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RESEARCH: Dag Tidemalm, Niklas Långström, Paul Lichtenstein, and Bo Runeson Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up BMJ 2008; 337: a2205 [Abstract] [Full text]

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Completed Suicide After a Suicide Attempt in a Community Sample

Wen-Hung Kuo   (21 December 2008)

Completed Suicide After a Suicide Attempt in a Community Sample 21 December 2008
Wen-Hung Kuo, Assistant Professor Zayed University, Abu Dhabi, United arab Emirates Send response to journal: Re: Completed Suicide After a Suicide Attempt in a Community Sample	To the Editor: Tidemalm et al. (1) followed a Swedish cohort of 39685 suicide attempters for up to 31 years and found more than 20% of female former attempters and more than 35% of male former attempters eventually commit suicide. The large number of study subjects and the long follow-up period is impressive. However, as the authors discussed about the study's limitation is that they included only people with suicide attempts that led to inpatient care. We would like to highlight our findings based on a community sample from the United States. The Baltimore Epidemiologic Catchment Area Study was a community- based longitudinal study starting in 1981. History of suicide attempts was assessed at baseline. Mortality and causes of death were identified by death certificates after deaths were confirmed by searching the National Death Index. Our study analyzed deaths confirmed up to 1998. By the end of 1998, 861 of the 3,481 baseline participants were deceased. Death certificates of 762 deceased participants (88.5%) were collected, and causes of death were identified, with 729 having died of natural causes. Thirty-three had died of nonnatural causes (4.3% among all known causes of death), including 19 from accidents, six from homicides, and two undetermined. The remaining seven died from suicide (0.9% among all known causes of death). The method was firearms in 57% of the suicide deaths, hanging in 29%, and drug overdoses in 14%. Only two suicides were women (29%). The year of suicide did not cluster in any specific years. History of suicide attempts was not associated with overall mortality after sociodemographic characteristics were adjusted. In our sample, only 1.7% of the participants with a history of attempts eventually completed suicide in the 17-year period. Compared to people without a history of attempts, former attempters had a much higher odds of completing suicide (odds ratio=11.3, p<0.001). In a multiple logistic regression model with adjustment for sociodemographic variables, only history of attempts and gender were associated with later suicide: men were six times more likely to commit suicide than women (odds ratio=5.9, p<0.001). History of suicide attempts was not associated with the likelihood of other nonnatural deaths. Although our analysis had a much lower percent of eventual suicide than the study by Tidermalm et al., our findings overall showed a comparable, although less significant, pattern between gender, history of attempts, and eventual suicide. Our sample also included a comparison group (nonattempters) that the study by Tidermalm et al did not have. Our less significant result might have come from our much shorter follow-up period and other intrinsic population differences. Unfortunately, due to the design of Baltimore ECA, many informations, including diagnoses of pychotic disorders, was not well measured. Exact timeline for all sorts of suicidal behaviors is also difficult to confirm. Thus, we did not look into how different types of psychiatric diagnoses influenced the risk for eventual suicide deaths among former attempters in ECA. 1. Tildermalm D, Langstrom N, Lichtenstein P, Runeson B. Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up. BMJ 2008; 337- 342. Competing interests: None declared