Beyond impulsivity: planning in suicide reattempts at one-year follow-up in the SURVIVE cohort

Introduction and Objectives: Suicide represents a significant global public health issue. In 2019, it accounted for over 700,000 deaths worldwide, reflecting an age-standardized rate of 9.0 per 100,000 people [1]. Previous suicidal behavior is the strongest clinical predictor of future suicide reattempts [2], underscoring the need to better characterize risk factors associated with recurrence. Among these, impulsivity has been consistently linked to suicidal behavior, particularly to unplanned or less premeditated attempts. However, impulsivity is a multidimensional construct, and the extent to which trait impulsivity, as opposed to situational or state-related factors, contributes to the planning of suicidal behavior remains unclear. The distinction between planned and unplanned suicide reattempts is clinically relevant, as it may reflect different underlying psychological mechanisms and require tailored prevention strategies. Elucidating this distinction is essential to optimize risk assessment in secondary suicide prevention [3]. The aim of this study was to determine whether trait impulsivity predicts unplanned versus planned suicide reattempts in the longitudinal SURVIVE cohort of suicide reattempters, and to identify associated clinical predictors, including depressive symptomatology, acquired capability for suicide, reflective functioning, and substance use [4].

Methods

A total of 1,373 adults from the Spanish SURVIVE cohort were included and classified according to the recurrence of suicidal behavior during a 12-month prospective follow-up into single attempt (n = 1007), unplanned reattempt (n = 263), and planned reattempt (n = 103). Logistic regression analyses and multivariate models were conducted to assess the independent contribution of impulsivity measured by the Barratt Impulsiveness Scale (BIS), acquired capability for suicide measured by the Acquired Capability for Suicide Scale (ACSS), reflective functioning measured by the Reflective Functioning Questionnaire (RFQ), depressive symptomatology measured by the Patient Health Questionnaire-9 (PHQ-9) and the Brief Symptom Inventory depression subscale (BSI-Depression), and psychoactive substance use prior to the attempt assessed by the Columbia–Suicide Severity Rating Scale (CTA-related items).

Results

No dimension of trait impulsivity predicted planning. Acquired capability for suicide (OR = 1.03; 95% CI 1.01–1.06; p = 0.004), depressive symptomatology (OR = 1.03; 95% CI 1.01–1.06; p = 0.007), and psychoactive substance use prior to the attempt (OR = 1.87; 95% CI 1.08–3.27; p = 0.033) were independently associated with unplanned reattempts. Depressive symptomatology (OR = 1.62; 95% CI 1.29–2.04; p < 0.001) and tobacco use prior to the attempt (OR = 1.56; 95% CI 1.03–2.38; p = 0.04) were independently associated with planned reattempts. Acquired capability showed a trend toward significance in predicting planned reattempts (p = 0.053).

Conclusions

These findings did not provide evidence that suicide reattempt planning is driven by trait impulsivity [5]. Instead, acquired capability and psychoactive substance use prior to the attempt appear to play a more prominent role in unplanned reattempts. Notably, depressive symptomatology emerged as a consistent predictor across both planned and unplanned reattempts, suggesting a transdiagnostic and clinically relevant factor. These results highlight the importance of systematically assessing and treating depressive symptoms, as well as addressing substance use, in order to improve risk stratification and enhance the effectiveness of secondary suicide prevention strategies.

References

1. World Health Organization. Suicide worldwide in 2019: Global health estimates. Geneva: World Health Organization
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3. Beckman, K., Lindh, A. U., Waern, M., Stromsten, L., Renberg, E. S., Runeson, B., & Dahlin, M. (2019). Impulsive suicide attempts among young people: A prospective multicentre cohort study in Sweden. Journal of Affective Disorders, 243, 421–426. https://doi.org/10.1016/j.jad.2018.09.070
4. Pérez, V., Elices, M., Toll, A., Bobes, J., López-Solà, C., Díaz-Marsá, M., Grande, I., López-Peña, P., Rodríguez-Vega, B., Ruiz-Veguilla, M., de la Torre-Luque, A., & SURVIVE Group. (2023). The Suicide Prevention and Intervention Study (SURVIVE): Study protocol for a multisite cohort study with nested randomized-controlled trials. Revista de Psiquiatría y Salud Mental, 16(1), 16–23. https://doi.org/10.1016/j.rpsm.2020.11.004
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