Suicide Attempts Without Psychiatric Diagnosis: Understanding the Facts

Suicide is a preventable tragedy that affects millions worldwide, with over 720,000 lives lost each year. This statistic underscores the critical need for effective suicide prevention strategies. Many individuals will attempt suicide at some point in their lives, as reported by the World Health Organization (2024). Research indicates that suicide is influenced by a variety of complex factors, including biological, psychological, environmental, and socio-cultural aspects (O’Connor, 2011). Importantly, there is a significant relationship between psychiatric disorders—such as major depressive disorder, personality disorders, and psychotic disorders—and an increased risk of suicide among diverse populations (Baldessarini & Tondo, 2020; Bradvik, 2018).

Traditionally, suicide has been viewed through the lens of mental illness, with mainstream suicidology and psychiatry positing that suicide is primarily a result of psychiatric disorders (Hjelmeland & Jaworski, 2019; White, 2017). However, as noted by Marsh (2016), these perspectives often present themselves as ‘unassailable truths,’ which can overshadow the multifaceted nature of suicidality. This perspective limits our understanding of the socio-cultural contexts that contribute to suicidal behavior (White, 2017). Consequently, it is essential to recognize that individuals who experience suicidal distress or who survive suicide attempts may not necessarily have a history of psychiatric disorders. This understanding challenges the notion that risk discourses should solely define our approaches to suicide prevention, allowing for a more nuanced response to the needs of individuals.

The recent study conducted by Oquendo and colleagues (2024) seeks to fill a crucial gap in the existing literature. Their research focuses on individuals who have made lifetime suicide attempts without any prior psychiatric disorders, aiming to shed light on this overlooked population.

Research Methodology for Understanding Suicide Attempts

The researchers employed a secondary analysis approach, utilizing data from the US National Epidemiological Study of Addictions and Related Conditions III (NESARC-III), which represents a comprehensive national survey conducted from 2012 to 2013. The study involved a total of 36,309 participants aged between 20 and 65 years. Among those who reported a lifetime suicide attempt, the research aimed to determine the percentage of individuals whose initial attempt occurred prior to the onset of any psychiatric disorder. Data analysis was performed using SAS software, focusing on several key outcomes and measures:

• Demographic data, including age group, sex, race, and ethnicity

• Frequency of lifetime suicide attempts within the total sample (n=36,309)

• Among a sub-sample (n=1948), self-reported presence or absence of a psychiatric disorder before the first lifetime suicide attempt

• Separate analyses for sex and age differences within the sub-sample (20-34, 35-49, and 50-65 years)

Key Findings on Lifetime Suicide Attempts

From the total participant pool of 36,309, a notable 1948 individuals (5.2%; 95% CI, 4.8% to 5.6%) reported having made one or more suicide attempts in their lifetime. Within this sub-sample, the majority were female, accounting for 66.8% (95% CI, 64.1% to 69.4%), while males comprised 33.3% (95% CI, 30.6% to 35.9%). A significant portion of the participants identified as White (70.9%), with the remainder comprising Hispanic (14%), Black (9.8%), American Indian or Alaska Native (3.5%), and Asian, Native Hawaiian, or Other Pacific Islander (1.8%).

Understanding Suicide Attempts Among Participants Without Psychiatric Diagnoses

The study revealed that 6.2% (95% CI, 4.9% to 7.4%) of participants who reported a lifetime suicide attempt did not meet the criteria for any lifetime psychiatric disorder at the time of the survey. Furthermore, approximately 13.4% (95% CI, 11.6% to 15.2%) indicated that their first suicide attempt took place prior to the onset of any psychiatric disorder. Collectively, this indicates that around 19.6% of respondents in this sub-sample experienced a lifetime suicide attempt without an antecedent psychiatric diagnosis.

Analyzing Sex Differences in Suicide Attempts

Interestingly, the analysis indicated no significant sex differences in the percentage of individuals with lifetime suicide attempts lacking a psychiatric disorder, nor in those reporting an attempt prior to the onset of any psychiatric disorder. However, it was observed that females (n=195) were more likely to have made a suicide attempt in the same year that their first psychiatric disorder emerged (14.9%; 95% CI, 12.5% to 17.3%) compared to males. In contrast, males (n=410) were more likely to have made a suicide attempt following the onset of a psychiatric disorder (70%; 95% CI, 65.2% to 74.9%) than females (60.3%; 95% CI, 56.9% to 63.7%).

Exploring Age Differences in Suicide Attempts

The study did not find significant differences across the three specified age groups regarding the likelihood of reporting a lifetime suicide attempt without a psychiatric disorder. Additionally, there were no notable differences in the timing of suicide attempts relative to the onset of psychiatric diagnoses across the three age categories.

Insights and Recommendations for Suicide Prevention

The authors of the study draw a critical conclusion, stating that:

These findings suggest that suicide risk-reduction strategies that focus exclusively on individuals with psychiatric disorders would overlook nearly 20% of those who ultimately attempt suicide.

Evaluating the Study’s Strengths and Limitations

This cross-sectional study presents groundbreaking findings that reveal that not all individuals who attempt suicide have a history of psychiatric disorders or mental illness prior to their attempts (19.6%). While the analysis involved a large overall sample size of 36,309 participants, the sub-sample of individuals who had made a suicide attempt (n=1948) was relatively small for such a comprehensive study. Furthermore, cross-sectional studies are inherently limited in their ability to establish causality, and they are susceptible to bias, including self-reporting bias where participants may inaccurately report their experiences. Additionally, as acknowledged by the authors, the NESARC-III survey does not encompass all psychiatric diagnoses, such as autism spectrum disorder, obsessive-compulsive disorder, and intermittent explosive disorder, which are linked to a heightened risk of suicide attempts (Hirvikoski et al., 2019; Pellegrini et al., 2020).

Based on their findings, the authors propose that suicidal behavior may not inherently indicate a pathological condition. However, they also contend that suicide attempts can “manifest like other psychiatric disorders, which are often comorbid with each other” (p.576). Moreover, they advocate for the classification of suicidal behavior as a distinct psychiatric disorder, which would provide a standardized definition and diagnostic code beneficial for clinicians. Although this recommendation could enhance suicide risk screening and prevention efforts, other scholars have questioned the idea that suicidal behavior is invariably pathological and should be classified as a psychiatric disorder (Hjelmeland & Jaworski, 2019; Marsh, 2016; White, 2017).

Transforming Suicide Prevention Practices

The insights derived from this cross-sectional study hold significant implications for clinical practices, policymakers, future research, and suicide prevention strategies. Oquendo and colleagues emphasize the necessity for clinicians to document any history of suicidal behavior or attempts, regardless of the presence of a psychiatric diagnosis. This approach is vital, as previous suicidal behavior has been correlated with an increased risk of future attempts and death by suicide. The authors also suggest that acknowledging suicidal behavior as a distinct psychiatric disorder could lead to a more standardized definition and diagnostic code, which would be advantageous for suicide prevention efforts.

Current suicide risk reduction strategies may be overlooking nearly one-fifth of individuals who have attempted suicide in their lifetime. Therefore, it is essential to broaden suicide risk screening beyond individuals with psychiatric disorders or existing mental health diagnoses. Mental health professionals should be aware that suicidal behaviors can manifest independently or in conjunction with psychiatric disorders, and thus they must gather and record comprehensive histories of suicidal experiences, irrespective of any prior psychiatric conditions.

Health and social care policies should prioritize implementing wider screening protocols for suicide risk across various demographics. Such screenings could be beneficial in settings including hospitals, physician offices, behavioral health organizations, and other healthcare environments. Addressing suicide risk in a broader context aims to enhance the effectiveness of prevention strategies.

There is a critical need for further research focusing on suicide risk within populations that do not have pre-existing psychiatric disorders or mental illnesses. Future studies could delve into the myriad factors that contribute to the increased likelihood of suicide attempts among these individuals, utilizing national healthcare data to improve patient safety, enhance care, and ultimately reduce suicide risk.

Disclosure of Interests

The author has no competing interests to declare.

Essential Links for Further Reading

Primary Research Article

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

Relevant References

Baldessarini, R. J., & Tondo, L. (2020). Suicidal risks in 12 DSM-5 psychiatric disorders. Journal of affective disorders, 271, 66-73.

Brådvik, L. (2018). Suicide risk and mental disorders. International journal of environmental research and public health, 15(9), 2018.

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.

Marsh, I. (2016). Critiquing Contemporary Suicidology. In J. White, I. Marsh, M. Kral, & J. Morris (Eds.), Critical Suicidology—Transforming suicide research and prevention for the 21st century (pp. 15–30). UBC Press.

Probert-Lindström, S., Bötschi, S., & Gysin-Maillart, A. (2024). The influence of treatment latency on suicide-specific treatment outcomes. Archives of suicide research, 28(3), 1009-1021.

Pellegrini, L., Maietti, E., Rucci, P., Casadei, G., Maina, G., Fineberg, N. A., & Albert, U. (2020). Suicide attempts and suicidal ideation in patients with obsessive-compulsive disorder: A systematic review and meta-analysis. Journal of affective disorders, 276, 1001-1021.

White, J. (2017). What can critical suicidology do? Death Studies, 41(8), 472–480. https://doi.org/10.1080/07481187.2017.1332901.

World Health Organisation. (2024). Suicide. https://www.who.int/news-room/fact-sheets/detail/suicide.

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