A first suicide attempt is an even greater risk factor for a completed suicide than previously appreciated, and the great majority of completed suicides occur within a year of the first attempt, a new cohort study shows.

The findings suggest that first suicide attempts may be "even more lethal than we knew," the authors state in the article's title. However, it appeared that hospitalization following the attempt, as well as a scheduled follow-up visit with a psychiatrist significantly, reduced that risk.

"Historical studies are frequently limited to samples looking at individuals who have not been recruited from their initial attempt, and first attempters who die are also often excluded from the purview of these studies," Alastair McKean, MD, assistant professor of psychiatry, Mayo Clinic College of Medicine, Rochester, Minnesota, told Medscape Medical News.

"So we hoped our design would address these shortcomings — by recruiting based on first attempt presenting for medical attention and by including those dying on first attempt," he said. "By doing this, we argue that our study presents a more accurate picture of the suicide rate for those who attempt suicide at all."

The study was published online August 13 in the American Journal of Psyciatry.

The Rochester Epidemiology Project identified 1490 residents living in Olmsted County, Minnesota, who had attempted suicide at some point between January 1, 1986, and December 31, 2007.

During the study period, 81 of 1490 participants, or 5.4% of the overall cohort, died by suicide, lead author Michael Bostwick, MD, professor of psychiatry, Mayo Clinic, Rochester, and colleagues report.

Of these 81 persons who completed suicide, almost 60% died on their first attempt. Close to 82% of the remaining survivors killed themselves within a year of their first attempt.

The mean age of individuals who died on their first attempt was 33.2 years; the mean age was 41.6 years for those who died on a subsequent attempt.

The highest rates of death by suicide on the first attempt were among those between 25 and 44 years of age as well as those aged 65 years and older.

"For those dying from subsequent suicide attempts, the prevalence increased across the lifespan," the authors write.

For example, almost 12% of men between 45 and 64 years of age who had survived an initial attempt died by suicide during this interval, as did more than 23% of men aged 65 years and older.

In contrast, none of the 12 women who were 65 years of age or older who had survived their first attempt died by suicide later on.

Indeed, risk factors for suicide completion following the initial attempt were older age and male sex.

That said, the authors say it was "noteworthy" that almost 1 in 10 males from 15 to 24 years of age in the suicide cohort killed themselves. This rate was not much different from the 1 in 9 men between the ages of 24 and 44 who died by suicide.

Men were more prone to use guns to commit suicide than women, but "females using guns were just as likely as their male counterparts to die on the index suicide attempt," they write.

Dr McKean noted that the lethality of firearms and the fact that they are commonly used in completed suicides, at least in the United States, was borne out in their study, as firearms were responsible for close to 75% of deaths on the first suicide attempt.

Being hospitalized following the first attempt — at least on a medical or psychiatric ward — significantly reduced the risk for subsequent suicide attempts.

More importantly, a scheduled follow-up appointment with a psychiatrist proved to be "highly protective" against subsequent suicide attempts, as patients who had a follow-up appointment were 79% less likely to kill themselves than those who had no follow-up appointment.

"It is difficult to overstate what an important public health issue suicide is, and prevention clearly needs to start well before the first attempt coming to medical attention," Dr McKean observed.

However, as he also pointed out, there is evidence to suggest that almost half of people who die by suicide have met with their primary care provider in the month before the attempt. This suggests that there needs to be more active collaboration between mental health services and primary care practitioners to help address what remains a substantial problem.

The authors also suggest that research initiatives should be undertaken to identify people at risk for their first suicide attempt, and direct suicide prevention efforts should be directed toward those at high risk.

Medically Serious Attempt

Asked by Medscape Medical News to comment on the study, Timothy Lineberry, MD, adjunct clinical professor of psychiatry, University of Wisconsin, Madison, who was formerly with the Mayo Clinic but who was not involved in the study, emphasized that the sample in the current analysis had come to medical attention because they had made a medically serious attempt, and so they were a group at higher risk for death by suicide than patients who do not come to medical attention.

Nevertheless, "the finding about the increased risk [for a completed suicide] within the first year of the initial attempt is a significant and critical finding, and I think these authors have a better sample to look at that than many of the others do," Dr Lineberry said.

The findings again indicate the profound danger associated with firearms and suicide in the United States and support efforts to restrict firearm sales, or at least to impose some kind of waiting period before allowing individuals to purchase a gun, he added.

"The study also emphasized the need for larger efforts to be made towards identifying people at risk for suicide attempt," Dr Lineberry said.

"And it also emphasized the surprising but critical nature of ensuring people get follow-up after a medically serious suicide attempt and the protective nature of that follow-up visit," he added.

"So we absolutely need to make sure people get in for follow-up and treatment after an attempt, and even a brief treatment with cognitive-behavioral therapy that is suicide specific can decrease suicide attempts after a patient has made an attempt."

The study was made possible through resources of the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health. Neither the authors nor Dr Lineberry have disclosed any relevant financial relationships.

Am J Psychiatry. Published online August 13, 2016. Abstract