,treatment and specific medical follow-up, personal history ofsuicide attempt(s) or family history of suicide attempt(s) andcompleted suicide. Finally, the psychologist performed a psy-chopathological assessment using the Mini international neu-ropsychiatric interview (M.I.N.I., French version 5.0), which isa structured interview for the assessment of the psychiatricdisease diagnosis.
Four self-administered psychometric scales were alsofilled in by the patient: the Beck Depression Inventory shortform (BDI-SF) (Beck et al., 1961; Furlanetto et al., 2005), theBarratt Impulsiveness Scale-10 items (BIS-10) (Bayle et al.,2000), the Buss and Durkee Hostility Inventory (BDHI)(Buss and Durkee, 1957) and the Beck Suicidal Intent Scale(SIS) (Beck et al., 1974).
2.3. Evaluation of suicidal recurrence
The index suicide attempt was defined as the suicide at-tempt occurring just before the inclusion of the patient.
The suicide re-attempts were evaluated in the 2 yearsfollowing the index suicide attempt according to the regionalobservatory of suicide registers, an organization that makesan exhaustive inventory of suicide attempts listed in each hos-pital of the region of Franche-Comté. Previous works on thestudy of repeated suicide attempts have shown that over1 year, the repetition ratewas 16% (Owens et al., 2002), this in-creases to 30% in the 2 year follow-up study of Bille-Brahe and
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Jessen (1994) but remains at approximately the same levelover 4 or 5 years (Scoliers et al., 2009; Suominen et al., 2009),at 31% and 29.2% respectively. A two year follow-up seems suit-able for a representative study of repeated suicide attempts.
These data divided the population into non repeaters andrepeaters. Repeaters made at least one suicide attempt dur-ing the two year follow-up whereas nonrepeaters havemade no further attempt in the two year follow-up. For thisgroup, suicide attempts occurring after the two year follow-up were not considered for the statistical analysis.
No patient died by suicide during the two year follow-upaccording to the regional legal medicine unit of the UniversityHospital of Besançon.
For each group described above, analyses were conductedon the one hand in the entire population, and on the otherhand in the specific populations of men and women.
2.4. Statistical analysis
Statistical analyses were conducted by STATA/SE 10.0.The normality of variables was determined with the
Shapiro test and the variance equality was evaluated withthe Fisher–Snedecor test.
In the event of a normal distribution and equality of vari-ances, continuous variables were compared with the Student'st-test. In the absence of a normal distribution and varianceequality, continuous variables were compared with the Wil-coxon test.
Qualitative variables were compared with the Pearsonchi-square test or the Fisher exact test.
The significance level was determined at p≤0.05.We modeled the time to onset of the suicide re-attempt
using Kaplan–Meier survival analysis in the whole sample,in men and in women. The equality of survival functions ofmen and women was tested using the logrank test.
Cox regressions were conducted to identify sociodemo-graphic and psychopathological variables linked to the suicidere-attempt and resulted in hazard ratios (HR) with a 95% con-fidence interval (95% CI).
3. Results
3.1. Descriptive analysis of the index population
A total of 273 patients were included in the study, 112 ofwhom were first attempters and 159 of whom had made atleast one previous suicide attempt. Two patients only provid-ed sociodemographic data and refused to provide clinicaldata.
Table 1 presents the sociodemographic, psychopathologi-cal and psychometric data describing the index population.At index, the majority of patients were aged between 20and 59, the mean age being 37.6 years (SD=13.2). Patientswere mainly women, employees or workers and were mostlyinactive and living alone (single, divorced or widowed).
Concerning the index suicide attempt, the more frequentmethod was self-poisoning: 59% of patients had made atleast one previous suicide attempt and 41% had a family his-tory of suicide attempt and/or completed suicide.
A great majority of patients were in care at the time ofindex SA, and only a few (14/273; 5%) of them had stopped
their treatment between 6 months and 48 h before theindex attempt.
Regarding the psychopathological data, only 4% of partic-ipants had no diagnosis for axis 1 psychiatric disorder by theM.I.N.I. interview. The main psychiatric disorders identifiedwere anxiety disorders, unipolar depression and substancemisuse (see Table 1 for detailed items).
The index population was also characterized by a greatpercentage of comorbidity. Indeed only 15.8% (43/272) hadonly one axis 1 psychiatric disorder. The main comorbiditiesobserved were unipolar depression and anxiety disorders(85/272; 31.2%), unipolar depression, anxiety and substancemisuse (44/272; 16.2%), bipolar disorder and anxiety disor-der (29/272; 10.7%), and finally bipolar disorder, anxiety dis-order and substance misuse (15/272; 5.5%).
It should be noted that the method used for the index sui-cide attempt was associatedwith suicide intent and impulsive-ness scores. Indeed, violent suicide attempts (i.e. hanging,drowning, cutting, stabbing, use of firearm) had a higher totalSIS score: 16.9 (SD=1.9) for violent suicide attempts and13.3 (SD=5.7) for self poisoning (p=0.01), and a higher SISsubscore of protection against discovery: 4 (SD=2.3) vs 3(SD=1.8) (p=0.019). Violent methods for suicide attemptwere associated with a lower BIS subscore of cognitive impul-sivity: 15 (SD=5.85) vs 18.4 (SD=5.9) (p=0.019).
3.2. Comparison of men and women at index
In total, 30% of the index population were men and 70%were women. Men and women present several differences(Table 2). First, more women had a follow-up care before theindex suicide attempt. Secondly, the main differences betweenmen and women concern psychiatric disorders. Indeed,womenwere characterized by a significantly higher rate of cur-rent agoraphobia and current panic disorder whilemen tendedto present with substance use disorders, particularly past alco-hol dependence, past substance abuse and dependence.
Finally, in psychometric evaluations men had a higherscore of suicide intent and women had a higher score of cog-nitive impulsivity.
3.3. Risk factors for repeating suicide attempts in the wholesample
Fig. 1 shows the Kaplan–Meier curve modeling the time toonset of the re-attempt in the whole sample.
Table 3 shows the characteristics and risk factors associatedwith repetition of suicide attempts over 2 years of follow-up.
First, sociodemographic characteristics associated withthe repetition of suicide attemptwere being a cigarette smok-er (72% vs 54.8%, p=0.011, HR=1.92, 95% CI=1.16–3.18)and having current follow-up (70.3% vs 52.5%, p=0.015,95% CI=1.13–3.02) and treatment (77.3% vs 55.7%,p=0.002, HR=2.39, 95% CI=1.39–4.11).
Furthermore the proportion of subjects with a personal his-tory of multiple suicide attempt is higher in repeaters than innonrepeaters (70.3% vs 54.3%, p=0.033, HR=1.71, 95%CI=1.04–2.79). Results also showed that the risk of re-attemptwithin 2 years was also correlatedwith the number of past sui-cide attempt, indeed repeaters have had made 5.5±6.5past suicide attempts whereas nonattempters have had made
Table 1Sociodemographic and psychopathological data at index.
Index population Men Women
N=273 N=84 N=189
Mean (SD) Mean (SD) Mean (SD)
SociodemographicsAge 37.6 (13.2)Age at first suicide attempt 31.7 (14)
n (%) n (%) n (%)Age: 20–59 235 (86) 73 (87) 162 (86)Gender: female 189 (69)Professional status
38 J. Monnin et al. / Journal of Affective Disorders 136 (2012) 35–43
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2.7±4 suicide attempts in the past (p=0.000, HR=1.06, 95%CI=1.03–1.09) meaning that the higher the number of pastsuicide attempt, the higher the risk tomake subsequent suicideattempt in 2 years.
Concerning psychopathological data, repeaters were char-acterized by a higher prevalence of PTSD (20.6% vs 9.6%,p=0.01), current recurrent psychotic syndrome (13.7% vs2.5%, p=0.000) and substance use disorders, particularlycurrent alcohol dependence (23.3% vs 11.1%, p=0.007) andcurrent abuse or dependence for drug and/or alcohol (30.1%vs 15.7%, p=0.005). Cox regression has shown that thesemarkers were associated with high hazard ratios, respectively
2.12, 95% CI=1.2–3.74, 3.48, 95% CI=1.78–6.79, 2.12, 95%CI=1.23–3.66 and 2.06, 95% CI=1.25–3.39. Cox regressiondidn't show an association between re-attempt and comor-bidity, but Pearson's correlation has shown that the numberof suicide attempt and the number of comorbidities werepositively correlated (p=0.033).
3.4. Risk factors for repeating suicide attempts in men andwomen
Fig. 2 shows the Kaplan–Meier curve modeling the time toonset of the re-attempt in men and women. The survivalfunctions were not significantly different.
0 5 10 15 20 25
Time from the index suicide attempt (month)
No
re-a
ttem
pt p
roba
bilit
y0,
000,
250,
500,
751,
00
Fig. 1. Kaplan Meier survival curve of re-attempt by time in the wholesample.
39J. Monnin et al. / Journal of Affective Disorders 136 (2012) 35–43
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Table 3 shows the characteristics and risk factors associat-ed with the repetition of suicide attempts during the twoyear follow-up in men and women.
First, some characteristics of repeaters have been identi-fied both in men and women, this is the case for the numberof past suicide attempt (p=0.003, HR=95% CI=1.05–1.25for men and p=0.000, HR=1.06, 95% CI=1.03–1.25 inwomen) and current recurrent psychotic syndrome (12% vs1.7%, p=0.031, HR=3.83, 95% CI=1.13–12.98 for men and14.3% vs 2.9%, p=0.004, HR=3.3, 95% CI=1.48–7.35 forwomen). In contrast, results have highlighted some specificfeatures of repeaters of each gender. Indeed, current substancemisuse was specific for men repeaters (41.7% vs 15.3%,p=0.009, HR=2.98, 95% CI=1.32–6.72), and particularlycurrent alcohol dependence (37.5% vs 10.2%, p=0.003,HR=3.58, 95% CI=1.56–8.21) and current alcohol abuse(25% vs 6.8%, p=0.03, HR=2.76, 95% CI=1.09–6.97). Con-cerning women, suicide re-attempt was associated with cur-rent follow up (75.5% vs 59%, p=0.033, HR=2.03, 95%CI=1.06–3.9) and treatment (80% vs 50.8%, p=0.007,
Table 2Men and women sociodemographic and psychopathological differences atindex.
HR=2.58, 95% CI=1.23–5.16), PTSD (24.5% vs 9.4%,p=0.003, HR=2.67, 95% CI=1.39–5.13) and higher BDI-SFscore (23±7.1 vs 19.1±7.95, p=0.019, HR=1.06, 95%CI=1.01–1.12).
4. Discussion
The aim of the study was to characterize the specific pop-ulation of repeaters of suicide attempt on sociodemographicand psychometric levels and to identify possible risk factorsassociated with the repetition of suicide attempts.
The study population was mainly characterized by mid-dle-aged patients, women, lonely people and inactiveworkers. In many cases, the suicide attempt method wasself-poisoning but 7% used a violent method (hanging, stran-gulation, gassing, jumping, stabbing, phlebotomy, etc.). Thesemethods are linked to higher suicide intent, protectionagainst discovery and impulsivity. These findings are inaccordance with those of Klerman (Klerman, 1987) andBaca-Garcia (Baca-Garcia et al., 2001; Baca-Garcia et al.,2005) who have found an inverse association between theimpulsivity and the lethality of the suicide attempt. Thiscould also be related to the findings of Runeson et al.(Runeson et al., 2010) who highlight that the highest relativerisk for eventual successful suicide is found in violent suicideattempts in a 21–31 year follow-up study and those of Evans(Evans et al., 1996) that shown that repetition of suicide be-havior was significantly related to higher impulsiveness. Thislast relationship was not found in our study.
Most patients included had a personal history of suicideattempt and a sizeable proportion had a family history of sui-cide attempts or completed suicide. These characteristics arefound in many similar studies (Bille-Brahe and Jessen, 1994;Chastang et al., 1997; Kapur et al., 2006; Osvath et al., 2003;Scoliers et al., 2009) and are well known vulnerability factorsfor suicidal behavior (Lee et al., 2010; Malone et al., 1995;Marquet et al., 2005; Masocco et al., 2008; Sher et al., 2001;Sokero et al., 2005).
The psychopathological characteristics of the index popu-lation show a high proportion of mental disorders in theattempter population, predominantly unipolar depression,anxiety disorders and substance use disorders. These findingsare concordant with previous results highlighting that amental disorder is the most significant risk factor for suicidalbehavior (Bolton et al., 2010; Krysinska and Lester, 2010; Leeet al., 2010; Sareen et al., 2005) and that depressive disordersand substance use disorders are the most frequent disorders insuicide attempters. In contrast, the link between anxiety disor-ders and suicide attempts is more controversial since somestudies show no differences between attempters (Goldston etal., 1998) and nonattempters in the rate of anxiety disorders.However, others identify anxiety disorders and particularlypost traumatic stress disorder (Bolton et al., 2010; Krysinskaand Lester, 2010) and panic disorder (Bolton et al., 2008;Bolton et al., 2010) as risk factors for suicide attempts(Bolton et al., 2008; Sareen et al., 2005) and for repetition(Lopez-Castroman et al., 2011). Another interesting result isthe high frequency of comorbidity in suicide attempters. It iswell established that comorbid conditions increase the riskof attempted suicide in mood disorders (Scocco et al., 2008;Sher et al., 2001), the main comorbid disorders being
Table 3Risk factors associated with re-attempts in the 2 years following the index suicide attempt, in the whole sample, in men and in women.
Repeatersn=75(27.7%)
Nonrepeatersn=198(73.1%)
p HR[95%CI]
Men(n=84)
Women (n=189)
Repeatern=25(29.8%)
Nonrepeatersn=59(70.2%)
p HR[95% CI]
Repeatersn=50(26.5%)
Nonrepeatersn=139(73.5%)
p HR [95% CI]
Sociodemographics n (%) n (%) n (%) n (%) n (%) n (%)Cigarette smokers 54 (72) 108 (54.8) 0.011 1.92 [1.16–3.18] NS NSFollow up care 52 (70.3) 104 (52.5) 0.015 1.85 [1.13–3.02] NS 37 (75.5) 82 (59) 0.033 2.03 [1.06–3.9]Current treatment 58 (77.3) 107 (55.7) 0.002 2.39 [1.39–4.11] NS 40 (80) 79 (58.5) 0.007 2.58 [1.29–5.16]Personal history ofmultiple suicide attempt
52 (70.3) 107 (54.3) 0.033 1.71 [1.04–2.79] NS NS
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Number of past suicide attempts 5.5 (6.5) 2.7 (4) 0.000 1.06 [1.03–1.09] 3.6 (4.4) 1.9 (1.5) 0.003 1.15 [1.05–1.25] 6.4 (7.2) 3.1 (4.6) 0.000 1.06 [1.03–1.25]
Psychopathologyn (%) n (%) n (%) n (%) n (%) n (%)
Fig. 2. Kaplan Meier survival curves of re-attempt by time in men andwomen.
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substance use disorders (Bolton et al., 2008; Malone et al.,1995), anxiety disorders (Oquendo et al., 2005; Sareen et al.,2005), and personality disorders (Corbitt et al., 1996). The psy-chometric evaluation of participants shows that these mentaldisorders are associated with a high self-evaluated depressionseverity and a relatively high suicide intent, impulsiveness andhostility. These results are generally similar to those obtainedin other studies on suicide attempters (Courtet et al., 2004;Malone et al., 1995).
The fact that participants are often currently treated andunder medical care reflects the high frequency of psychiatricdisorders and comorbidities found in this population, andalso emphasizes the unmet need reported in the NCS-Rstudy in which Kessler et al. (Kessler et al., 2003) foundthat despite the increased use of psychotropic medications,suicide rates did not decrease substantially in time.
The comparison in our study between repeaters and non-repeaters highlights specific sociodemographic and psycho-pathological features of the repeaters: they are undergoingcurrent follow-up and treatment, have post traumatic stressdisorder, current recurrent psychotic syndrome and substanceuse disorders. Moreover, the number of comorbidities is signif-icantly correlated with the number of suicide attempts. Takentogether, these data suggest that repeaters may have moresevere and complex psychiatric disturbances.
The higher complexity and severity of the psychiatric dis-orders of multiple attempters have already been underlinedin many research studies (da Silva Cais et al., 2009; Mechriet al., 2005; Michaelis et al., 2003; Scoliers et al., 2009) andis emphasized by the significant correlation between thenumber of comorbidities and the number of suicide attempt,the higher proportion of patients undergoing current followup and treatment in repeaters and the association betweenPTSD, psychotic syndrome and substance use disorders withrepetition shown in this study. Our study and others showthat the main comorbidities associate mood disorders withanxiety (Brezo et al., 2008; Lopez-Castroman et al., 2010;Scoliers et al., 2009) and/or substance use disorders (Groholtand Ekeberg, 2009). Comorbid personality disorders, such asborderline personality disorder, have also been considered asan important characteristic of multiple attempters (Osvathet al., 2003). This dimension has not been taken into accountin our study.
As hypothesized, we found specific characteristics andrisk factors in each gender in our study. Indeed, women arecharacterized by a higher rate of anxiety disorders such asagoraphobia and panic disorder, and men are more likely tobe associated with alcohol dependence and drug dependenceand abuse. Furthermore, there are gender differences in thefeature of the suicidal act since women are more impulsiveand men have a higher suicidal intent. This confirms the ben-efit of investigating men and women separately for the risk ofsuicide re-attempts.
It is interesting to note that differences between men andwomen also appeared in risk factors for re-attempt. Indeed,on a psychopathological level, PTSD and higher self evaluateddepression severity were significant risk factors for re-attempt in women. Moreover, female repeaters were charac-terized by current follow-up care and treatment. On contrast,repetition of suicide attempt in men was associated withsubstance use disorders, especially alcohol misuse. Fewstudies on multiple suicide attempts have clearly focused ondifferentiating men and women and unlike in this study, theyhave not clearly identified specific risk factors for each sub-population. Osvath et al. (2003) highlighted the importanceof unemployment in male multiple attempters but not inwomen. This result did not appear in our study. Concerningpsychopathological data, results are more contradictory. Psy-chotic disorder has been identified as a risk factor for repetitionin men by Osvath et al. (2003) whereas Kapur et al. (2006)showed that reported hallucinations are a risk factor for repeti-tion in women. No other psychopathological characteristicshave been clearly identified. The diversity of assessmentmethods (i.e. prospective or retrospective) and studied vari-ables did not allow results to be compared and only providedus with variables of interest for further research.
It is noticeable that the risk factors and characteristics ofrepeaters are mainly the same as those identified in the fe-male population. This is likely to be due to the predominanceof women who re-attempt. This observation underlines thelack of consideration of male specificities in many studies.Taking into account these results, it is essential to differenti-ate between men and women in the care of suicidal behavior,and particularly recurrence, since these two subpopulationsseem to have specific approaches to the suicidal act and spe-cific psychopathological characteristics. The risk factors forthe repetition of suicidal behavior identified may be helpfulfor promoting specific preventive strategies. Special attentionmust be given to patients who have a personal history ofmultiple suicide attempts, current treatment and care andpsychopathologies. Results also showed that the distinctionbetween male and female attempters is essential for ade-quate preventive care and strategies. In fact, men with sub-stance use disorders and women with current treatmentand care and PTSD, should be considered at risk populationsfor future re-attempts.
This study has various limitations. First, patientswere select-ed in psychiatric emergency units, apart from patients whomade suicide attempts requiring surgery or intensive medicalinterventions. Moreover a proportion of suicide attempts didnot lead to hospitalization. In France, this proportion of nonhos-pitalized suicide attempters is quite small and is estimated to beabout 10–20% (Kovess et al., 2001). Secondly, participants werevolunteers and some patients may have refused to participate.
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Thirdly, the evaluation of previous suicide attempts was self-reported and may represent a source of error. This limitationhas been partially counterbalanced by the use of the register ofthe regional observatory of suicide that takes an inventory ofeach suicide attempt listed in the hospital of the region forlater suicide attempts. The possible loss of patients may be dueto nonhospitalized suicide attempters, although this is unlikelygiven the history of suicide attempt in the population consid-ered. Furthermore, completed suicide or death was listedthrough the legal medicine unit and none of the patients includ-ed died in the two year follow-up. However, three patients diedby suicide after the two year follow-up period. Finally, consider-ing the rate of immigration in the regions studied, the loss due tomigration is probably insignificant (INSEE, 2007).
Finally, it is worth noting that some subgroups were toosmall, for example the male subgroups. It would be worthstudying these specifically on larger samples.
5. Conclusion
Given the results obtained in this study, the subpopula-tion of repeaters needs to be considered in contrast to nonre-peaters as they seem to have specific psychopathologicalfeatures and a more complex psychopathology. Furthermore,female and male patients have specific characteristics andrisk factors associated with repetition of the suicide attempt.These gender differences must be included in future researchand particularly in prevention programs for recurrence ofsuicide attempts and completed suicide.
Role of funding sourceThis study was supported by a grant from the French Ministry of Health
(Programme Hospitalier de Recherche Clinique). The sponsor has no role inthe study.
ter, University Hospital of Besançon) for proofreading the manuscript.
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