Lethality Of Suicide Attempts Research Articles

Pain persistence and lethality of suicide attempts.

The interpersonal-psychological theory of suicide posits that elevated pain tolerance is necessary to engage in suicidal behaviour. It is assumed that suicidal intent only leads to lethal (or near lethal) suicide attempts when an individual has the capability to persist the pain involved in dying. The aim of this study was to assess whether objective pain persistence moderates the association between suicide intent and lethality of a recent suicide attempt. Ninety-seven inpatients, who were hospitalized due to a recent suicide attempt, were interviewed regarding lifetime suicide attempts as well as their most recent suicide attempt: Method of attempt, intention to die, medical risk of death, probability of an intervention, and physical condition following the attempt were inquired. Pain persistence was examined using a pressure algometer. Contrary to the expectation, pain persistence did not moderate the association between suicide intent and lethality of a recent suicide attempt, that is, medical risk of death, probability of an intervention, or physical condition following the attempt. Future studies are needed to examine method specific pain persistence for suicidal behaviour in a longitudinal study design.

Dexamethasone Suppression Test May Predict More Severe/Violent Suicidal Behavior.

IntroductionSeveral studies demonstrated that the hypothalamic-pituitary-adrenal (HPA) axis is dysregulated in suicide attempters. Prospective studies found that people with an abnormal response at the dexamethasone suppression test (DST) are more likely to commit suicide. However, whether DST may predict suicide attempts remains less clear. A possible strategy to address this question is to consider the suicide attempt lethality.Objectives(1) To compare the pre- and post-DST cortisol levels in serious/violent suicide attempters and in non-serious/non-violent suicide attempters, and (2) to investigate whether cortisol level can predict new suicide attempts or their lethality.MethodsThe study included 70 recent suicide attempters (25 with a serious or violent attempt) who were followed for two years. Three saliva samples for cortisol measurement were obtained at 8a.m., 3p.m., and 9p.m. before the DST (pre-DST). Then, at 11 p.m., 1 mg of dexamethasone was given orally. The following day (post-DST), three saliva samples were collected at the same hours as before. The post-DST–pre-DST salivary cortisol Δ index was calculated for each collection time. The Risk-Rescue Ratio Scale (RRRS) and the Suicidal Intent Scale (SIS) were used to characterize the suicide attempt at inclusion and those occurring during the follow-up.ResultsPost-DST cortisol level at 9 p.m. was higher in patients with an initial violent or serious suicide attempt than in non-violent/non-serious attempters (p < .010). Higher post-DST cortisol at 9p.m. was associated with lower RRRS rescue score and higher clinical impression of suicide severity at inclusion. Among the 66 patients who completed the follow-up, 26 attempted suicide again at least once. Higher pre-DST cortisol at 8a.m. predicted new suicide attempts during the follow-up (OR = 2.15 [1.11, 4.15]), and higher cortisol Δ index at 9p.m. was associated with higher suicide intent during the follow-up.ConclusionsOur results suggest that HPA axis hyper-reactivity monitored with the DST is a marker of violent/serious suicide attempt with lower rescue possibility. Furthermore, higher changes between pre-DST and post-DST cortisol levels may predict higher suicide intent. These findings might help to characterize the biological features of nearest suicide phenotypes.

Contemporary Characteristics and Lethality Correlates of Serious Suicide Attempts in Children and Adolescents.

Adolescent suicide rates have increased in the past decade. Few studies have examined contemporary pediatric suicide attempters with medically serious suicide attempts, particularly among younger pediatric suicide attempters. This preliminary chart review study examined 200 adolescents with medically serious suicide attempts and sought to identify general cohort characteristics, differences in cohort characteristics based on age, correlates of lethality, and correlates of rescue (likelihood of prompt medical attention). Our study found that younger adolescents specifically endorsed increased cyberbullying (β=1.1, p=.046) and less hopelessness (β=-0.83, p=.02) compared to older adolescents. Suicide attempt lethality was negatively associated with female gender (β=-0.59, p=.041), rescue (β=-0.19, p=.005), an anxiety diagnosis (β=-0.81, p=.0003), and history of consensual sexual activity (β=-0.79, p=.002). Rescue was positively associated with an ADHD diagnosis (β=0.73, p=.018) and less attempt planning (β=0.96, p=.01), while a history of previous suicide attempt (β=-0.54, p=.04) and more proximal suicide attempt (β=-0.045, p=.008) were associated with a lower rescue score. Our preliminary findings suggest clinicians and future researchers may need to assess certain social and diagnostic factors in children and adolescents at particularly high risk for death by suicide.

Predicting suicidal behavior among lesbian, gay, bisexual, and transgender youth receiving psychiatric emergency services

Lesbian, gay, bisexual, and transgender (LGBT) youth are at elevated risk for self-injurious thoughts and behaviors (SITBs). However, few studies have comprehensively examined SITBs and their longitudinal course in LGBT youth at high risk for suicide. The aims of the present study were to characterize histories of SITBs among high-risk LGBT youth and to examine prospective associations with suicidal behavior. Participants were 285 youth (41.8% LGBT) ages 13–25 years receiving psychiatric emergency department (ED) services. Post-discharge suicidal behavior was assessed via 4-month phone interviews and 12 month chart reviews. The sample was 42.1% male, 57.9% female, 2.5% gender minority, 41.8% sexual minority. LGBT participants were more likely to have prior psychiatric ED visits and hospitalizations, more frequent past week suicide ideation, and more severe nonsuicidal self-injury (NSSI). We conducted stratified survival analyses to identify predictors of time to suicidal behavior post discharge. The final model for LGBT youth included past week suicide ideation and past month NSSI episodes. Among non-LGBT youth, the final model included number of lifetime NSSI methods and use of a highly lethal suicide attempt method. Within this sample of youth receiving psychiatric emergency services, LGBT youth were overrepresented and had more severe histories of SITBs. Results suggest the importance of assessing both lifetime and recent factors (i.e., past week and month), particularly for LGBT youth. Future research should replicate these findings in larger samples to explore whether there are unique risk factors that can aid in predicting and preventing suicide among LGBT youth.

A Comparative study of impulsivity, lethality and intent among patients attempting suicide by self-immolation and poisoning

Background: Suicide is one of the top ten leading causes of death in the world as well as India. Poisoning is one of the most common modes of attempting suicide. Self-immolation is a devastating form of suicide attempt. Impulsivity has been demonstrated as an important risk factor for suicide. Lethality and intent were found to be interrelated in previous studies. But a comparative study of impulsivity, lethality and intent between self-immolation and poisoning was not found in a literature search. Objectives: To compare socio-demographic characteristics, impulsivity, intent and lethality in those who attempt suicide by self-immolation and poisoning. To find the intercorrelations between intent, impulsivity and lethality. Methods: A cross-sectional comparative study was done among persons attempting suicide by self-immolation (n=40) and poisoning (n=50). Barratt's impulsivity scale, Smith's LSARS (lethality of suicide attempt rating scale) and Beck's suicide intent scale were used to assess impulsivity, lethality and intent, respectively. Percentages, mean, median and range were used to describe the data. Chi-square test, t-test and Pearson correlation were used for statistical analysis. Results and discussion: There were significant associations between occupation, family income and socioeconomic status and mode of suicide attempt. Lethality was higher in self-immolation. Lethality and intent were significantly intercorrelated in both groups. Impulsivity and lethality were negatively correlated in the self-immolation group. Conclusion: Self-immolation is a highly lethal method of attempting suicide. Highly lethal suicide attempts have high intent. Greater the impulsivity, less lethal the attempt is likely to be.

Childhood trauma predicts multiple, high lethality suicide attempts in patients with schizophrenia

Childhood trauma has been shown to increase the risk of suicide attempts in individuals with schizophrenia. However, previous literature has been limited by considerable heterogeneity within the category of suicide attempters. Here we tested the predictive effect of childhood maltreatment on lifetime suicide attempt in a homogeneous sample of 650 patients with schizophrenia spectrum disorders. Childhood trauma was assessed using the Childhood Trauma Questionnaire-Short Form and suicide history was measured using subjective and objective validated scales as well as medical chart reviews. We refined our sample into two homogenous groups: 1) suicide attempters: patients who had attempted suicide multiple times, with highly lethal results (medical hospitalization required) (n = 24); and 2) non-ideators: patients who had no personal history of suicide attempt or ideation, or family history of attempt (n = 25). Binary logistic regression models revealed that total childhood trauma (β = 0.002; OR: 1.07; 95% CI: 1.00–1.14) and emotional abuse (β = 0.04; OR: 1.38; 95% CI: 1.08–1.77), but not other trauma subtypes, significantly predicted lifetime multiple, high lethality suicide attempts after adjusting for demographic and clinical covariates. Thus, childhood trauma is a weak, independent risk factor for extreme suicide attempts in patients with schizophrenia spectrum disorders.

A comprehensive analysis of attempted and fatal suicide cases involving frequently used psychotropic medications

ObjectivesSelf-poisoning is the most common suicide method in non-lethal suicide attempts and the third most frequent in fatal suicides. Psychoactive drugs are often used for intentional self-poisoning. While poisons centre data typically focus on survived suicide attempts and underrepresent fatal self-poisoning, medical examiner reports give insight into suicide deaths. To close this gap, we combined and compared data sets from both sources, assessing the mortality of psychotropic drugs used for self-poisoning. MethodsAnonymized cases of self-poisoning with suicidal intention from 2000 to 2010 were extracted from the national poisons centre case database and compared with cases of suicide documented in the project “Suicides, a national survey”. All cases with single substance exposure to a psychoactive drug (antidepressants, mood stabilizers, antipsychotics, sedatives) were included in the analyses. Opioids, over-the-counter- and illicit- drugs were excluded from the analysis. A mortality index was calculated by the ratio of the number of suicides and the sum of all (lethal and non-lethal) suicide attempts. ResultsTricyclics had a higher mortality rate than other antidepressants. Among the sedatives, zolpidem was found to have a higher mortality index compared to benzodiazepines. Clozapine and levomepromazine were found to be the most lethal antipsychotics. Non-lethal suicide cases with single substance exposure (n = 4697) diminished as age increased, while the rate of suicide cases (n = 165) was higher in elderly subjects (>65 years of age, p < 0.001). ConclusionIn summary, our findings confirm previous study results on the relative toxicity of distinct classes of psychotropic drugs. In this comprehensive analysis of a national cohort lorazepam had a lower mortality rate compared to other sedatives.

Suicide attempt trends leading up to and following gun lock changes in the 2013 National Defense Authorization Act

PurposeFirearms account for the majority of suicide deaths in the US military and general population. The percentage of suicides resulting from firearms is higher in the military, however, and as such, the ratio of non-lethal to lethal suicide attempts is lower in the military than in the general population. In 2013, Congress passed the National Defense Authorization Act, which facilitated a Department of Defense (DoD) shift toward allowing commanding officers and clinicians to inquire about personal firearms with service members perceived as being at risk and also began giving free cable locks to firearm-owning military personnel. The purpose of this paper is to provide a preliminary understanding of the effectiveness of this change, the authors examined trends in firearm suicide attempts within the US military and general population from 2010 to 2015.Design/methodology/approachData on non-lethal and lethal suicide attempts overall and within specific methods were extracted from the Department of Defense Suicide Event Report and the Centers for Disease Control and Prevention’s Web-based Injury Statistics Query and Reporting System (2011–2015).FindingsContrary to expectations, firearms were not utilized in a smaller proportion of suicide attempts within the military post-law change. Consistent with expectations, however, the ratio of non-lethal to lethal suicide attempts increased, particularly after the change in law, with the ratio in the military converging somewhat with that of the general population.Originality/valueOverall, results were mixed, with only limited and tangential evidence that the change in law has proven effective. More precise data collection will be required in order to fully evaluate such laws.

The Association Between Dyslipidemia and Lethality of Suicide Attempts: A Case-Control Study.

Evidence supports the existence of an association between dyslipidemia, psychiatric disorders, and suicide risk due to the effects of altered lipid profiles on serotoninergic neuron membranes. The aim of this study was to investigate the differences in c-reactive protein (CRP), thyroid functioning, total cholesterol, high lipoprotein density cholesterol (HDL-c), low-lipoprotein density cholesterol (LDL-c), and triglycerides (TG) serum levels in low lethality (LLSA) vs. high lethality suicide attempters (HLSA) within 24 h from the suicide attempt and inpatients who never attempted suicide (NAS). After attempting suicide, subjects were admitted to the emergency ward of the IRCCS Ospedale Policlinico San Martino and later to the section of Psychiatry from 1st August 2013 to 31st July 2018. Socio-demographic and clinical characteristics, serum lipids profile, CRP, and thyroid functioning were collected. The sample consisted of 133 individuals with a HLSA, 299 subjects with LLSA, and 200 patients NAS. HLSA subjects were more likely to be males and diagnosed as having a bipolar disorder. Furthermore, HLSA subgroup showed significantly lower total cholesterol and LDL-c levels and higher CRP serum levels compared to LLSA and control group, respectively. LLSA subgroup showed higher HDL-c levels compared to HLSA subgroup (no differences between HLSA and control group were observed). Additionally, the control group reported higher triglycerides levels compared to patients admitted to psychiatric ward for a suicide attempt. Only male gender, having a diagnosis of bipolar disorder, lower total cholesterol, and higher CRP serum levels predicted HLSA. Investigating the relation between dyslipidemia and the severity of suicide attempts may contribute to reveal the complex determinants underlying at-risk behaviors such as suicide, thus playing a relevant role in the possible prevention of this disabling phenomenon.

Beyond the mental pain: A case-control study on the contribution of schizoid personality disorder symptoms to medically serious suicide attempts

BackgroundClinical and research findings have highlighted the role of interpersonal factors in suicidal behavior with high levels of intent and lethality. Schizoid personality disorder (SPD) is at the extreme end of interpersonal difficulties. Thus, we aimed to understand the contribution of SPD symptoms to suicide behavior and specifically to more lethal suicide attempts. MethodFour groups were investigated (N = 338): medically serious suicide attempters, medically non-serious suicide attempters, psychiatric and healthy controls. SPD symptoms, mental pain variants, and clinical characteristics were assessed. ResultsOverall, attempters were characterized by higher levels of most SPD symptoms. Solitary lifestyle and emotional detachment were higher among medically serious suicide attempters relative to less-serious attempters. Emotional detachment doubled the risk for high lethality, beyond mental pain variables. ConclusionsSPD symptoms of interpersonal difficulties and low levels of emotional expressions are important risk factors for more severe suicidal behavior. Implications for identification of at-risk groups for suicide are discussed.

Prolonged Risk of Suicide Reattempts in Patients with Alcohol Use Disorder and Acute Alcohol Use: A Register-Based Follow-Up Study (2010-2015).

ObjectiveThis study aimed to clarify the role of acute alcohol use and alcohol use disorder in individuals exhibiting suicidal behaviors, including repetition of suicide attempt. MethodsData pertaining to 691 suicide attempters who had visited an emergency center and had been followed-up from 2010 to 2015 were gathered. Participants were categorized into following three groups according to alcohol use pattern at the time of the suicide attempt: 1) suicide attempters with neither alcohol use disorder nor acute alcohol consumption (NAU), 2) suicide attempters who had used alcohol during the suicide attempt but did not have alcohol use disorder (AAU), and 3) suicide attempters with alcohol use disorder (AUD). Group comparisons and multivariate Cox proportional models for suicidal behavior were used for statistical analysis. ResultsAUD have been shown to have lower lethality of suicide attempt but higher risk of suicide reattempts in the future. Furthermore, positive relationships between suicide reattempts and AUD persisted throughout the longer period than other groups. ConclusionSuicide attempters with AUD should be considered a high-risk group for suicide reattempts in future, and this group should be followed-up for a longer period with specialized care program.

The role of seasonality and photoperiod on the lethality of suicide attempts: A case-control study.

The risk factors related to suicidal behaviors are complex and not yet fully known. Several studies underline how suicide results from the combination of psycho-social, biological, cultural, and environmental factors. The aim of this study was to investigate the potential role of seasonality and photoperiod on high-lethality suicide attempts (HLSA) compared with low-lethality suicide attempts (LLSA) in a sample of psychiatric inpatients. After attempting suicide, subjects were admitted in the emergency/psychiatric ward of the IRCCS Ospedale Policlinico San Martino from 1st August 2013 to 31st July 2018. Socio-demographic and clinical characteristics were collected. The sample consisted of four hundred thirty-two individuals admitted for suicide attempt. One hundred thirty-three subjects (30.8%) of the sample committed a HLSA. The HLSA group peaked in the months with a higher sunlight exposure (June and July). Bivariate correlation analyses between seasonality/photoperiod in the whole sample and HLSA were positively associated with summer and highest solar intensity period. Data were limited to a single hospital, patients' seasonal environment, meteorological variables and psychological factors. In addition, the presence of acute life-events fostering the suicidal crisis has not been investigated. The current study provides a novel perspective on the questions surrounding the impact of seasonality and daylight exposure on lethality of suicide attempts. further studies are needed to provide deeper understandings on the delicate molecular network that links suicide behaviors, seasonality and daylight in order to develop more effective prevention and treatment strategies in the future.

Lethality of Previous Suicidal Behavior among Patients Hospitalized for Suicide Risk Predicts Lethality of Future Suicide Attempts.

A suicide attempt is an established risk factor for subsequent suicide attempts and suicide. Nonetheless, the prediction of future suicidal behavior is poor. The lethality of previous suicidal behavior may be informative to better understand future suicide risk among patients hospitalized for suicidal thoughts and behavior. The current study examined whether the lethality of patients' index (most recent suicidal episode at hospitalization), first, and worst suicidal episode predicts the lethality of one's most lethal suicide attempt during a 2-year follow-up period. A total of 98 patients hospitalized at an emergency department for high suicide risk (i.e., acute suicidal ideation or a suicide attempt) were included in the study. Results indicated that the lethality of the index suicidal episode predicted the lethality of the worst suicide attempt during a 2-year follow-up period. These findings extend a growing literature examining risk factors that influence the progression toward high lethality suicidal behavior.

Gray matter volumetric study of major depression and suicidal behavior

Structural brain deficits are linked to risk for suicidal behavior. However, there is disagreement about the nature of these deficits, probably due to the heterogeneity of suicidal behavior in terms of the suicidal act's lethality. We hypothesized that individuals with major depressive disorder (MDD) and history of more lethal suicide attempts would have lower gray matter volume (GMV) of the prefrontal regions and insula compared with MDD lower-lethality attempters and MDD non-attempters. We collected structural MRI scans on 91 individuals with MDD; 11 with history of higher-lethality suicide attempts, 14 with lower-lethality attempts, and 66 were non-attempters. Differences in GMV between these three groups were examined using both regions-of-interest (ROI) and brain-wide voxel-based morphometry (VBM) analyses. Both ROI and VBM analyses showed that higher-lethality suicide attempters have greater GMV of the prefrontal cortical regions and insula, compared with the other two groups. Although this contrasts with our hypothesis, the observed larger prefrontal cortex GMV in higher-lethality suicide attempters may underlie the set of attributes observed previously in this suicidal subgroup, including enhanced suicide attempt planning, greater response inhibition, and delayed reward capabilities. Future studies should further examine the role of these brain regions in relation to suicidal intent and planning.

Single-Nucleotide Polymorphisms in Interleukin 6 (IL-6) Gene Are Associated with Suicide Behavior in an Iranian Population.

Previous association studies have demonstrated the association between immune regulatory genes and suicide behavior. Among these genes are those coding for cytokines. In the present study, we genotyped two interleukin 6 (IL-6) variants (rs2069845 and rs1800795) in 320 suicide attempters, 236 suicide completers, and 341 individuals without any history of psychiatric disorders or suicide ideation. The rs2069845 was not associated with suicide behavior. The rs1800795 C allele was significantly more common among suicide completers compared with suicide attempters (OR (95% CI) = 1.33 (1.04-1.71)), adjusted P = 0.04). Besides, the rs1800795 was associated with the lethality of suicide attempt in recessive model (adjusted P value = 0.01). Consequently, the present study supports the role of IL-6 in suicide behavior and warrants further researches to confirm its effect and explain the underlying mechanism.

The intensity of suicidal ideation at the worst point and its association with suicide attempts

This study seeks to determine if the severity of suicidal ideation at the worst point can differentiate individuals who think about suicide (ideators) from those who make a suicide attempt (attempters). Subsequently, the indirect effect of worst point ideation on differentiating ideators from attempters through various pathways such as an increased capability for suicide, painful and provocative experiences, non-suicidal self-injury (NSSI), and planning for suicide was examined. The sample included 229 adults with a lifetime history of suicidal ideation who were recruited through Amazon's Mechanical Turk program and asked to complete a battery of self-report questionnaires. Furthermore, the sample was oversampled on the basis of prior suicide attempts. Our results suggest that there is a strong relationship between worst point ideation and suicide attempts such that there is a greater likelihood of endorsing past suicide attempts when individuals reported high intensity at the worst point of their suicidal ideation. An elevated level of painful and provocative events partially accounted for the aforementioned relationship while a heightened capability for suicide. The results from the present study suggest utility in managing intensity of suicidal ideation and the importance of addressing painful and provocative behaviors to prevent potentially lethal suicide attempts in the future.

Disillusionment and Suicidality: When a Developmental Necessity Becomes a Clinical Challenge.

Both illusion and disillusion play an important role in development, fostering processes of going-on-being and separation (Winnicott 1960). The capacity to bear disillusionment is both a developmental necessity and an ongoing challenge. Disillusionment penetrates the sphere of illusion and invites the individual into an expanded encounter with shared realities. But when disillusionment becomes chronic and pervasive or is accompanied by severe psychic pain, then suicide is felt by some to be an urgent option for refusing or escaping this pain. Contextualized within a review of psychoanalytic developmental theories of disillusion, vignettes from a research study of participants who have survived a near lethal suicide attempt illuminate the phenomenon of suicide as an illusory solution to what feels like unbearable disillusionment.

Quantification of 5-HT1A and 5-HT2A receptor Binding in Depressed Suicide Attempters and Non-Attempters

Objective: To determine serotonin system abnormalities related to major depression or previous suicidal behavior.Methods: [11C]WAY100635, [18F]altanserin and positron emission tomography were used to compare 5-HT1A and 5-HT2A binding in MDD patients divided into eight past suicide attempters (>4yrs prior to scanning) and eight lifetime non-attempters, and both groups were compared to eight healthy volunteers.Results: The two receptor types differed in binding pattern across brain regions from each other, but there were no differences in binding between healthy volunteers and the two depressed groups or between depressed suicide attempters and non-attempters. No effects of depression severity or lifetime aggression were observed for either receptor.Conclusion: Limitations of this study include small sample size and absence of high lethality suicide attempts in the depressed attempter group. No trait-like binding correlations with past suicide attempt or current depression were observed. Given the heterogeneity of nonfatal suicidal behavior, a larger sample study emphasizing higher lethality suicide attempts may find the serotonin biological phenotype seen in suicide decedents.

Association between Impulsivity and Medical Lethality of Suicide Attempts among Suicide Attempters

Objectives Although impulsivity has long been thought as an important factor influencing suicidal behaviors, it is unknown whether impulsivity increases the risk of dying from suicidal behaviors and what specific component among constructs of impulsivity contributes to the risk of dying among suicid...

Aggression, impulsivity, and their predictive value on medical lethality of suicide attempts: A follow-up study on hospitalized patients

BackgroundThis study examined the role of aggressive-impulsive variants, and suicide history in predicting the medical severity of follow-up suicide attempts. Methods97 consecutive psychiatric in-patients who participated in earlier study 2–5 years previously. Thirty-three had a history of a medically serious suicide attempt (MSSA), 29 had a history of a medically non-serious suicide attempt (MNSSA), and 35 had no history of suicide. Participants completed a battery of instruments measuring aggressive-impulsive variables, hopelessness and communication difficulties. Findings were analyzed in relation to follow-up suicide attempts and their severity. Results32 patients (33%) had attempted suicide: 9 (9.27%) (including one death) MSSSA. Of these, 7 patients were MSSAs in the index attempt and 2 were MNSSAs in the index attempt. 23 (23.7%) MNSSA: Of these, 6 were MSSAs in the index attempt; 13, MNSSAs in the index attempt and 4 from the non-suicidal psychiatric group. 65 patients (67%) did not attempt suicide during the period since the index studies. Anger-out, violence impulsivity and hopelessness had significant positive correlations with medical severity of follow-up suicide attempts. Similar correlations were found between anger-out, violence and the amount of follow-up suicide attempts. A hierarchical regression analysis was conducted to determine contribution of study variables to severity of future suicide attempts. Severity of index attempt, hopelessness aggressive-impulsive variants and two interactions (medical severity of index suicide attempt X impulsivity and self-disclosure X anger-in) accounted for 44.7% of the variance of the medical severity of follow-up suicide attempts. Limitations(i) Possibly incomplete patient information, as some of the patients who participated in the index studies could not be located. (ii) Relatively small group of patients with an index MSSA. ConclusionsThe major findings of this paper are the predictive value of MSSA vs. MNSSA. The Lethality of future suicide attempt is closely linked to the lethality of former suicide attempt, impulsivity and hopelessness. Thus, patients who have made a suicide attempt should be assessed for medical severity of the attempt, impulsive-aggressive measures hopelessness, and communication difficulties, which are important factors in follow-up attempts.