ISSN-L 0227-5910 · ISSN-Print 0227-5910 · ISSN-Online 2151-2396

Published under the Auspices of the International Association of Suicide Prevention (IASP)

Crisis
The Journal of Crisis Intervention
and Suicide Prevention

Volume 30 / Number 1 / 2009

www.hogrefe.com/journals/crisis

Crisis — The Journal of Crisis Intervention and Suicide Prevention

Editors-in-Chief
Abstracted/Indexed in:
Diego De Leo Index Medicus/ Medline
Associate Editors Current Contents/
Ad J. F. M. Kerkhof Social & Behavioral Sciences (CC/S&BS)
Maria A. Oquendo Social Sciences Citation Index (SSCI)
Social SciSearch
PsycINFO
PsyINDEX
Scopus
Published under the Auspices of the International Association for Suicide Prevention (IASP)

Your article has appeared in a journal published by Hogrefe Publishing. This e-

offprint is provided exclusively for the personal use of the authors. It may not be
posted on a personal or institutional website or to an institutional or disciplinary
repository.

If you wish to post the article to your personal or institutional website or to

archive it in an institutional or disciplinary repository, please use either a pre-print
or a post-print of your manuscript in accordance with the publication release for
your article and our “Online Rights for Journal Articles”
(www.hogrefe.com/journals).
 Author's personal copy (e-offprint)

W.-C. Chien et al.: Evidence-B ased Data Analysis of Repeated SuicideCrisis

© 2012 Hogrefe Attempts
Publishing
2012

Research Trends

A Nation-Wide Evidence-Based Data

Analysis of Repeated Suicide Attempts
Wu-Chien Chien1, Ching-Huang Lai1, Chi-Hsiang Chung2, Lu Pai3,
and Wei-Ting Chang2
1
School of Public Health, National Defense Medical Center, Taiwan, Republic of China, 2Graduate
Institute of Life Sciences, National Defense Medical Center, Taiwan, Republic of China, 3Institute of
Injury Prevention and Control, Taipei Medical University, Taiwan, Republic of China

Abstract. Background: Taiwan is a high-risk area for suicide. Repeated suicide attempts are an important factor of suicide mortality. Yet
there has been little research on the factors associated with repeated suicidal behavior in Taiwan. Aims: To explore the characteristics of
repeated suicide attempts. Methods: Data were obtained from the National Health Insurance Research Database for 2005 to 2008. We
then classified repeated suicide attempts into single method, two different methods, and three different methods. Results: A total of 1,004
inpatients were admitted to Taiwanese hospitals due to repeated suicide attempts, and the use of a single suicide method constituted the
majority of the cases (71%). Risk factors related to repeated suicide attempts included being female, aged 30–39, suicide by poisoning
using solid and/or liquid substances, the fall season, living in Northern Taiwan, more psychiatric nature of injury codes (N-codes), seeking
medical attention from a psychiatrist, receiving more surgeries or procedures, a longer length of stay in a hospital, coming from a
low-income background, and having a serious illness. Conclusions: Consultation and treatment are particularly crucial for patients with
mental illnesses and other concomitant diseases, so that the psychiatric symptoms such as auditory and visual hallucinations can be
controlled.

Keywords: repeated suicide attempts, National Health Insurance Research Database

is beyond estimation (Department of Health Executive

Background
According to a 2002 report by the World Health Organiza-
tion (WHO), suicide is the fourteenth leading cause of
death worldwide, constituting 1.5% of all deaths, at an av-
erage rate of 16.7 per 100,000 people. For the past 45 years,
the rate of suicide has risen by 60% worldwide. It is esti-
mated that one million lives will be lost in 2020 as a result
of suicide, a rate of one case of suicide every 40 seconds
(Peden et al., 2008). By 2030, the number of suicides
worldwide is estimated to be 1.5 times higher than the cur-
rent number (Mathers & Loncar, 2006).
According to the WHO, Taiwan is a high-risk area for
suicide (with a rate of more than 13 cases per 100,000 peo-
ple) (World Health Organization, 2009). Taiwanese domes-
tic statistics showed that suicide has risen from the tenth
leading cause of death in 1997 to ninth leading cause in
1999. From 1986 to 2009, the suicide rate increased from
11.58 to 27.7 per 100,000. In adolescents aged 15–24, sui-
cide is a major cause of death, second only to unintentional
injuries, while in adults aged 25–44 it is the third leading
cause of death, preceded only by malignant tumors and un-
intentional injuries. The potential loss of life from suicide
Yuan, ROC, 2010).
Suicide also causes tremendous economic losses to so-
ciety. The literature reveals that, among all intentional in-
juries, suicide results in the highest burden in developed
countries (Goldsmith, 2002). In the United States alone,
annual productivity losses resulting from suicide are as
high as 11.8 billion USD (Goldsmith, 2002). During the
next few decades, it is projected that the global burden of
disease (GBD) from suicide will grow even larger (Mathers
& Loncar, 2006).
Repeated suicide attempts are a major risk factor of sui-
cide mortality (Christiansen & Jensen, 2007). Past research
suggests that each prior suicide attempt increases the rela-
tive risk of a following suicide attempt (Leon, Friedman,
Sweeney, Brown, & Mann, 1990). One fifth of all suicide
attempters repeat a suicide attempt within 1 year after the
first attempt, resulting in deaths in 10%–14% of these peo-
ple. The 3- to 6-month timeframe following a suicide
attempt represents a high-risk period for repeated suicide
attempts (Nordström, Samuelsson, & Asberg, 1995). Fur-
thermore, the methods employed by the attempters serve
as a predictor of repeated attempts, particularly poisoning
by gas, cutting and piercing, jumping from high places, and

© 2012 Hogrefe Publishing Crisis 2012

DOI: 10.1027/0227-5910/a000157
 Author's personal copy (e-offprint)
2 W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts
intentional traffic injuries (Christiansen & Jensen, 2007).
The methods used to attempt suicide may reflect how
strongly the attempter’s intention is to die; a fiercer, more
intense way of trying to commit suicide indicates a higher
desire of death (Christiansen & Jensen, 2007; Nordström
et al., 1995). Some researchers have suggested that the
more violent the method chosen by first-time suicide at-
tempters, the higher the risk of repeated attempts (Chris-
tiansen & Jensen, 2007). But there has been little research
done on the factors associated with repeated suicidal be-
havior in Taiwan. This study aimed to fill this gap by iden-
tifying the epidemiological characteristics of patients hos-
pitalized for repeated suicide attempts. A better under-
standing of these factors should enable a better grasp of
how to prevent suicide, prevent repeated suicide attempts,
and reduce potential deaths.
Methods
This study was conducted using the “inpatient expenditures
by admissions” and “registry for contracted medical facil-
ities” data sourced from Taiwan’s National Health Insur-
ance Research Database from 2005 through 2008. Since its
launch on March 1, 1995, the NHI has reached a coverage
rate of 99% in Taiwan (National Health Research Institutes,
ROC, 2011). In addition, patients hospitalized as a result
of repeated suicide attempts are defined as people who are
admitted twice or more for suicide attempts during the
study period. Therefore, a patient would be included in this
study if he or she had two hospitalization records or more
for suicides between 2005 and 2008.
Our research was reviewed and approved by the Profes-
sional Peer Review Committee, and the ID of patients had
already encrypted in NHI Research Database in Taiwan;
therefore, our research complied with the Helsinki Decla-
ration and preserved patient anonymity.
Based on ICD-9-CM E-codes, suicide methods consists
of nine categories: “poisoning by solid or liquid substances
(E950),” “poisoning by gases in domestic use (E951),”
“poisoning by other gases and vapors (E952),” “hanging
(E953),” “drowning (E954),” “firearms (E955),” “use of
cutting and piercing instruments (E956),” “jumping from
high places (E957),” and “other means (E958).” We clas-
sified repeated suicide attempts into three categories: using
only one method, two different methods, and three different
methods.
Moreover, we categorized hospitalization as the follow-
ing: hospitalization due to repeated suicide attempts and
hospitalization due to nonrepeated (single) suicide at-
tempts. The chi-square test was adapted to analyze the cor-
relation between hospitalization and different variables.
Logistic regression was employed to calculate the impact
of demographic characteristics, suicide methods, and med-
ical factors on the odds ratio of repeated suicide attempts
Crisis 2012
versus nonrepeated suicide attempts. Statistical analyses
were performed using the software SPSS 18.0.
Results
From 2005 to 2008, a total of 1,004 people were hospital-
ized due to repeated suicide attempts, contributing to 5.7%
of all hospitalized suicides. There were 426 men and 578
women hospitalized due to repeated suicide attempts. Fe-
male patients made up a larger share of those hospitalized
due to repeated suicide attempts than among hospitalized
patients resulting from nonrepeated suicide attempts. The
majority of patients hospitalized due to repeated suicide
attempts were aged 20–39. In addition, the proportion of
people aged 20–59 in this group was higher than that in
patients hospitalized for nonrepeated suicide attempts.
With regards to the type of methods used to commit suicide,
the most common method was poisoning by solid or liquid
substances (E950), followed by injury by cutting and/or
piercing instruments (E956), and poisoning by other gases
or vapor (E952) (Table 1).
Further analysis showed that 65.8% of male patients
hospitalized for repeated suicide attempts using E950 were
aged 20–49, whereas 50.9% of female patients hospitalized
for repeated suicide attempts using the same method were
aged 30–49. Patients aged 20–39 consisted of 62.5% and
59.0% of male and female hospitalized patients, respective-
ly, for repeated suicide attempts using E952. Patients aged
20–39 contributed to 52.9% and 63.9% of male and female
hospitalized patients, respectively, of repeated suicide at-
tempts using E956 (Table 2).
The majority of people using only one suicide method
employed E950. The largest number of people using two
different suicides methods chose E950 and E956. On the
other hand, among people using three suicide methods, the
largest number used a combination of E950, E956, and
E958. However, analyses of each suicide method chosen
by the patients hospitalized for repeated suicide attempts
revealed that, in general, 713 employed only one suicide
method, followed by 284 people who used two different
methods. Moreover, 4 people out of all those who had been
hospitalized six times due to repeated suicide attempts used
two different suicide methods, whereas those with two,
three, four, or five records of hospitalization used only one
suicide method and consisted of a majority (Table 3).
Diagnostic codes (N-codes) (e.g., schizophrenic disor-
ders [295], affective psychoses [296]) are used to group and
identify disease in this study. Of the 1,004 patients hospi-
talized for repeated suicide attempts, 670 had been diag-
nosed with mental illness, 511 of whom had one N-code
and 159 of whom had two or more N-codes. Only 46.5%
of the patients hospitalized for nonrepeated suicide at-
tempts had been diagnosed with mental illness. While
18.6% of the patients hospitalized for repeated suicide at-
tempts had previously visited the psychiatric department,
© 2012 Hogrefe Publishing
 Author's personal copy (e-offprint)

W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts 3

Table 1. Demographic characteristics of patients hospitalized for repeated and nonrepeated suicide attempts during
2005–2008
Repeated suicide attempts Nonrepeated suicide attempts Total
Sex*
Male ,426 42.4% 7,867 48.0% 8,293 47.7%
Female ,578 57.6% 8,510 52.0% 9,088 52.3%
Age*
10–19 ,36 3.6% ,788 4.8% ,824 4.7%
20–29 ,240 23.9% 3,783 23.1% 4,023 23.1%
30–39 ,246 24.5% 3,579 21.9% 3,825 22.0%
40–49 ,232 23.1% 3,094 18.9% 3,326 19.1%
50–59 ,123 12.3% 1,763 10.8% 1,886 10.9%
60–69 ,42 4.2% 1,381 8.4% 1,423 8.2%
70–79 ,48 4.8% 1,282 7.8% 1,330 7.7%
80–89 ,34 3.4% ,648 4.0% ,682 3.9%
≥ 90 ,3 0.3% ,59 0.4% ,62 0.4%
Methods
Solid or liquid (E950) ,606 60.4% 9,510 58.1% 10,116 58.2%
Gases in domestic use (E951) ,2 0.2% ,54 0.3% ,56 0.3%
Other gases and vapors (E952) ,134 13.3% 2,209 13.5% 2,343 13.5%
Hanging (E953) ,22 2.2% ,420 2.6% ,442 2.5%
Drowning (E954) ,9 0.9% ,121 0.7% ,130 0.7%
Firearms (E955) ,1 0.1% ,31 0.2% ,32 0.2%
Cutting and piercing (E956) ,151 15.0% 2,849 17.4% 3,000 17.3%
Jumping (E957) ,28 2.8% ,340 2.1% ,368 2.1%
Others (E958) ,51 5.1% ,843 5.1% ,894 5.1%
Season*
Spring (March–May) ,237 23.6% 4,339 26.5% 4,576 26.3%
Summer (June–August) ,273 27.2% 4,282 26.1% 4,555 26.2%
Fall (September–November) ,286 28.5% 4,085 24.9% 4,371 25.1%
Winter (December–February) ,208 20.7% 3,671 22.4% 3,879 22.3%
Area*
Northern Taiwan ,381 37.9% 5,517 33.7% 5,989 33.9%
Central Taiwan ,272 27.1% 5,235 32.0% 5,507 31.7%
Southern Taiwan ,333 33.2% 5,135 31.4% 5,468 31.5%
Eastern Taiwan ,18 1.8% ,483 2.9% ,501 2.9%
Offshore islands ,0 0 ,7 0.04% ,7 0.04%
Total 1,004 100.0% 16,377 100.0% 17,381 100.0%
Note. *p < .05 (χ² test).

only 7.5% of patients hospitalized for nonrepeated suicide
attempts had done so. Among patients hospitalized for re-
peated suicide attempts, the percentage receiving surgery
and other procedures was lower. The proportion of patients
who had been hospitalized for 5 days or more was higher
in patients with repeated suicide attempts. Among those
with repeated suicide attempts, the percentage that visited
regional hospitals was significantly higher. Low-income
individuals constituted 5.6% of patients hospitalized for re-
peated suicide attempts compared to only 2.7% in patients
with nonrepeated suicide attempts. There were an in-
creased proportion of patients hospitalized for repeated sui-
cide attempts for victims of chronic diseases, compared to
patients with nonrepeated suicide attempts. Among pa-
tients hospitalized for repeated suicide attempts, the per-
centage of those with a Charlson Comorbidity Index (CCI)
of one or more was significantly lower. The mortality rate
of patients hospitalized for repeated suicide attempts was
significantly lower (Table 4).
We used multivariate logistic regression to analyze the
factors influencing the hospitalization of patients for re-
peated suicide attempts between 2005 and 2008. After con-

© 2012 Hogrefe Publishing Crisis 2012

 Author's personal copy (e-offprint)

4 W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts

Crisis 2012 © 2012 Hogrefe Publishing

 Author's personal copy (e-offprint)

W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts 5

Table 3. Suicide methods employed by patients hospitalized for repeated suicide attempts during 2005–2008
Suicide methods Number of repeated suicide attempts
2 (n = 884) 3 (n = 116) 4 (n = 29) 5 (n = 9) 6 (n = 6) Total
E950 429 50.8% 56 48.3% 13 44.8% 4 44.4% 1 16.7% ,503 50.1%
E952 78 9.2% 11 9.5% 0 0% 0 0% 0 0% ,89 8.9%
E953 5 0.6% 0 0% 0 0% 1 11.1% 0 0% ,6 0.6%
E954 1 0.1% 0 0% 0 0% 0 0% 0 0% ,1 0.1%
E955 0 0% 1 0.9% 0 0% 0 0% 0 0% ,1 0.1%
E956 71 8.4% 8 6.9% 3 10.3% 1 11.1% 0 0% ,83 8.3%
E957 10 1.5% 0 0% 1 3.4% 0 0% 0 0% ,11 1.1%
E958 15 1.8% 4 3.4% 0 0% 0 0% 0 0% ,19 1.9%
E950 + E951 2 0.2% 0 0% 0 0% 0 0% 0 0% ,2 0.2%
E950 + E952 63 7.5% 6 5.2% 2 6.9% 2 22.2% 1 16.7% ,74 7.4%
E950 + E953 13 1.5% 0 0% 0 0% 0 0% 0 0% ,13 1.3%
E950 + E954 7 0.8% 0 0% 0 0% 0 0% 0 0% ,7 0.7%
E950 + E956 76 9.0% 16 13.8% 6 20.7% 1 11.1% 3 50.0% ,102 10.2%
E950 + E957 8 0.9% 5 4.3% 0 0% 0 0% 0 0% ,13 1.3%
E950 + E958 18 2.1% 1 0.9% 0 0% 0 0% 0 0% ,19 1.9%
E951 + E952 2 0.2% 0 0% 0 0% 0 0% 0 0% ,2 0.2%
E952 + E953 2 0.2% 0 0% 0 0% 0 0% 0 0% ,2 0.2%
E952 + E956 15 1.8% 0 0% 1 3.4% 0 0% 0 0% ,16 1.6%
E952 + E957 2 0.2% 0 0% 0 0% 0 0% 0 0% ,2 0.2%
E952 + E958 6 0.7% 1 0.9% 0 0% 0 0% 0 0% ,7 0.7%
E953 + E956 2 0.2% 0 0% 0 0% 0 0% 0 0% ,2 0.2%
E953 + E958 1 0.1% 1 0.9% 0 0% 0 0% 0 0% ,2 0.2%
E954 + E956 4 0.5% 0 0% 0 0% 0 0% 0 0% ,4 0.4%
E954 + E957 1 0.1% 0 0% 0 0% 0 0% 0 0% ,1 0.1%
E954 + E958 1 0.1% 0 0% 0 0% 0 0% 0 0% ,1 0.1%
E955 + E958 1 0.1% 0 0% 0 0% 0 0% 0 0% ,1 0.1%
E956 + E957 2 0.2% 0 0% 2 6.9% 0 0% 0 0% ,4 0.4%
E956 + E958 7 0.8% 1 0.9% 0 0% 0 0% 0 0% ,8 0.8%
E957 + E958 2 0.2% 0 0% 0 0% 0 0% 0 0% ,2 0.2%
E950 + E952 + E956 – – 0 0% 0 0% 0 0% 1 16.7% ,1 0.1%
E950 + E953 + E958 – – 1 0.9% 0 0% 0 0% 0 0% ,1 0.1%
E950 + E956 + E958 – – 2 1.7% 1 3.4% 0 0% 0 0% ,3 0.3%
E952 + E956 + E957 – – 1 0.9% 0 0% 0 0% 0 0% ,1 0.1%
E954 + E956 + E958 – – 1 0.9% 0 0% 0 0% 0 0% ,1 0.1%
Only one method 609 72.2% 80 69.0% 17 58.6% 6 66.7% 1 16.7% ,713 71.0%
Two different methods 235 27.8% 31 26.7% 11 37.9% 3 33.3% 4 66.6% ,284 28.3%
Three different methods – – 5 4.3% 1 3.4% 0 0% 1 16.7% ,7 0.7%
Total 844 100% 116 100% 29 100% 9 100% 6 100% 1,004 100%

trolling for factors that failed to show statistical signifi-
cance in univariate logistic regression, such as surgery and
CCI, we found that the influencing factors of patients hos-
pitalized for repeated suicide attempts consisted of: sex,
age, suicide method, season, geographic area, number of
psychiatric N-codes, department of care, number of proce-
dures received, length of stay in a hospital, type of hospital,
low-income family, and chronic illness. Controlled for oth-
er variables, men had a 0.832 times lower risk for repeated
suicide attempts. People aged 60–69 and 70–79 were at a
smaller risk of hospitalization due to repeated suicide at-
tempts, compared to those aged 30–39 (OR: 0.198 and
0.651). With regards to methods, suicide attempters using
cutting and piercing instruments (E956) had a 0.776 times
lower risk of hospitalization due to repeated suicide at-
tempts than those who used solid or liquid substance poi-
soning (E950). Analysis of seasons showed that the risks
of hospitalization due to repeated suicide attempts in the

© 2012 Hogrefe Publishing Crisis 2012

 Author's personal copy (e-offprint)

6 W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts

Table 4. Factors related to hospitalization of patients for repeated and nonrepeated suicide attempts during 2005–2008
Repeated suicide attempts Nonrepeated suicide attempts Total
Number of psychiatric N-code*
0 ,334 33.3% 8,770 53.6% 9,104 52.4%
1 ,511 50.9% 6,381 39.0% 6,892 39.7%
≥2 ,159 15.8% 1,226 7.5% 1,385 8.0%
Department of care*
Psychiatric ,187 18.6% 1,228 7.5% 1,415 8.1%
Others ,817 81.4% 15,149 92.5% 15,966 91.9%
Number of surgery*
0 ,704 70.1% 10,879 66.4% 11,583 66.6%
1 ,152 15.1% 2,840 17.3% 2,992 17.2%
≥2 ,148 14.7% 2,658 16.2% 2,806 16.1%
Number of procedure
0 ,675 67.2% 10,483 64.0% 11,158 64.2%
1 ,185 18.4% 3,209 19.6% 3,394 19.5%
≥2 ,144 14.3% 2,685 16.4% 2,829 16.3%
Length of stay*
≤ 1 day ,178 17.7% 3,464 21.2% 3,642 21.0%
2 days ,133 13.2% 2,736 16.7% 2,869 16.5%
3–4 days ,190 18.9% 3,647 22.3% 3,837 22.1%
5–9 days ,225 22.4% 3,473 21.2% 3,698 21.3%
≥ 10 days ,278 27.7% 3,057 18.7% 3,335 19.2%
Type of hospital*
Medical center ,291 28.9% 5,288 32.3% 5,579 32.1%
Regional hospital ,580 57.8% 8,314 50.8% 8,894 51.2%
Local hospital ,133 13.3% 2,775 16.9% 2,908 16.7%
Low-income family*
Yes ,56 5.6% ,442 2.7% ,498 2.9%
No ,948 94.4% 15,935 97.3% 16,883 97.1%
Chronic illness*
Yes ,225 22.4% 1,654 10.1% 1,879 10.8%
No ,779 77.6% 14,723 89.9% 15,502 89.2%
Charlson comorbidity index (CCI)
≥1 ,161 16.0% 2,962 18.1% 3,123 18.0%
0 ,843 84.0% 13,415 81.9% 14,258 82.0%
Prognosis*
Died ,36 3.6% ,857 5.2% ,893 5.1%
Survived ,968 96.4% 15,520 94.8% 16,488 94.9%
Total 1,004 100% 16,377 100% 17,381 100%
Note. *p < .05 (χ² test).

fall were 1.282 times higher than that in spring. Geograph-
ically speaking, the risks of hospitalization due to repeated
suicide attempts were 0.554 times lower in Eastern Taiwan,
including offshore islands, compared to Northern Taiwan.
In addition, the more psychiatric N-codes a patient had, the
higher his or her risks were of being hospitalized due to
repeated suicide attempts. Compared to patients without
any N-code, patients with one or two N-codes demonstrat-
ed a 1.664 or 2.324 times higher risk of hospitalization due
to repeated suicide attempts, respectively. Patients who had
visited the psychiatric department had a 1.262 times higher
risk for repeated suicide attempts. Receivers of medical
procedures had a 0.836 times lower risk of repeated suicide
attempts. The shorter the length of the hospital stay, the
lower the risks of hospitalization due to repeated suicide
attempts. Patients visiting medical centers had a 0.774
times lower risk of hospitalization due to repeated suicide
attempts than those visiting regional hospitals. Low-in-

Crisis 2012 © 2012 Hogrefe Publishing

 Author's personal copy (e-offprint)

W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts 7

Table 5. Factors affecting hospitalization of patients for re- OR 95% CI p

peated suicide attempts using multivariate logistic Type of hospital
regression (N = 17,381) Medical center* 0.774 0.666–0.899 .001
OR 95% CI p Regional hospital 1
Sex Local hospital 0.844 0.692–1.030 .096
Male* 0.832 0.728–0.951 .007 Low-income family
Female 1 Yes* 2.067 1.535–2.783 <.001
Age No 1
10–19 0.743 0.516–1.070 .110 Chronic illness
20–29 1.006 0.834–1.214 .946 Yes* 1.935 1.615–2.320 <.001
30–39 1 No 1
40–49 1.071 0.886–1.295 .476 Notes. 1. Dependent variable: repeated suicide attempts (repeated sui-
cide attempts: 1,004 cases, 6.3%; Nonrepeated suicide attempts:
50–59 1.050 0.833–1.323 .679 16,337 cases, 93.7%). 2. Adjusted for “number of surgery” and
60–69* 0.198 0.352–0.703 <.001 “Charlson comorbidity index (CCI)”. *p < .05.
70–79* 0.651 0.466–0.909 .012
80–89 0.934 0.635–1.375 .730 come families and chronic illnesses were associated with
≥ 90 0.925 0.284–3.007 .896 2.067- and 1.935 times higher risks of hospitalization due
Methods to repeated suicide attempts, respectively (Table 5).
Solid or liquid (E950) 1
Gases and vapors (E951, E952) 0.985 0.879–1.414 .887
Cutting and piercing (E956)* 0.776 0.572–0.874 .019 Discussion
Others (E953, E954, E955, 0.840 0.792–1.236 .128
E957, E958) Factors of Repeated Suicide
Season
Spring (March–May) 1 This study reveals that the influencing factors of hospital-
ization due to repeated suicide attempts include sex, age,
Summer (June–August) 1.168 0.974–1.401 .093
suicide method, season, geographic area, number of psy-
Fall (September–November)* 1.282 1.071–1.535 .007
chiatric N-code, department of care, number of medical
Winter (December–February) 1.046 0.864–1.274 .626 procedure, length of stay, type of hospital, low-income
Area family, and presence of chronic illness. We discovered that
Northern Taiwan 1 women had a 1.2 times higher risk of hospitalization due
Central Taiwan 0.855 0.725–1.009 .064 to repeated suicide attempts than men, which is in line with
Southern Taiwan 1.008 0.862–1.179 .918 a Brazilian study that found the risks for women to commit
repeated suicide attempts are 2.7 times higher than that for
Eastern Taiwan and offshore 0.554 0.339–0.905 .018
islands* men (da Silva Cais, Stefanello, Fabrício Mauro, Vaz Sca-
vacini de Freitas, & Botega, 2009). Some researchers have
Number of psychiatric N-codes
suggested potential reasons accounting for such gender dis-
0 1
crepancies in risks of repeated suicide attempts, such as that
1* 1.664 1.427–1.941 <.001 the possibility that men may have a variety of avenues other
≥ 2* 2.234 1.849–2.919 <.001 than suicide to release tension, such as indulgence in alco-
Department of care hol. In addition, a proportion of males may not seek help
Psychiatric* 1.262 1.008–1.579 .042 after attempting suicide, so that males more likely to die
Others 1 than be hospitalized by suicide. Consequently, male suicide
attempts may not be as likely to be recorded in health data-
Number of procedures
bases. In contrast, however, a British study showed no gen-
≥ 1* 0.836 0.721–0.969 .017
der difference in repeated suicide attempts (Bennewith et
0 1 al., 2002), and an Irish study reported a higher risk of re-
Length of stay peated suicide attempts in men, which was suggested to be
≤ 1 day* 0.708 0.561–0.894 .004 associated with the alcoholic behavior of the local male
2 days* 0.633 0.494–0.811 <.001 population (Corcoran, Keeley, O’Sullivan, & Perry, 2004).
3–4 days* 0.659 0.528–0.823 <.001
In addition, this study discovered that the young popu-
lation aged 30–39 had a higher risk of repeated suicide at-
5–9 days* 0.813 0.664–0.995 .044
tempts than the older population aged 60–79. The above-
≥ 10 days 1 mentioned Irish study also pointed out a correlation be-

© 2012 Hogrefe Publishing Crisis 2012

 Author's personal copy (e-offprint)
8 W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts
tween age and repeated suicides, where people aged 30–49
have a 1.687 times higher risk for repeated suicide attempts
than people aged 15–29 (Corcoran et al., 2004). According
to another study from Switzerland, the incidence of repeat-
ed suicide attempts decreases with age (Bradvik & Berg-
lund, 2009), which corresponds with our findings.
We found that suicide attempters who used poisonous
solid or liquid substances demonstrated a higher risk for
repeated suicide attempts. A previous study found that a
patient with more suicide attempts using poisons is associ-
ated with greater risks of further repeated suicide attempts
(Carter, Reith, Whyte, & McPherson, 2005). Furthermore,
an Australian study pointed out that female suicide attempt-
ers’ aged 25–44 using poisons are at a higher risk of repeat-
ed suicide attempts (Carter & O’Connell, 1999). Repeated
suicide attempters using poisons are a high-risk group for
suicide mortality (Carter et al., 2005). In addition, the use
of poisons may be also related to sociocultural factors
(Chen, Park, & Lu, 2009).
This study showed that an increase in risks for hospital-
ization due to repeated suicide attempts was associated
with a higher number of psychiatric N-codes. A US study
also revealed that patients with more concomitant mental
illnesses are at a greater risk for committing suicide (Nock,
Hwang, Sampson, & Kessler, 2010). Further, a larger pro-
portion of repeated suicide attempters suffer from mental
illnesses, compared to nonrepeated suicide attempters (Ev-
ans, Middleton, & Gunnell, 2004). According to a British
study, patients with concomitant mental illnesses demon-
strate a higher rate of repeated suicide attempts (Hawton,
Houston, Haw, Townsend, & Harriss, 2003), which is sim-
ilar to our finding. The potential reason for this phenome-
non may be due to the symptoms of mental illnesses or
depressive disorders that are so agonizing to the patients
and hence goad them to escape through attempting suicide.
In addition, persons who have attempted to commit suicide
may be more open to such an act again and may be prone
to repeat it after even minor emotional troubles (Joiner et
al., 2003). This study also showed that patients who had
visited psychiatrists were at a higher risk for repeated sui-
cide attempts. An Indian study has elaborated on the asso-
ciation between psychiatric treatment and repeated suicide
attempts (Chandrasekaran & Gnanaselane, 2008). Another
study conducted in South Africa pointed out that psychiat-
ric treatments increase the incidence of repeated suicides
(Dirks, 1998); both studies are in line with our findings. It
has also been implied that, although a suicide attempter
with underlying mental illness may receive medical care
following an attempt, treatment for such illnesses fails to
prevent further repeated suicide attempts (McKenzie et al.,
2003).
This study confirmed the higher risks of repeated suicide
attempts in victims of chronic illnesses and in people from
low-income families. According to an Australian study, pa-
tients with chronic diseases demonstrate a 329% higher risk
of repeated suicide attempts than those without chronic dis-
eases, which corresponds with our finding. Such patients
Crisis 2012
may be prone to end their lives because of unbearable pain
and a sense of humiliation stemming from having to con-
stantly rely on others (Peden et al., 2008). In addition, 40%
of suicide attempters with a physical illness also suffer
from mental problems (De Leo, 1999). On the other hand,
there is a reciprocal relationship between physical condi-
tions and income. It has been suggested that people with
lower income are at a disadvantaged social position, which
not only affects socioeconomic status and education sourc-
es, but also hinders their accessibility to healthcare (Ho,
2006). It is a vicious cycle in which sickened people with-
out healthcare have greater difficultly finding gainful em-
ployment, and unemployment leads to poverty and an even
worse health status; hence, this situation increases risks of
repeated suicide attempts. Some researchers have indicated
that the presence of social maladaptation, which may lead
to being unproductive at work and a lower income, consti-
tutes one of the risk factors of repeated suicide attempts
(Chandrasekaran & Gnanaselane, 2008). However, a 6-
year study in Norway reported no correlation between so-
cioeconomic status and repeated suicide attempts (Hjelme-
land, 1996).
In addition, we discovered an increased risk of repeated
suicide attempts associated with longer durations of hospi-
talization. According to a Taiwanese study on the length of
hospital stays in patients with mental illnesses, there is no
evidence showing that longer hospitalization periods result
in better outcome, or in other words, there is no increased
in the effectiveness of psychiatric treatments following
longer period of stay (Cheng, Liao, Lee, & Tseng, 2007).
Implication for Prevention
This study revealed that the influencing factors on hospi-
talization due to repeated suicide attempts were: female
sex, age of 30–39 years, poisoning by solid and liquid sub-
stances, the fall season, living in Northern Taiwan, having
multiple psychiatric N-codes, having previous psychiatric
visits, having a history of medical procedures, longer
length of stay in a hospital, having visited a regional hos-
pital following a suicide attempt, coming from low-income
families, and presence of chronic illness. Of all of these
factors, the number of N-codes was the most influential risk
factor of hospitalization due to repeated suicide attempts,
which corresponds to a statistical power of 87.3%. As a
result, consultation and treatment are particularly crucial
for patients with mental illnesses and other concomitant
diseases so that the psychiatric symptoms such as auditory
and visual hallucinations can be controlled. Furthermore,
special attention should be given to hospitalized patients
from low-income families and to those with chronic illness-
es. During a hospital stay, these patients should be referred
to social workers that may ensure continuous follow-ups,
hence minimizing the occurrence of repeated suicide at-
tempts.
© 2012 Hogrefe Publishing
 Author's personal copy (e-offprint)
W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts
Limitation
As the period of our study period fell between 2005 and
2008, there was a lack of extant data on potential suicide
attempts before 2005 by patients who had been admitted
only once due to suicide during 2005–2008, hence perhaps
resulting in an underestimation of repeated suicide at-
tempts. In addition, since private insurance companies pro-
hibit claims of suicide, suicide attempters or their families
may consider insurance issues and request the doctor pro-
vide diagnoses of unintentional causes instead of suicide.
Moreover, some persons may only attend an Emergency
Department for suicidal behavior, but leave before being
thoroughly assessed. These may account for a further un-
derestimation of overall suicide numbers. Furthermore, we
were unable to conduct further analyses because the NHI
Research Database failed to provide data on suicide-related
important variables such as marital and employment sta-
tuses.
Conclusions
This is the first study in Taiwan to analyze the suicide meth-
ods adapted by patients hospitalized for repeated suicide
attempts using the NHI Research Database, and our analyt-
ical methods can serve as a reference for future researchers.
Among the risk factors related to repeated suicide attempts,
number of psychiatric N-code, or psychiatric diagnoses,
was a risk associated with repeated suicide attempts. Fur-
ther studies are needed to elaborate the mortality and mor-
bidity post suicide attempt at different time frame dura-
tions.
Acknowledgments
This study is based in part on data from the National Health
Insurance Research Database provided by the Bureau of
National Health Insurance, Department of Health and man-
aged by National Health Research Institutes. The interpre-
tation and conclusions contained herein do not represent
those of Bureau of National Health Insurance, Department
of Health, or National Health Research Institutes. We thank
the anonymous reviewers for their valuable comments.
This study was not supported by any funding.
The author(s) declare that they have no competing inter-
ests.
References
Bennewith, O., Stocks, N., Gunnell, D., Peters, T. J., Evans,
M. O., & Sharp, D. J. (2002). General practice based interven-
tion to prevent repeat episodes of deliberate self-harm: Cluster
© 2012 Hogrefe Publishing
9
randomised controlled trial. British Medical Journal, 324,
1254–1257.
Bradvik, L., & Berglund, M. (2009). Repetition and severity of
suicide attempts across the life cycle: A comparison by age
group between suicide victims and controls with severe de-
pression. BMC Psychiatry, 9, 62.
Carter, G. L., & O’Connell, D. L. (1999). Preventing suicide:
What will work and what will not. The Medicine Journal of
Australia, 170, 620–621.
Carter, G., Reith, D. M., Whyte, I. M., & McPherson, M. (2005).
Repeated self-poisoning: Increasing severity of self-harm as a
predictor of subsequent suicide. The British Journal of Psychi-
atry, 186, 253–257.
Chandrasekaran, R., & Gnanaselane, J. (2008). Predictors of re-
peat suicidal attempts after first-ever attempt: A two-year fol-
low-up study. Hong Kong Journal of Psychiatry, 18, 131–135.
Chen, Y. Y., Park, N. S., & Lu, T. H. (2009). Suicide methods used
by women in Korea, Sweden, Taiwan and the United States.
Journal of the Formosan Medical Association, 108, 452–459.
Cheng, I. C., Liao, S. C., Lee, M. B., & Tseng, M. M. (2007). Pre-
dictors of treatment response and length of stay for inpatients
with major depression. Journal of the Formosan Medical As-
sociation, 106, 903–910.
Christiansen, E., & Jensen, B. F. (2007). Risk of repetition of sui-
cide attempt, suicide or all deaths after an episode of attempted
suicide: A register-based survival analysis. The Australian and
New Zealand Journal of Psychiatry, 41, 257–265.
Corcoran, P., Keeley, H. S., O’Sullivan, M., & Perry, I. J. (2004).
The incidence and repetition of attempted suicide in Ireland.
European Journal of Public Health, 14(1), 19–23.
da Silva Cais, C. F., Stefanello, S., Fabrício Mauro, M. L., Vaz
Scavacini de Freitas, G., & Botega, N. J. (2009). Factors asso-
ciated with repeated suicide attempts. Preliminary results of
the WHO Multisite Intervention Study on Suicidal Behavior
(SUPRE-MISS) from Campinas, Brazil. Crisis, 30, 73–78.
De Leo, D. (1999). Cultural issues in suicide and old age. Crisis,
20, 53–55.
Department of Health Executive Yuan, ROC (Taiwan). (2010).
Statistics of causes of death – Number of deaths classified ac-
cording to the basic tabulation list by gender and age. Re-
trieved from http://www.doh.gov.tw/CHT2006/DisplayStatis-
ticFile.aspx?d=75 924&s=1
Dirks, B. L. (1998). Repetition of parasuicide – ICD-10 person-
ality disorders and adversity. Acta Psychiatrica Scandinavica,
98, 208–213.
Evans, J., Middleton, N., & Gunnell, D. (2004). Social fragmen-
tation, severe mental illness and suicide. Social Psychiatry and
Psychiatric Epidemiology, 39, 165–170.
Goldsmith, S. (2002). Reducing suicide: A national imperative.
Washington, DC: National Academies Press.
Hawton, K., Houston, K., Haw, C., Townsend, E., & Harriss, L.
(2003). Comorbidity of axis I and axis II disorders in patients
who attempted suicide. The American Journal of Psychiatry,
160, 1494–1500.
Hjelmeland, H. (1996). Repetition of parasuicide: A predictive
study. Suicide and Life-Threatening Behavior, 26, 395–404.
Ho, T. P. (2006). Duration of hospitalization and post discharge
suicide. Suicide and Life-Threatening Behavior, 36, 682–686.
Joiner, T. E. Jr., Steer, R. A., Brown, G., Beck, A. T., Pettit, J. W.,
& Rudd, M. D. (2003). Worst-point suicidal plans: A dimen-
sion of suicidality predictive of past suicide attempts and even-
Crisis 2012
 Author's personal copy (e-offprint)

10 W.-C. Chien et al.: Evidence-Based Data Analysis of Repeated Suicide Attempts

tual death by suicide. Behaviour Research and Therapy, 41, About the authors
1469–1480.
Leon, A. C., Friedman, R. A., Sweeney, J. A., Brown, R. P., & Wu-Chien Chien is assistant professor at the School of Public
Mann, J. J. (1990). Statistical issues in the identification of risk Health, National Defense Medical Center, Taiwan, Republic of
factors for suicidal behavior: The application of survival anal- China.
ysis. Psychiatry Research, 31(1), 99–108.
Mathers, C. D., & Loncar, D. (2006). Projections of global mor- Ching-Huang Lai is associate professor at the School of Public
tality and burden of disease from 2002 to 2030. PLoS Medi- Health, National Defense Medical Center, Taiwan, Republic of
cine, 3, e442. Retrieved from http://www.ncbi.nlm.nih.gov/ China.
pmc/articles/PMC1664601/pdf/pmed.0030442.pdf
McKenzie, K., van Os, J., Samele, C., van Horn, E., Tattan, T., & Chi-Hsiang Chung is a doctoral candidate at the Graduate Institute
Murray, R., & UK700 Group. (2003). Suicide and attempted of Life Sciences, National Defense Medical Center, Taiwan, Re-
suicide among people of Caribbean origin with psychosis liv- public of China.
ing in the UK. The British Journal of Psychiatry, 183, 40–44.
National Health Research Institutes, ROC (Taiwan). (2011). Nation- Lu Pai is associate professor at the Institute of Injury Prevention
al Health Insurance Research Database – Introduction of ser- and Control, Taipei Medical University, Taiwan, Republic of Chi-
vice. Retrieved from http://w3.nhri.org.tw/nhird/brief_01.htm na.
Nock, M. K., Hwang, I., Sampson, N. A., & Kessler, R. C. (2010).
Wei-Ting Chang is a PhD student at the Graduate Institute of Life
Mental disorders, comorbidity and suicidal behavior: Results
Sciences, National Defense Medical Center, Taiwan, Republic of
from the National Comorbidity Survey Replication. Molecular
China.
Psychiatry, 15, 868–876.
Nordström, P., Samuelsson, M., & Asberg, M. (1995). Survival
analysis of suicide risk after attempted suicide. Acta Psychiat-
rica Scandinavica, 91, 336–340. Wu-Chien Chien
Peden, M., Oyegbite, K., Ozanne-Smith, J., Hyder, A. A., Bran-
che, C., Rahman, A. F., . . . Bartolomeos, K. (2008). World re- National Defense Medical Center
port on child injury prevention. Retrieved from http://whqlib- School of Public Health 4210R, No. 161, Section 6
doc.who.int/publications/2008/9789241563574_eng.pdf Min-Chuan East Road
World Health Organization. (2009). Suicide prevention (SUPRE). Neihu District, Taipei City 11490
Retrieved from http://www.who.int/mental_health/preven- Taiwan
tion/suicide/suicideprevent/en/ Republic of China
Tel. +886 2 8792-3100 ext. 18441
Received March 11, 2011 Fax +886 2 8792-3147
Revision received February 11, 2012 E-mail chienwu@mail.ndmctsgh.edu.tw
Accepted February 22, 2012
Published online August 3, 2012

Crisis 2012 © 2012 Hogrefe Publishing