Q. I suppose it is rather ridiculous to say that the most effective way to avoid suicide is to stop someone from that first attempt. However, isn't it true that after the first attempt, the following attempts increase in frequency?

Also, the following attempts may be only parasuicidal gestures, but even those may end up in accidental death. By increasing the frequency of such gestures, a person is at higher risk statistically speaking, of completing suicide. Is there any truth in this? If so, how would you suggest that the therapeutic community might best respond?

A. These are important questions, since, each year, there are at least 25 to 35 thousand suicides in the U.S, with probably 10 times that many suicide attempts [for a complete review, see the chapter by RI Shader in Manual of Psychiatric Therapeutics, 3rd, edition, 2003]. Men are at higher risk for completed suicide; women, for suicide attempts. I am not aware of large, prospective studies showing specifically that "after the first attempt, the following attempts increase in frequency"--i.e., "attempts per unit of time" increase.

This could be the case--and undoubtedly is with some patients--but I have not seen data demonstrating this. One would need to follow a large number of patients for many years, in order to answer this question conclusively.

On the other hand, there is some indication that, after the first suicide attempt, the second one commonly occurs within only 3 months. Since the first attempt probably occurred during or after adolescence, one could say that the overall frequency of attempts had increased. In one study, 65% of suicides occurred within 3 months of discharge from the hospital [Roy A (editor). Suicide. Williams & Wilkins, 1986].

Overall, between 9% and 33% of individuals with previous suicide attempts eventually go on to completed suicide [Perr IN, Legal Aspects of Psychiatric Practice 1:5-8, 1984]. So-called failed attempts in which the attempter expected to die are more likely to be repeated and ultimately to lead to death than are so-called manipulative attempts, in which the attempter did not expect to die, but hoped to change the behavior of others [see Shader, op cit].

In individuals with Borderline Personality Disorder, those with a high number of lifetime suicide attempts tend to have more serious attempts and higher lethality, compared with patients with a lower number of lifetime attempts [Soloff et al, Am J Psychiatry, 151:1316-23, 1994]. As the authors concluded, "As patients repeatedly attempt suicide, their attempts may become more serious and more lethal." Thus, the answer to your second question is probably yes, at least in this borderline population.

Your third question is the toughest--what do we do about detecting and preventing suicidal behavior? One area I think we need to improve is primary prevention, as you suggest at the beginning of your question. By this, I mean teaching parents, teachers, and even teens to recognize suicidal behavior and its early warning signs.

Too often, we read of friends, teachers, or parents who "thought he was kidding", when someone spoke of "ending it all." Primary care physicians are also on the front line of detecting and preventing suicidal behavior, yet often miss the clues or fail to ask the right questions (as do some psychiatrists and other clinicians).

Perhaps most important, recognizing the signs and symptoms of major depression is critical, since the vast majority of suicides occur in this context. For more information on depression, I recommend the recent book by Mark D. Miller MD and Charles F. Reynolds MD, entitled "Living Longer Depression Free" (2002).

Other Resources:

• More Questions on Suicide
• More Information on Suicide

November 2003

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