How to Stratify Six-Month Reattempt Risk After a Suicide Attempt
How should clinicians classify a recent suicide attempter into higher- or lower-risk groups for suicide reattempt or suicide within 6 months?
The first 6 months after a suicide attempt are a high-risk period for both nonfatal recurrence and suicide. This guide applies to adults evaluated after a suicide attempt and uses a simple set of baseline clinical factors from the French ALGOS cohort to structure near-term risk stratification.
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Confirm that the patient fits the article's target population
Apply this workflow to adults who survived a suicide attempt within the previous 7 days, which matches the population studied in the ALGOS cohort. The study excluded patients without suicidal intent, those who were homeless, those under guardianship, and multirepeaters defined as more than 4 suicide attempts in the last 3 years.
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Assess alcohol use disorder
At baseline, determine whether the patient has alcohol use disorder using the same type of screening approach used in the study, which relied on MINI screening questions corresponding to DSM-IV and ICD-10 criteria. Alcohol use disorder was one of the main branching factors in the survival tree and must be identified before applying the rest of the algorithm.
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Ask whether acute alcohol was used during the index attempt
For patients with alcohol use disorder, determine whether there was acute alcohol use during the suicide attempt that led to the current evaluation. In the highest-risk alcohol-related subgroup, 38 of 127 patients with alcohol use disorder and acute alcohol use reattempted or died by suicide within 6 months, whereas none of the 19 patients with alcohol use disorder but without acute alcohol use reattempted.
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Count suicide attempts in the past 3 years
Determine the number of previous suicide attempts in the past 3 years. A history of more than 2 suicide attempts in that period defined one of the higher-risk subgroups; among 46 patients without alcohol use disorder and with more than 2 prior attempts in the past 3 years, 12 reattempted, with RR 2.11 compared with the root node.
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Screen for anxiety disorder
Assess for anxiety disorder, specifically generalized anxiety disorder or panic disorder, using the same MINI-based screening approach described in the article. In the survival tree, anxiety disorder helped identify a subgroup with increased concern among patients without alcohol use disorder and without a high recent repetition burden.
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Classify the patient into poor- or good-prognosis group
Place the patient in the poor-prognosis group if any of the following are present: alcohol use disorder with acute alcohol use during the last suicide attempt, anxiety disorder, or more than 2 suicide attempts in the past 3 years. Classify all other patients in the good-prognosis group, which was the simplified clinician-facing algorithm proposed by the authors.
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Use the classification to structure follow-up planning
Interpret a poor-prognosis classification as indicating higher risk of suicide reattempt within 6 months, with HR 1.78 compared with the good-prognosis group. Use the result to support post-attempt follow-up planning rather than as a stand-alone disposition rule, because the algorithm had sensitivity 0.8 and negative predictive value 0.94 but modest specificity 0.47, positive predictive value 0.19, and AUC 0.63.
Clinical Considerations
- The simplified algorithm had only modest overall discrimination, with an AUC of 0.63, so it should not replace clinical judgment.
- About 9.5% of the cohort was lost to follow-up at 6 months, which may affect the precision of the observed recurrence estimates.
- Baseline psychiatric assessment covered only 4 disorders from the MINI, so the algorithm does not incorporate other psychiatric conditions that may also influence risk.
- The study was conducted in France, where alcohol use disorder is common, which may limit extrapolation to other settings.
Bottom Line
After a suicide attempt, classify patients as poor prognosis if they have alcohol use disorder with acute alcohol use during the attempt, anxiety disorder, or more than 2 suicide attempts in the past 3 years, and use that result to intensify 6-month follow-up planning rather than to make decisions in isolation.
