Suicide is preventable and not inevitable. Despite this, more than 720,000 people die by suicide every year, and there are many more people who will make a suicide attempt in their lifetime (World Health Organisation, 2024). It is well established that suicide involves a complex and dynamic interaction of biological, psychological, environmental, and socio-cultural factors (O’Connor, 2011). Nevertheless, a wealth of evidence has demonstrated the strong association between psychiatric disorders, including major depressive disorder, personality disorders and psychotic disorders, and elevated risk of suicide among different populations (Baldessarini & Tondo, 2020; Bradvik, 2018).
Notably, mainstream suicidology, psychiatric and medical disciplines have typically theorised death by suicide to be the end result of psychiatric disorders, or mental illnesses (Hjelmeland & Jaworski, 2019; White, 2017). However, as Marsh (2016) asserts, these claims have often been framed as ‘unassailable truths’ which have dominated perspectives on suicide, and therefore also suicide prevention efforts. Critically though, it has been argued that the complexity and socio-cultural formation of suicidality cannot be understood, or responded to, within this perspective (White, 2017). As such, it is important to emphasise that an individual who has experienced suicidal distress, or survived a suicide attempt, may not have also experienced psychiatric disorders or mental illness. This fact reminds us that discourses of risk, rather than a person’s individual lived experiences or needs, have often framed our understanding of suicidal distress, thus limiting our responses to suicide prevention.
In the current study, Oquendo and colleagues (2024) aimed to address the lack of available evidence on lifetime suicide attempts among otherwise healthy individuals, who had not met the criteria for any psychiatric disorders prior to their first attempt.
Is suicide simply the ‘end result’ of mental illness or can it occur outside of mental illness?
Methods
The researchers conducted secondary analysis of existing cross-sectional data using the US National Epidemiological Study of Addictions and Related Conditions III (NESARC-III), a nationally representative population-based survey from 2012-2013. The overall sample was comprised of 36,309 participants who were aged between 20 and 65 years old. Among those who had experienced a lifetime suicide attempt, the aim was to estimate the percentage of people whose first suicide attempt occurred before the onset of any psychiatric disorder. Data analysis was conducted using SAS, and the main outcomes and measures were:
- Demographics including age group, sex, race and ethnicity
- Lifetime suicide attempt frequencies among overall sample (n=36,309)
- Among the sub-sample (n=1948), who were individuals who had experienced a lifetime suicide attempt, the self-reported presence or absence of a psychiatric disorder before the first lifetime suicide attempt
- Among sub-sample, separate analyses for sex differences (male/female), and age differences were also conducted (20-34, 35-49, and 50-65 years)
Results
From the overall sample of 36,309 participants, 1948 individuals had experienced one or more suicide attempts in their lifetime (5.2%; 95% CI, 4.8% to 5.6%). From this sub-sample, 66.8% (95% CI, 64.1% to 69.4%) were female, and 33.3% (95% CI, 30.6% to 35.9%) were male. The vast majority of these participants were White (70.9%), and the others were Hispanic (14%), Black (9.8%), American Indian or Alaska Native (3.5%), and Asian, Native Hawaiian or Other Pacific Islander (1.8%).
Participants without any psychiatric diagnosis
The study reported that 6.2% (95% CI, 4.9% to 7.4%) of participants who had made a suicide attempt in their lifetime did not meet the criteria for a lifetime psychiatric disorder at the time of the survey administration. Additionally, an estimated 13.4% (95% CI, 11.6% to 15.2%) of individuals had reported that their first suicide attempt occurred before any psychiatric disorder onset. Therefore, an estimated total of 19.6% respondents in the sub-sample had experienced a suicide attempt in their lifetime without an antecedent psychiatric disorder.
Sex differences
Notably, there were no significant sex differences in the percentage of individuals with lifetime suicide attempts who did not have a psychiatric disorder, nor in those reporting a lifetime suicide attempt before the onset of any psychiatric disorder. However, females (n=195) were more likely to have made a suicide attempt during the same year as the onset of their first psychiatric disorder (14.9%; 95% CI, 12.5% to 17.3%) than males. Moreover, males (n=410) were more likely to have made a suicide attempt after the onset of a psychiatric disorder (70%; 95% CI, 65.2% to 74.9%) compared to females (60.3%; 95% CI, 56.9% to 63.7%).
Age differences
There were no significant differences across the three age groups in relation to the likelihood of reporting a lifetime suicide attempt without a psychiatric disorder, nor were there any significant differences in the onset of suicide attempts across the lifespan relative to the onset of psychiatric diagnoses between the three specified age groups.
This research suggests that not all people who have made a suicide attempt in their lifetime have experienced psychiatric disorders, or mental illness.
Conclusions
The authors conclude that:
These data suggest that suicide risk-reduction strategies attending solely to individuals with psychiatric disorders, even if those strategies were to result in perfect detection and prevention, would miss about 20% of people who go on to attempt suicide.
Focussing suicide prevention efforts only on those who have previously experienced a psychiatric disorder would miss around 20% of people who go on to attempt suicide.
Strengths and limitations
This cross-sectional study provides us with important and novel findings which demonstrate that not all people who make a suicide attempt in their lifetime will have experienced psychiatric disorders, or mental illness, prior to their suicide attempt (19.6%). Although the study analysed data from a substantial overall sample of 36,309 individuals, the sub-sample of those who had made a suicide attempt in their lifetime (n=1948) was relatively small for a cross-sectional study of this nature. Additionally, cross-sectional studies have inherent limitations in relation to establishing cause and effect, susceptibility of bias, and self-reporting bias where participants may misreport information. Moreover, as the author acknowledges, the NESARC-III survey does not include all diagnoses such as autism spectrum, obsessive-compulsive, and intermittent explosive disorders which are associated with increased likelihood of suicide attempts across ones’ lifetime (Hirvikoski et al., 2019; Pellegrini et al., 2020).
Given their findings, the authors go some way towards suggesting that suicidal behaviour may not necessarily be pathological. However, they also assert that suicide attempts may “manifest like other psychiatric disorders, which are often comorbid with each other” (p.576). Additionally, they recommend that suicidal behaviour be recorded as a separate psychiatric disorder, which would lead to a uniform definition and a diagnostic code which would be useful for clinicians. Although this recommendation has positive implications for suicide risk screening, and thus suicide prevention, other scholars have challenged the notion that suicidal behaviour is inevitably pathological, and that it should be classified as a psychiatric disorder (Hjelmeland & Jaworski, 2019; Marsh, 2016; White, 2017).
While the large overall sample size strengthens the findings, limitations include a small sub-sample of suicide attempters, self-reporting bias, and excluded diagnoses, raising important questions about how we define and address suicidal behavior
Implications for practice
The findings of this cross-sectional study have significant implications for clinical practice, policymakers, future research, and suicide prevention policies or strategies. Oquendo and colleagues suggest that a history of suicidal behaviour or suicide attempts should be recorded by clinicians, regardless of whether an individual has a psychiatric diagnosis or not. This is particularly important since a previous history of suicidal behaviour has been shown to be associated with an increased likelihood of future attempts, and death by suicide. The authors also suggest that recording suicidal behaviour as a separate psychiatric disorder may lead to a more uniform definition and diagnostic code, which may prove useful for suicide prevention.
The current suicide risk reduction strategies are not detecting an estimated one-fifth of individuals who have experienced a suicide attempt in their lifetime. Consequently, suicide risk screening should be expanded beyond psychiatric populations and those who have a pre-existing mental illness diagnosis. Clinicians and mental health professionals should be aware that suicidal behaviour may manifest separately, or as comorbidities associated with psychiatric disorders or mental illness and should therefore obtain and record the history of an individual’s experiences with suicidal behaviour, regardless of whether the person has a pre-existing psychiatric disorder or not.
Health and social care policies should consider implementing broader screening protocols for suicide risk among different populations. It may be useful for screening to occur at hospitals, doctor surgeries, behavioural health organisations, and other healthcare settings. Health and social care policies should consider implementing broader screening protocols for suicide risk among different populations. It may be useful for screening to occur at hospitals, doctor surgeries, behavioural health organisations, and other healthcare settings.
There remains limited research on suicide risk among populations that do not have a pre-existing psychiatric disorder or mental illness. Future research could explore the complex factors which may be associated with increased likelihood of suicide attempt among this population, using national healthcare data. Using national healthcare data may improve patient safety, improve care and therefore reduce suicide risk.
This research suggests that it may be helpful to screen everyone for previous experiences of suicide, not just those with existing psychiatric diagnoses.
Statement of interests
The author has no competing interests to declare.
Links
Primary paper
Oquendo MA, Wall M, Wang S, Olfson M, Blanco C. Lifetime Suicide Attempts in Otherwise Psychiatrically Healthy Individuals. JAMA Psychiatry. 2024;81(6):572–578. doi:10.1001/jamapsychiatry.2023.5672
Other references
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Hirvikoski, T., Boman, M., Chen, Q., D’Onofrio, B. M., Mittendorfer-Rutz, E., Lichtenstein, P., … & Larsson, H. (2020). Individual risk and familial liability for suicide attempt and suicide in autism: a population-based study. Psychological medicine, 50(9), 1463-1474.
Hjelmeland, H., Jaworski, K., Knizek, B., & Marsh, I. (2019). Problematic advice from suicide prevention experts. Ethical Human Psychology and Psychiatry, 20(2), 79-85.
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