Clinical Summary: Risk Factors for Suicide Attempts and Psychiatric Hospitalization Among Brazilian Health Care Professionals
Health care professionals in emotional distress need rapid suicide risk stratification, especially during sustained crises such as the COVID-19 pandemic when sleep disruption, burnout, and suicidal thoughts are common. This study identifies which baseline factors most strongly separated those who later attempted suicide or required psychiatric hospitalization over 24 weeks, highlighting a small subgroup with markedly elevated near-term risk.
Key Findings
- Baseline suicidal ideation on PHQ-9 item 9 showed the strongest independent association with suicide attempts in the multivariable model: HR=39.58, 95% CI, 14.03–111.64, P<.001 for “nearly every day,” HR= 7.67, 95% CI, 2.32–25.35, P<.001 for “more than half of the days,” and HR =3.17, 95% CI, 1.42–7.07, P=.005 for “several days.”
- Sleep problems remained independently associated with suicide attempts after adjustment: severe sleep HR=17.39, 95% CI, 2.05–147.46, P=.009; moderate sleep HR= 12.10, 95% CI, 1.55–94.24, P=.017; and mild sleep HR =9.96, 95% CI, 1.23–80.43, P=.031.
- The combination of nearly every day suicidal ideation and severe sleep problems identified the highest-risk group: 24-week attempt probabilities were 57.1% with both factors, 42.3% with ideation alone, 12.3% with severe sleep alone, and 1.2% with neither (log-rank P<.001); additive interaction showed RERI was 11.51, attributable proportion of 0.40, and synergy index of 1.66.
- For psychiatric hospitalizations, only nearly every day ideation retained significance in the multivariable model (HR = 8.11, 95% CI, 3.10–21.18, P < .001); depression, anxiety, sleep, and life satisfaction lost significance after adjustment.
- PHQ-9 item 9 had sensitivity of 71.7%, specificity of 77.8%, PPV of 12.9%, and NPV of 98.3% for predicting suicide attempts; the clinical risk score combining ideation, sleep, and sex achieved AUC= 0.83 (95% CI, 0.77–0.89), with attempt rates of 0.8% for low risk, 4.2% for moderate risk, 18.7% for high risk, and 45.3% for very high risk.
In distressed Brazilian health care professionals, suicidal ideation was the clearest predictor of both suicide attempts and psychiatric hospitalization, and sleep disturbance added substantial independent risk for suicide attempts. Daily suicidal ideation plus severe sleep problems marks an urgent high-risk subgroup that warrants immediate, integrated intervention.
Practice Implications
- Do not rely on PHQ-9 item 9 alone for high-risk decisions: its PPV was 12.9%, but its NPV was 98.3%, so it is more useful for ruling out than ruling in risk and should be followed by a fuller suicide risk assessment.
- Treat severe sleep disturbance as a suicide risk signal in its own right, not just as a symptom of depression or anxiety, because sleep remained independently associated with suicide attempts after multivariable adjustment.
- Escalate monitoring and preventive intervention when nearly every day suicidal ideation and severe sleep problems co-occur, since the 24-week attempt probability reached 57.1% in this subgroup.
- Consider structured triage using the article’s clinical risk score combining ideation, sleep, and sex, which showed AUC= 0.83 and separated attempt rates from 0.8% to 45.3% across risk strata.
