Five-Year Outcomes of First Suicide Attempts: Insights on Lethality, Recurrence, and Mortality

Eugènia Nicolau-Subires, MD; Maria Irigoyen-Otiñano, MD, PhD; Laura Arenas-Pijoan, MD; Marina Adrados-Pérez, MD; Carla Albert-Porcar, MD; Lucía Ibarra-Pertusa, MD; María Mur-Laín, MD, PhD; Jorge Lopez-Castroman, MD, PhD; Vicent Llorca-Bofí, MD

J Clin Psychiatry 2025;86(4):24m15754

Abstract

Introduction: Suicide is a leading cause of death globally. Although prior suicidal behavior is the strongest predictor of future attempts, clinical outcomes following a first suicide attempt (FSA) remain poorly understood. This study evaluates 5-year outcomes after an FSA, focusing on recurrence, lethality, and mortality to address gaps in understanding clinical trajectories and risk factors.

Methods: A cohort of 387 FSA patients was followed for 5 years. Sociodemographic and clinical data were collected at baseline and during follow-up. Outcomes included recurrence, lethality of subsequent attempts, and all-cause mortality. Multivariable logistic and Cox regression models were used to identify risk factors.

Results: During follow-up, 37.2% of patients experienced recurrence, with 27.8% classified as frequent reattempters (≥3 attempts). Overall, 5.7% of participants died, including 1.8% by suicide. High-lethality FSAs were observed in 17.3% of the sample and were strongly associated with alcohol use (odds ratio [OR], 2.142; 95% CI, 1.231–3.724; P=.021). Female sex was a significant risk factor for multiple reattempts (OR, 2.388; 95% CI, 1.036–5.507; P=.041). High-lethality FSAs significantly increased the risk of suicide deaths (hazard ratio [HR], 5.430; 95% CI, 1.189–24.792; P=.029), while older age was associated with a higher risk of nonsuicidal deaths (HR, 1.093; 95% CI, 1.035–1.153; P=.001).

Conclusions: Lethality, recurrence, and mortality following an FSA are influenced by distinct risk factors. Alcohol use predicted high-lethality FSAs, female sex predicted multiple reattempts, high-lethality FSAs predicted suicide deaths, and age predicted nonsuicidal deaths. Targeted interventions for these high-risk populations are needed.

J Clin Psychiatry 2025;86(4):24m15754

Author affiliations are listed at the end of this article.

Members Only Content

This full article is available exclusively to Professional tier members. Subscribe now to unlock the HTML version and gain unlimited access to our entire library plus all PDFs. If you’re already a subscriber, please log in below to continue reading.

Subscribe Now

Already a member? Log in

References (61)

Suicide worldwide in 2019: Global Health Estimates. World Health Organization; 2019. Accessed August 19, 2025:4–9. https://www.who.int/publications/i/item/9789240026643.
Sher L, Oquendo MA. Suicide: an overview for clinicians. Med Clin North Am. 2023;107(1):119–130. PubMed CrossRef
Franklin JC, Ribeiro JD, Fox KR, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull. 2017;143(2):187–232. PubMed CrossRef
Irigoyen M, Porras-Segovia A, Galván L, et al. Predictors of re-attempt in a cohort of suicide attempters: a survival analysis. J Affect Disord. 2019;247:20–28. PubMed CrossRef
Parra-Uribe I, Blasco-Fontecilla H, Garcia-Parés G, et al. Risk of re-attempts and suicide death after a suicide attempt: a survival analysis. BMC Psychiatry. 2017;17(1):1–11. PubMed
Pemau A, Marin-Martin C, Diaz-Marsa M, et al. Risk factors for suicide reattempt: a systematic review and meta-analysis. Psychol Med. 2024;54(9):1897–1904. PubMed CrossRef
de la Torre-Luque A, Pemau A, Ayad-Ahmed W, et al. Risk of suicide attempt repetition after an index attempt: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2023;81:51–56. PubMed
Kreitman N, Casey P. Repetition of parasuicide: an epidemiological and clinical study. Br J Psychiatry. 1988;153:792–800. PubMed CrossRef
Carroll R, Metcalfe C, Gunnell D. Hospital management of self-harm patients and risk of repetition: systematic review and meta-analysis. J Affect Disord. 2014;168:476–483. PubMed CrossRef
Liu BP, Lunde KB, Jia CX, et al. The short-term rate of non-fatal and fatal repetition of deliberate self-harm: a systematic review and meta-analysis of longitudinal studies. J Affect Disord. 2020;273:597–603. PubMed CrossRef
Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry. 2002;181(9):193–199. PubMed CrossRef
Oh SH, Kim HJ, Kim SH, et al. Which deliberate self-poisoning patients are most likely to make high-lethality suicide attempts? Int J Ment Health Syst. 2015;9:35. PubMed CrossRef
Levi-Belz Y, Beautrais A. Serious suicide attempts. Crisis. 2016;37(4):299–309. PubMed CrossRef
Aguglia A, Solano P, Parisi VM, et al. Predictors of relapse in high lethality suicide attempters: a six-month prospective study. J Affect Disord. 2020;271:328–335. PubMed CrossRef
Czernin S, Vogel M, Flückiger M, et al. Cost of attempted suicide: a retrospective study of extent and associated factors. Swiss Med Wkly. 2012;142:w13648. PubMed CrossRef
Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064–2074. PubMed CrossRef
Gvion Y, Levi-Belz Y. Serious suicide attempts: systematic review of psychological risk factors. Front Psychiatry. 2018;9(3):56. PubMed CrossRef
Beautrais AL. Subsequent mortality in medically serious suicide attempts: a 5 year follow-up. Aust N Z J Psychiatry. 2003;37(5):595–599. PubMed CrossRef
Beautrais AL. Further suicidal behavior among medically serious suicide attempters. Suicide Life Threat Behav. 2004;34(1):1–11. PubMed CrossRef
Cai Z, Junus A, Chang Q, et al. The lethality of suicide methods: a systematic review and meta-analysis. J Affect Disord. 2022;300:121–129. PubMed CrossRef
Irigoyen-Otiñano M, Puigdevall-Ruestes M, Mur-Laín M, et al. Absence of association between the level of lethality and the recidivism of suicide attempts in a Spanish province. Actas Esp Psiquiatr. 2019;47(5):179–189. PubMed
Nicolau-Subires E, Llorca-Bofí V, Arenas-Pijoan L, et al. Lethality and recidivism in suicide attempters: a longitudinal study. J Psychiatr Res. 2025;189:148–156. PubMed CrossRef
Park CHK, Lee JW, Lee SY, et al. Suicide risk factors across suicidal ideators, single suicide attempters, and multiple suicide attempters. J Psychiatr Res. 2020;131:1–8. PubMed CrossRef
Tachikawa H, Takahashi S, Nemoto K, et al. Predictive factors for recurrent suicide attempts: evidence from the ACTION-J study. PCN Rep. 2022;1(2):e7. PubMed CrossRef
Quesada-Franco M, Braquehais MD, Valero S, et al. A comparison of medically serious suicide attempters admitted to intensive care units versus other medically serious suicide attempters. BMC Psychiatry. 2022;22(1):805–810. PubMed CrossRef
Aguglia A, Solano P, Parisi VM, et al. Predictors of relapse in high lethality suicide attempters: a six-month prospective study. J Affect Disord. 2020;271:328–335. PubMed CrossRef
Irigoyen-Otiñano M, Llorca-Bofí V, Adrados-Pérez M, et al. The MCOSUL Cohort: lethality, recurrence, and mortality in suicide attempts in the Lérida Region, Spain—Rationale, objectives, and preliminary findings. Psiquiatr Biológica. 2024:100548.
World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–2194. PubMed CrossRef
von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–349. PubMed CrossRef
American Psychiatric Association. DSM-IV Text Revision (DSM-IV-TR). 4th ed. Text Rev. American Psychiatric Association; 2000.
Silverman MM. The language of suicidology. Suicide Life Threat Behav. 2006;36(5):519–532. PubMed CrossRef
Beautrais AL. Suicides and serious suicide attempts: two populations or one? Psychol Med. 2001;31(5):837–845. PubMed CrossRef
Beck AT, Schuyler D, Herman I. Development of suicidal intent scales. In: BecK AT, Resnik HL, Lettieri DJ, eds. The Prediction of Suicide. Charles Press Publishers; 1974:45–58.
Wisniewski SR, Leon AC, Otto MW, et al. Prevention of missing data in clinical research studies. Biol Psychiatry. 2006;59(11):997–1000. PubMed CrossRef
Hidalgo B, Goodman M. Multivariate or multivariable regression? Am J Public Health. 2013;103(1):39–40. PubMed CrossRef
Jafari M, Ansari-Pour N. Why, when and how to adjust your P values? Cell J. 2019;20(4):604–607. PubMed CrossRef
Esmaeili ED, Farahbakhsh M, Sarbazi E, et al. Predictors and incidence rate of suicide re-attempt among suicide attempters: a prospective study. Asian J Psychiatr. 2022;69:102999. PubMed CrossRef
Bommersbach TJ, Olfson M, Rhee TG. National trends in emergency department visits for suicide attempts and intentional self-harm. Am J Psychiatry. 2024;181(8):741–752. PubMed CrossRef
Instituto Nacional de Estadística. 2023
Demesmaeker A, Chazard E, Vaiva G, et al. Risk factors for reattempt and suicide within 6 months after an attempt in the French ALGOS cohort: a survival tree analysis. J Clin Psychiatry. 2021;82(1):20m13589. PubMed CrossRef
Qadeer Shah A, Prasad D, Caropreso L, et al. The comorbidity between borderline personality disorder (BPD) and generalized anxiety disorder (GAD): a systematic review and meta-analysis. J Psychiatr Res. 2023;164:304–314. PubMed CrossRef
Cohen LJ, Imbastaro B, Peterkin D, et al. A suicide-specific diagnosis—the case for. Crisis. 2023;44(3):175–182. PubMed CrossRef
Galynker, I, Bloch-Elkouby, S, Cohen, LJ. Suicide crisis syndrome: a specific diagnosis to aid suicide prevention. World Psychiatry. 2024;23(3):362–363. PubMed CrossRef
Bloch-Elkouby S, Yanez N, Chennapragada L, et al. The narrative crisis model of suicide: a novel and empirically grounded diathesis-stress model of suicide. Suicide Risk Assess Prev. 2022;1-16;151–166.
Bloch-Elkouby S, Rogers ML, Goncearenco I, et al. The narrative crisis model of suicide: a review of empirical evidence for an innovative dynamic model of suicide and a comparison with other theoretical frameworks. Personalized Med Psychiatry. 2024;45:100131.
Bloch-Elkouby S, Barzilay S, Gorman BS, et al. The Revised Suicide Crisis Inventory (SCI-2): validation and assessment of prospective suicidal outcomes at one month follow-up. J Affect Disord. 2021;295:1280–1291. PubMed CrossRef
Blasco-Fontecilla H, Jaussent I, Olié E, et al. A cross-sectional study of major repeaters: a distinct phenotype of suicidal behavior. Prim Care Companion CNS Disord. 2014;16(4). doi: 4088/PCC.14M01633 PubMed CrossRef
Irigoyen-Otiñano M, Puigdevall-Ruestes M, Prades-Salvador N, et al. Further evidence for major repeaters as a subgroup of suicide attempters. Rev Psiquiatr Salud Ment. 2018;11(1):19–26.
Amiri S, Behnezhad S. Alcohol use and risk of suicide: a systematic review and meta-analysis. J Addict Dis. 2020;38(2):200–213. PubMed CrossRef
Lange S, Jiang H, Kaplan MS, et al. Association between Acute alcohol use and firearm-involved suicide in the United States. JAMA Netw Open. 2023;6(3):e235248–e235248.3;6(3):e235248–e235248. PubMed CrossRef
Castillo-Carniglia A, Keyes KM, Hasin DS, et al. Psychiatric comorbidities in alcohol use disorder. Lancet Psychiatry. 2019;6(12):1068–1080. PubMed CrossRef
Nagin DS. Group-based trajectory modeling: an overview. Ann Nutr Metab. 2014;65(2–3):205–210. PubMed CrossRef
Hirot F, Ali A, Azouvi P, et al. Five-year mortality after hospitalisation for suicide attempt with a violent method. J Psychosom Res. 2022;159:110949. PubMed CrossRef
Jokinen J, Talbäck M, Feychting M, et al. Life expectancy after the first suicide attempt. Acta Psychiatr Scand. 2018;137(4):287–295. PubMed CrossRef
Suominen K, Isometsä E, Suokas J, et al. Completed suicide after a suicide attempt: a 37-year follow-up study. Am J Psychiatry. 2004;161(3):562–563. PubMed CrossRef
Giner L, Jaussent I, Olié E, et al. Violent and serious suicide attempters: one step closer to suicide? J Clin Psychiatry. 2014;75(3):e191–e197. PubMed CrossRef
Witt K, Pirkis J, Scott D, et al. Trajectories in suicide attempt method lethality over a five-year period: associations with suicide attempt repetition, all-cause, and suicide mortality. PloS One. 2021;16(1):e0245780. PubMed CrossRef
Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry. 2003;182(6):537–542. PubMed CrossRef
Liu BP, Jia CX, Qin P, et al. Associating factors of suicide and repetition following self-harm: a systematic review and meta-analysis of longitudinal studies. eClinicalMedicine. 2022;49:101461. PubMed CrossRef
Barker J, Oakes-Rogers S, Leddy A. What distinguishes high and low-lethality suicide attempts in older adults? A systematic review and meta-analysis. J Psychiatr Res. 2022;154:91–101. PubMed CrossRef
Jordan JT, McNiel DE. Characteristics of persons who die on their first suicide attempt: results from the National Violent Death Reporting System. Psychol Med. 2020;50(8):1390–1397. PubMed CrossRef