Toward a clinical model of suicidal behavior in psychiatric patients

Objective: Risk factors for suicide attempts have rarely been studied compr ehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of sui cide attempts in patients with mood disorders, psychoses, and other diagnos es. Their goal was to determine the generalizability and relative importanc e of risk factors for suicidal acts across diagnostic boundaries and to dev elop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study. Method: Following admission to a university psychiatric hospital, 347 consecutive patients wh o were 14-72 years old (51% were male and 68% were Caucasian) were recruite d for study. Structured clinical interviews generated axis I and axis II di agnoses. Lifetime suicidal acts, traits of aggression and impulsivity, obje ctive and subjective severity of acute psychopathology, developmental and f amily history, and past substance abuse or alcoholism were assessed. Result s: Objective severity of current depression or psychosis did not distinguis h the 184 patients who had attempted suicide from those who had never attem pted suicide. However, higher scores on subjective depression, higher score s on suicidal ideation, and fewer reasons for living were reported by suici de attempters. Rates of lifetime aggression and impulsivity were also great er in attempters. Comorbid borderline personality disorder, smoking, past s ubstance use disorder or alcoholism, family history of suicidal acts, head injury, and childhood abuse history were more frequent in suicide attempter s. Conclusions: The authors propose a stress-diathesis model in which the r isk for suicidal acts is determined not merely by a psychiatric illness (th e stressor) but also by a diathesis. This diathesis may be reflected in ten dencies to experience more suicidal ideation and to be more impulsive and, therefore, more likely to act on suicidal feelings. Prospective studies are proposed to test this model.