What factors are associated with the repetition of suicidal behaviour?

by Andrés Pemau

Past behavior is often a good predictor of any future behavior. Suicide is no exception. Over the years, many studies have shown that a history of previous suicide attempts is one of the strongest predictors of both future attempts and death by suicide.

One might assume that after surviving a suicide attempt, the individual is no longer at risk. In an ideal world, they would have received the support that they need and be cared for by the healthcare system. However, for many, this isn’t the case and the emotional distress that led to the suicide attempt continues. This was captured powerfully by Rory O’Connor in his book When It Is Darkest where he talks about a man who had recently attempted suicide:

“When I asked how he felt now, after his suicide attempt, and whether anything had changed for him, he told me, tearfully: ‘No, nothing has changed. I don’t care. I feel the same way as I did last night. I feel as depressed and as useless as I did yesterday.’ (…) He had been diagnosed with an adjustment disorder and would soon be discharged, receiving no more support beyond a letter sent to his GP. (…) He was leaving hospital with more problems than when he had arrived barely conscious in an ambulance hours earlier.”

This is why it’s essential to recognize the ongoing risk these individuals face, to remain vigilant so that together we can prevent further attempts.

How many people make more than one suicide attempt?

This question is more complex than it might seem. Answering this question has been hampered by different terms and methodologies that have been used to study this issue, resulting in a wide range of estimated recurrence rates.

Globally, it is estimated that about one in five individuals who present at a hospital after a suicide attempt will make another attempt. However, the variability is striking. Some studies report repetition rates as high as 75%, while others report 0%. This wide variation prompts a crucial question: Why do some people attempt suicide again while others don’t?

What factors are associated with the repetition of suicidal behaviour?

As you’ll see below, a wide range of factors have been studied. However, none of the identified risk factors alone offer strong predictive power, although some patterns are particularly noteworthy.

Let’s start with demographic variables. Women, individuals with lower levels of education, those who are single, or unemployed appear to be at higher risk for multiple suicide attempts.

Psychological variables have also been studied. Individuals who have experienced trauma or stressful life events are at an increased risk of suicide attempt repetition. This risk is also elevated among those exhibiting higher levels of hopelessness or aggression.

Regarding mental health diagnoses, individuals with substance or alcohol use disorders are more likely to make another attempt. Likewise, those with anxiety or psychotic disorders also show an increased likelihood of repetition.

When examining the person’s history of suicidality, having multiple prior suicide attempts is one of the most significant predictors. So is the presence of active suicidal ideation at the time of assessment. Additionally, individuals who used cutting methods in their previous attempt show a higher risk of repeating the behaviour.

But generally speaking, people who repeat suicidal behaviour show a profile of greater symptom severity rather than distinctly different characteristics.

How can we explain repeat suicidal behaviour?

Beyond identifying risk factors, we must seek to understand the underlying mechanisms associated with recurrence. To this end, let’s turn to two of the theories of suicide.

The Interpersonal Theory of Suicide addresses this by introducing the concept of the “acquired capability for suicide,” which includes reduced fear of death and increased pain tolerance—both of which may increase following an initial attempt. In other words, the individual may become more “accustomed” or habituate to the idea and process of attempting suicide. This may increase the likelihood of a future suicide attempt if similar circumstances occur again.

The Integrated Motivational–Volitional Model also acknowledges the role of previous suicidal behaviors in the suicidal process. It highlights the cyclical nature of suicidal behaviour, suggesting that not only do past attempts increase the likelihood of future ones, but they may also accelerate the entire process—from the emergence of suicidal thoughts to the execution of the act. Previous attempts can also heighten distress and amplify other key risk factors, as we’ve seen.

What can we conclude?

Despite identifying many relevant risk factors, none offer sufficient predictive accuracy. Many of these factors are also present in individuals at risk of a first attempt, which makes them non-specific – and difficult to identify who is at risk of a future attempt.

These findings should reinforce a crucial point: no variable should be overlooked, and due to the lack of precise predictive tools, every individual who seeks help after a suicide attempt deserves—and needs—the highest level of care and attention.

Crucially, evidence shows that preventive interventions can reduce the risk of repetition. And most importantly, it is important to remember that those who reattempt are a minority.

Even more importantly, having attempted suicide does not mean a person is destined to die by suicide. The overwhelming majority of people who attempt suicide make a full recovery. With compassionate care and appropriate support, we can tackle the scourge of suicide attempts and suicide together.