The findings of the present study confirm previous research suggesting that a high level of suicidal intent is a significant predictor of both subsequent death and suicide following a suicide attempt. Moreover, high suicidal intent scores at index attempt seem to be a more powerful predictor of eventual suicide than previous attempts or hopelessness.
To our knowledge, this is the first follow-up study of attempted suicide in Finland to include regions beyond the capital area, and is thus more representative of the country as a whole than earlier studies. As no differences in mortality between the four regions emerged, our findings support the generalizability of our previous findings from Helsinki-based cohorts to other parts of the country. The extensive structured interview and case report method used in the present study is comprehensive and provides a broad picture of suicide attempters and their outcomes. Most previous studies have been based on hospital records only or have included only attempters referred for psychiatric consultation or attempts made by self-poisoning.
The disadvantage of an interview study is that some patients refuse to participate. In this study no significant differences were found in sociodemographic variables between the interviewees and the entire suicide attempt population [19
]. The only statistically significant difference was that the male interviewees were more likely to have received psychiatric consultation than the other men in the entire parasuicide population [19
]. Thus we cannot exclude the possibility of overrepresentation of more severe cases in our initial parasuicide sample. However, our sample appears to be representative of those suicide attempters who are sufficiently motivated to stay in health care. The main limitation of the present study is that we were unable to use a structured diagnostic interview for all patients and thus could not include the DSM-diagnoses as possible risk factors. Previous studies have found that the vast majority of suicide attempters suffer from mental disorders [32
]. However, there appears to be only one previous study with 30 months of follow-up using structured diagnostic information [37
The overall mortality of suicide attempters was remarkably high, in accordance with previous studies [17
]: a fifth of the cohort died during the 12-year follow-up. The risk for suicide (8%) in the present study is consistent with the findings of a recent review of fatal repetition of self-harm [42
]. Most previous studies have found significant gender differences in suicide and overall mortality after attempted suicide [17
]. Somewhat surprisingly, we did not detect a statistically significant gender difference in suicide mortality in the present study. We cannot, however, exclude the possibility that male suicide attempters who were more motivated to stay in health care and to participate in the interviews and psychiatric consultation were selected. It has been found that patients who discharge themselves before completing initial management have a considerably increased rate of repetition [46
]. Furthermore, males with higher intent may have used more lethal methods and died rather than survived at an index attempt. Although the cohort was collected from several cities, the sample size remained moderate, and due to limited statistical power, we cannot rule out the possibility of gender differences in suicide mortality. However, male gender was a risk factor for death by all causes during the follow-up. These latter results accord with Nordentoft et al. [16
], who found male gender to be a predictive factor for death by all causes, but not for suicide during a ten-year follow-up period in Denmark.
Previously, hopelessness has been found predictive of actual suicide, both in psychiatric outpatients [13
] and in hospitalized suicide ideators [12
]. However, these studies measured only hopelessness and depression, not level of suicidal intent. Furthermore, in a sample of hospitalized suicide attempters a diagnosis of alcoholism and the SIS Precautions subscale predicted eventual suicide [47
], not hopelessness. In addition, Nimeus et al. [48
] found in a similar sample of suicide attempters with different diagnoses that the Hopelessness Scale was an unsatisfactory instrument for predicting future suicide; hopelessness was better associated with mood disorders. On the other hand, in patients with affective disorders [11
] degree of hopelessness appeared to be an important factor predicting eventual suicide, although its significance may depend on the history of drug and alcohol abuse [49
Very few follow-up studies after attempted suicide have used a comprehensive interview including known scales for assessing the severity of the attempt. Most follow-up studies have had small clinical samples or been large epidemiological studies without structured interview information. Thus, strongly significant risk factors for subsequent suicide, particularly high suicidal intent, may have remained undetected. Suicide attempters with high intent is a risk group of patients with high suicide and overall mortality, therefore various possibilities of surveillance may be considered. However, as the suicide risk remains high for decades, a more feasible approach might be focusing clinical attention to periods of likely elevated risk, such as episodes of depression.