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Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up

BMJ 2008; 337 doi: (Published 19 November 2008) Cite this as: BMJ 2008;337:a2205
  1. Dag Tidemalm, PhD student1,
  2. Niklas Långström, associate professor2,
  3. Paul Lichtenstein, professor3,
  4. Bo Runeson, professor4
  1. 1Department of Clinical Neuroscience, Karolinska Institutet, Division of Psychiatry, St Göran, SE-112 81 Stockholm, Sweden
  2. 2Centre for Violence Prevention, Karolinska Institutet
  3. 3Department of Medical Epidemiology and Biostatistics, Karolinska Institutet
  4. 4Department of Clinical Neuroscience, Karolinska Institutet
  1. Correspondence to: D Tidemalm dag.tidemalm{at}
  • Accepted 4 September 2008


Objective To investigate the impact of coexistent psychiatric morbidity on risk of suicide after a suicide attempt.

Design Cohort study with follow-up for 21-31 years.

Setting Swedish national register based study.

Participants 39 685 people (53% women) admitted to hospital for attempted suicide during 1973-82.

Main outcome measure Completed suicide during 1973-2003.

Results A high proportion of suicides in all diagnostic categories took place within the first year of follow-up (14-64% in men, 14-54% in women); the highest short term risk was associated with bipolar and unipolar disorder (64% in men, 42% in women) and schizophrenia (56% in men, 54% in women). The strongest psychiatric predictors of completed suicide throughout the entire follow-up were schizophrenia (adjusted hazard ratio 4.1, 95% confidence interval 3.5 to 4.8 in men, 3.5, 2.8 to 4.4 in women) and bipolar and unipolar disorder (3.5, 3.0 to 4.2 in men, 2.5, 2.1 to 3.0 in women). Increased risks were also found for other depressive disorder, anxiety disorder, alcohol misuse (women), drug misuse, and personality disorder. The highest population attributable fractions for suicide among people who had previously attempted suicide were found for other depression in women (population attributable fraction 9.3), followed by schizophrenia in men (4.6), and bipolar and unipolar disorder in women and men (4.1 and 4.0, respectively).

Conclusion Type of psychiatric disorder coexistent with a suicide attempt substantially influences overall risk and temporality for completed suicide. To reduce this risk, high risk patients need aftercare, especially during the first two years after attempted suicide among patients with schizophrenia or bipolar and unipolar disorder.


  • We thank Eva Carlström for data management.

  • Contributors: BR had the original idea for the study and designed it together with NL and PL. DT managed the dataset and performed the statistical analyses. PL and NL were advisers on statistics. DT, NL, BR, and PL all interpreted results and coauthored the paper. BR is guarantor.

  • Funding: Stockholm County Council, the Karolinska Institutet, and the Swedish Prison and Probation Service. NL is funded by the Swedish Research Council (Medicine).

  • Competing interests: None declared.

  • Ethical approval: This study was approved by the regional ethics committee at Karolinska Institutet.

  • All authors declare, as researchers, independence from the funders.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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