Journal of Affective Disorders 258 (2019) 144–150

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Interaction between prospective risk factors in the prediction of suicide risk T

a,b c d e e
Leandro N. Grendas , Sasha M. Rojas , Soledad Puppo , Patricia Vidjen , Alicia Portela ,
Luciana Chiapellaf,g, Demián E. Rodantea,h, Federico M. Daraya,g,
⁎

a
University of Buenos Aires, School of Medicine, Institute of Pharmacology, Argentina
b
Teodoro Alvarez Hospital, City of Buenos Aires, Argentina
c
University of Arkansas, Department of Psychological Science, Fayetteville, United States
d
Hospital de Clínicas José de San Martín, City of Buenos Aires, Argentina
e
José Tiburcio Borda Hospital, City of Buenos Aires, Argentina
f
National University of Rosario, School of Biochemical and Pharmaceutical Sciences, Argentina
g
National Scientific and Technical Research Council (CONICET), Argentina
h
Braulio A. Moyano Neuropsychiatric Hospital, City of Buenos Aires, Argentina

ARTICLE INFO ABSTRACT

Keywords: Background: To meet the goal of preventing suicide the most important thing is to know the risk factors of
Suicide suicidal behavior and understand their interaction.
Risk factors Aims: The current study aims to evaluate prospective predictors and the interaction between factors for suicide
Risk assessment and suicide re-attempts in high-risk, suicidal patients during a 24 month prospective follow-up period.
Suicide re-attempt
Methods: A multicenter prospective cohort study was designed to compare data obtained from 324 patients
Suicidal behavior
admitted to the emergency department for current suicidal ideation or a recent suicide attempt. Participants
were clinically evaluated at baseline and follow-up every 6 months to assess any unfavorable events (suicide or a
suicide attempt). To estimate the rate of unfavorable events, the Kaplan–Meier method was used and Cox
Proportional Hazards Regression Model was employed to examine predictors of suicide and suicide reattempt.
Results: The incidence of a new suicide attempt was 26,000 events/100,000 persons-years. The incidence of
death by suicide was 1110 events/100,000 person-year. The most reliable predictors of unfavorable events were
being women, previous suicide attempts, younger age, and childhood sexual abuse. Findings revealed an in-
teraction between childhood sexual abuse and low psychosocial functioning that increased the risk of an un-
favorable event.
Conclusion: The risk of suicide re-attempts and suicide in the current 2-year follow-up was high. There was an
interaction between low psychosocial functioning and childhood sexual abuse. This evidence should be taken
into account for the evaluation and planning of preventive strategies.

1. Introduction
Although suicide and suicidal behavior (SB) are preventable
(WHO, 2018), rates have not significantly declined in the last 50 years
(Suicide, 2016). The social, economic, and public health burden asso-
ciated with suicide and SB has increased, and consequently, the WHO
has declared reducing suicide-related mortality as a global imperative
(WHO, 2014). Therefore, research efforts focused on understanding and
reducing the incidences of these behaviors are now needed
(WHO, 2014).
The risk for suicide is higher among psychiatric patients as com-
pared to nonpsychiatric populations (Blumenthal and Kupfer, 1990).
Nonetheless, not every psychiatric patient will experience SB. Previous
suicide attempts is the most reliable predictor of future suicide attempts
(Franklin et al., 2017), however, it is difficult for clinicians to predict
who will engage in a future suicide attempt, given our limited under-
standing of how independent risk factors interact to predict SB
(Beghi et al., 2013). Although ideation to action theories (Klonsky et al.,
2018) have improved our conceptualization of SB, there are only a few
studies that evaluate the interaction between risk factors for SB. Despite
limited work, some studies indicate it is possible to reduce the risk of a
suicide re-attempt and suicide among individuals at risk for SB
(Hampton, 2010; Hegerl et al., 2010). More work examining the in-
teraction between risk factors for a suicide reattempt may shed light on

⁎
Corresponding author at: Instituto de Farmacología, Facultad de Medicina, Universidad de Buenos Aires. Paraguay 2155, piso 9, C1121ABG, Ciudad de Buenos
Aires, Argentina.
E-mail address: fdaray@hotmail.com (F.M. Daray).

https://doi.org/10.1016/j.jad.2019.07.071
Received 15 April 2019; Received in revised form 3 July 2019; Accepted 29 July 2019
Available online 30 July 2019
0165-0327/ © 2019 Elsevier B.V. All rights reserved.
L.N. Grendas, et al.
different pathways of risk among populations at highest risk for suicide.
Although several studies have examined multiple risk factors, to the
best of our knowledge, few prospective studies have comprehensively
assessed the interaction of a wide range of putative risk factors for SB.
Childhood sexual abuse (CSA) is one of the most frequently reported
risk factors for SB. However, the interactions between CSA and other
risks factors have been poorly investigated.
It is worth noting that the factors described as predictors of SB vary
among different world regions. To date, data regarding risk factors of
SB in the Latin American and Caribbean region is scarce and of low
quality (Teti et al., 2014). In the current study, we used a survival
analysis to examine the incidence of SB among high-risk suicidal pa-
tients to identify prospective risk factors for SB. In addition, we ex-
plored the interaction between CSA, and other significant risk factors.
There is limited research about the interaction of CSA and other risk
factors in the prediction of suicide reattempts. As such, our analyzes
exploring interactions with CSA were exploratory.
2. Methods
2.1. Study design
The present study was a multicenter prospective cohort study con-
ducted in Buenos Aires, Argentina. The cohort was recruited from three
different hospitals: the "Dr. Braulio A. Moyano” neuropsychiatric hos-
pital, the "Dr. José T. Borda" hospital and the Hospital de Clínicas "José
de San Martin", in the city of Buenos Aires. All hospitals in the current
study serve a large urban catchment area in Buenos Aires and pre-
dominantly treat low-income, uninsured patients. The study began in
2012 with the collection of baseline data finishing in December 2016.
The current study utilized data obtained at baseline and at 6, 12, 18 and
24 months of follow-up. The study time-frame includes the last follow-
up evaluation. The study was approved by the research ethics com-
mittee of each hospital included in the study.
2.2. Participants
Participants were patients admitted to the emergency department of
one of the three hospitals for suicidal ideation or a recent suicide at-
tempt. Suicidal ideation was defined as any current self-reported
thought of engaging in suicide-related behavior (Nock, 2014), and
suicide attempt was defined as a potentially self-injurious behavior with
a nonfatal outcome, for which there was evidence (either explicit or
implicit) that the person intended at some (non-zero) level to kill him or
herself (Nock, 2014).
Participants were eligible if they were between 18 and 65 years of
age, hospitalized for suicidal ideation or a suicide attempt (assessed by
the Columbia-Suicide Severity Rating Scale, C-SSRS) in the last 72 h
from assessment, sufficiently alert and able to respond with fluency in
Spanish, and able to provide written informed consent to participate.
Participants were excluded if they were unable to respond autono-
mously (i.e., due to sedative effects of medication or language limita-
tions) or were transferred to another institution.
All participants gave written informed consent to participate in the
study. Participants were included in the current study if all relevant
measures were completed at the baseline assessment. After discharge,
subjects who were recruited as inpatients received treatment as usual in
the community. Participants were evaluated 6, 12, 18 and 24 months
after hospitalization.
2.3. Measures
2.3.1. Baseline data
At the baseline evaluation, each participant completed a semi-
structured interview conducted by a psychiatrist at the emergency de-
partments. All psychiatrists on the research team had at least 5 years of
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Journal of Affective Disorders 258 (2019) 144–150
clinical experience and completed training in the semi-structured in-
terviews and data-gathering procedures of the study. The semi-struc-
tured interview included questions regarding clinical and demographic
variables. The Mini International Neuropsychiatric Interview (MINI)
(Ferrando et al., 2004) and the Structured Clinical Interview for DSM-IV
Axis II Disorders (SCID-II) (Villar Garcia et al., 1995) were used for
diagnostic purposes. Childhood sexual abuse, history of suicide at-
tempts, age of first suicide attempt, hospitalizations due to a suicide
attempt, family history of SB, psychiatric illness, and previous psy-
chiatric treatment were assessed during the interview. The Columbia-
Suicide Severity Rating Scale (C-SSRS) (Posner et al., 2011) was used to
assess suicidal ideation and suicide attempt history as well as additional
details of a participant's lifetime and most recent suicidal thoughts and
behaviors, including the lethality of the index suicide attempt. The
Barratt Impulsiveness Scale (BIS)-11 (Lopez et al., 2012) was used to
assess levels of impulsivity. The BIS-11 is composed of 30 items de-
scribing common impulsive or non-impulsive behaviors and pre-
ferences. The Buss–Durkee Hostility Inventory (BDHI) was used to
evaluate hostility (Oquendo et al., 2001b). The Beck Hopelessness Scale
(BHS) was used to assess hopelessness (Mikulic et al., 2009): the ne-
gative expectations that a person holds about his or her future and well-
being as well as his or her ability to overcome difficulties and achieve
success in life. Recent stressors were assessed with the Brugha Stressful
Life Events Scale (List of Threatening Experiences [LTE]) (Brugha and
Cragg, 1990). The Social Adaptation Self-evaluation Scale (SASS)
(Bobes et al., 1999) was used to assess psychosocial functioning. The
SASS is a 21-item self-report inventory developed to explore an in-
dividual's social functioning in the areas of work, family, leisure, social
relations, and motivation.
2.3.2. Follow-ups
Two trained psychiatrists performed telephone follow-up assess-
ments. Participants were contacted by telephone at 6, 12, 18 and 24
months following their baseline assessment. Follow-up assessments
were specific to any unfavorable events (suicide or a suicide attempt)
that occurred during the follow-up period. A semi-structured interview
and items from the C-SRSS were used as part of the follow-up assess-
ment. If participants could not be reached, calls were made on alternate
days and times for one week. If contact was still not established, in-
terviewers contacted two reference numbers that were provided upon
enrollment. If contact was still not possible, an e-mail was sent. If
contact was not established after three attempts, the participant was
declared as “loss to follow-up”. Participant or reference person pro-
vided data for unfavorable events (i.e., suicide, suicide reattempt).
2.4. Data analysis
Descriptive statistics were used to summarize the characteristics of
patients. The following variables were classified as high or low ac-
cording to the median value for the 293 patients (i.e., low if the value
was less than the median): 1) hopelessness, 2) hostility, 3) impulsive-
ness and 4) psychosocial functioning. Categorical variables were re-
ported as frequencies and percentages (%), and quantitative variables
were reported as means ± standard deviations (SDs). Comparisons
between patients who completed the follow-up and patients lost during
follow-up depend on the variable type. Specifically, categorical vari-
ables were compared using Pearson's chi-square test or Fisher's exact
test and quantitative variables were compared using Student's t-test. All
analyses assumed an alpha level of p < 0.05. The number of days
elapsed between entering the study (date of hospitalization) and the
adverse event or censorship was calculated for all cases.
To estimate the rate of unfavorable events, the Kaplan–Meier
method was used. Subsequently, a bivariate Cox Proportional Hazards
Regression model was adjusted to analyze the relations between each
sociodemographic and clinical variable and the survival time of the
patients. The hazard ratios (HR) and their respective 95% confidence
L.N. Grendas, et al.
intervals (CI) were estimated for each variable.
Finally, a multivariate Cox Proportional Hazards Regression model
was completed. In this model, each sociodemographic and clinical
variable were included. Considering CSA is a frequently reported risk
factor for SB, we explored the interactions between CSA and all the
other risk factors. Psychosocial functioning was the only risk factor that
interacted with CSA. The interaction was included as a covariate. The
backward algorithm was used to find the best-fitted model. For ad-
justment of the models, only data from patients who completed all re-
levant measures was considered. The HRs and the respective 95% CIs
were estimated for all the variables were statistically significant.
Appropriate diagnostics were carried out to test the goodness of fit,
collinearity and atypical observations in each model. In all cases, the
fulfillment of assumptions in the model by means of exploration of
residual behavior was verified. All statistical analyses were conducted
using SAS University Edition.
3. Results
3.1. Sociodemographic
Three hundred twenty-four participants (Mean 36.95 ± 12.14
years with 78.70% of women) fulfilled all the specified inclusion cri-
teria and consented to enter the study. Of the total population, 183
(56.48%) participants met DSM-IV diagnostic criteria for current major
depressive disorder (MDD), 63 (19.44%) met criteria for schizophrenia
and related disorders, and 43 (13.27%) met criteria for bipolar disorder
(BD). A comorbid borderline personality disorder (BPD) was reported
by 45.18% of the sample. The participants who were lost to follow-up
(10%) were significantly more likely to have a comorbid substance use
disorder (SAD) as compared to participants who completed the follow-
up. Participants lost in follow-up did not significantly differ in any other
variables as compared to participants who completed the follow-up.
Other clinical and demographic variables are shown in Table 1.
3.2. Follow-ups
Of the 324 patients included in the study, 293 (90.43%) had at least
one follow-up after baseline evaluation and were included in the sur-
vival analysis. Suicide attempt (n = 93, 31.74%) or death by suicide
(n = 4, 1.37%) were the adverse events of interest. Participants who did
not report a suicide attempt or death by suicide during the entire
follow-up period were censored by, loss of follow-up, study completion,
or death by causes unrelated to suicide (n = 196, 66.89%).
3.3. Incidence and timing of the survival curve for unfavorable events
The incidence of unfavorable events during the follow-up period
was 27,110 cases per 100,000 person-years. There were 93 (31.74%)
patients with suicide re-attempts, (incidence rate: 26,000 cases per
100,000 person-year) and 4 (1.37%) patients who died by suicide,
(incidence rate: 1110 cases per 100,000 person-year). Fig. 1 displays
the survival curve of suicide reattempt and suicide as unfavorable
outcomes.
3.4. Risk factors for unfavorable events
Factors that independently modified risk for unfavorable events
after the index suicide attempt were the following, 1 to 2 previous
suicide attempts (HR: 2.13, 95% CI: 1.19–3.79); three or more previous
suicide attempts (HR: 2.11, 95% CI: 1.18–3.76), and CSA (HR: 1.53,
95% CI: 1.03–2.28). All other variables were not associated with the
unfavorable outcome (Table 2). Fig. 2 provides data indicating patients
with CSA were at higher risk for a suicide reattempt or suicide (Test
Log-Rank: p = 0.035) as compared to suicidal patients without a history
of CSA.
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Journal of Affective Disorders 258 (2019) 144–150
All risk factors and their interaction with CSA were entered into a
multivariate Cox regression (see Table 3). The three risk factors entered
were sex, previous suicide attempt, and age. In addition, the only sig-
nificant interaction (i.e., CSA and psychosocial functioning) that in-
dependently increased the risk for an unfavorable event was entered
into the model. Woman (HR: 1.96, 95% CI: 1.12–3.44) and 1 to 2
previous suicide attempts (HR: 2.30, 95% CI: 1.21–4.37) doubled the
risk of an unfavorable event. As age increases, the risk of unfavorable
events reduced (HR: 0.98, 95% CI: 0.96–0.99). Among patients with
CSA, those with low psychosocial functioning were more likely to have
an unfavorable event as compared to those with high psychosocial
functioning (HR: 2.01, 95%CI: 1.11–3.62). There was no statistically
significant association between the unfavorable event and psychosocial
functioning in patients without CSA (HR: 0.63, 95% CI: 0.34–1.15).
4. Discussion
The present work is the first study in Latin America to assess pro-
spective risk factors for suicidal behavior (SB) among a high-risk patient
sample. In accord with previous studies in occidental regions, we found
sex (i.e., female), previous suicide attempt, younger age, and childhood
sexual abuse (CSA) were associated with a greater likelihood for an
unfavorable outcome (i.e., suicide re-attempts and suicide) during a 2-
year follow-up period, independent of other factors. Albite not an in-
dependent predictor of suicide or suicide re-attempts for the current
sample, psychosocial functioning was a risk factor for future SB among
patients reporting CSA. The interaction between CSA and recent poor
psychosocial functioning increased the risk for suicide and suicide re-
attempts among the high-risk patient sample.
In the current study, we observed a high rate of suicide re-attempts
(i.e., 31.74%) and suicide (i.e., 1.37%) during 2 years of follow-up. The
observed increased risk for suicide and suicide re-attempts among pa-
tients with a history of previous suicide attempts is consistent with
previous findings (Beghi et al., 2013). Similar results have been pri-
marily documented within the first 2 years following an index suicide
attempt (Christiansen and Jensen, 2007; Owens et al., 2002), with the
greatest suicide risk occurring during the first 6 months (Irigoyen et al.,
2018). Nonetheless, the rate observed in our sample differs compared to
previous work. For example, findings differ from a systematic review of
177 studies, published between 1970 and 2012, which included in-
dividuals who received health care services for deliberate self-harm,
with or without suicidal intent. The pooled estimated incidence of re-
peated non-fatal self-harm was 16.3% at 1 year, 16.8% at 2 years, and
22.4% at 5 years, while the pooled estimated incidence rate of sub-
sequent suicide was 1.6% at 1 year, 2.1% at 2 years and 3.9% at 5 years
(Carroll et al., 2014). Our findings likely differ from these results for
one of two reasons. On the one hand, the patients included in the sys-
tematic review were a mixed sample of patients with and without SB
(i.e., as determined by intent), whereas in our sample all patients were
hospitalized for active suicidal thoughts or a recent suicide attempt. The
high-risk nature of our sample likely yielded a higher incidence of
suicide re-attempts. On the other hand, the systematic review included
samples from Asia, where the incidence of repeated self-harm may be
lower as compared to other parts of the world (Chung et al., 2012; Liu
and Xiao, 2002).
A survival analysis based on a one-year telephone follow-up pre-
vention program, part of the European Alliance against Depression,
included 1241 first-time suicide attempters and concluded 20.1% made
a suicide re-attempt at least once, and 1.2% died by suicide (Parra-
Uribe and Blasco-Fontecilla, 2017). One notable difference between
samples is that our entire sample reported previous suicide attempts,
while the sample in Parra-Uribe and Blasco-Fontecilla (2017) study
included individuals with a first suicide attempt. A previous suicide
attempt is an important risk factor used to determine the severity of risk
for the repetition of suicidal behavior (Irigoyen et al., 2018). In another
survival analysis based on the Danish registry of 2614 suicide
L.N. Grendas, et al. Journal of Affective Disorders 258 (2019) 144–150

Table 1
General characteristics of the suicidal patients at index admission.
All patients included in the Patients that complete the follow- Patients lost during the follow- p-value
study (n = 324) up (1) (n = 293) up (2) (n = 31)

Socio-demographic
Age (yrs.), mean (CI 95%) 36.95 (12.36) 37.32 (12.41) 33.48 (11.46) 0.101
Sex (%) Men 69 (21.30) 59 (20.14) 10 (32.26) 0.117
Women 255 (78.70) 234 (79.86) 21 (67.74)
Marital status (%) Partenership/cohabiting 78 (24.07) 70 (23.89) 8 (25.81) 0.813
Separated/divorced 246 (75.93) 223 (76.11) 23 (74.19)
Educational level (%) Incomplete primary 13 (4.01) 11 (3.75) 2 (6.45) 0.242
Complete primary 45 (13.89) 37 (12.63) 8 (25.81)
Incomplete high school 110 (33.95) 103 (35.15) 7 (22.58)
Complete high school 73 (22.53) 67 (22.87) 6 (19.35)
College 83 (25.62) 75 (25.60) 8 (25.81)
Diagnosis
MDD (%) No 141 (43.52) 126 (43.00) 15 (48.39) 0.565
Yes 183 (56.48) 167 (57.00) 16 (51.61)
BD (%) No 281 (86.73) 255 (87.03) 26 (83.87) 0.622
Yes 43 (13.27) 38 (12.97) 5 (16.13)
Schizophrenia and related disorders No 261 (80.56) 236 (80.55) 25 (80.65) 0.989
(%) Yes 63 (19.44) 57 (19.45) 6 (19.35)
Other (%) No 313 (96.60) 283 (96.59) 30 (96.77) 0.956
Yes 11 (3.40) 10 (3.41) 1 (3.23)
Co-occurring disorders
BPD (%) No 165 (54.82) 150 (54.95) 15 (53.57) 0.889
Yes 136 (45.18) 123 (45.05) 13 (46.43)
SAD (%) No 251 (77.47) 233 (79.52) 18 (58.06) 0.007
Yes 73 (22.53) 60 (20.48) 13 (41.94)
Suicidal history
Number of previous SA (%) 0 94 (29.01) 83 (28.33) 11 (35.48) 0.574
1o2 120 (37.04) 111 (37.88) 9 (29.03)
3 o more 110 (33.95) 99 (33.79) 11 (35.48)
Lethality index SA (%) Very low 96 (29.63) 89 (30.38) 7 (22.58) 0.655
Low 174 (53.70) 156 (53.24) 18 (58.06)
High 54 (16.67) 48 (16.38) 6 (19.35)
Age at first SA (yrs.), mean (CI 95%) 27.92 (12.93) 28.15 (13.12) 25.64 (10.87) 0.329
Rating scale scores
Hopelessness (BHS) (%) Low 138 (45.25) 128 (46.21) 10 (35.71) 0.288
High 167 (54.75) 149 (53.79) 18 (64.29)
Hostility (BDHI) (%) Low 149 (49.34) 136 (49.64) 13 (46.43) 0.747
High 153 (50.66) 138 (50.36) 15 (53.57)
Impulsiveness (BIS) (%) Low 138 (46.15) 129 (47.60) 9 (32.14) 0.118
High 161 (53.85) 142 (52.40) 19 (67.86)
Psychosocial functioning (SASS) (%) Low 141 (46.69) 127 (46.35) 14 (50.00) 0.712
High 161 (53.31) 147 (53.65) 14 (50.00)
Number of recent stressors (SLE) (%) Low 146 (48.50) 131 (47.99) 15 (53.57) 0.573
High 155 (51.50) 142 (52.01) 13 (46.43)
Impact of Recent stressors (SLE) (%) Low 154 (50.99) 137 (50.00) 17 (60.71) 0.280
High 148 (49.01) 137 (50.00) 11 (39.29)

Family history of S or SA (%) No 173 (53.40) 153 (52.22) 20 (64.52) 0.192

Yes 151 (46.60) 140 (47.78) 11 (35.48)
Psychiatry treatment history (%) No 60 (18.58) 54 (18.43) 6 (20.00) 0.833
Yes 263 (81.42) 239 (81.57) 24 (80.00)
Child sexual abuse (%) No 195 (60.56) 178 (60.96) 17 (56.67) 0.647
Yes 127 (39.44) 114 (39.04) 13 (43.33)

Ref.: MDD = major depressive disorder; BD = bipolar disorder; BPD = borderline personality disorder; Lethality index SA = lethality of the index (i.e., suicide
attempt that resulted in hospitilization at study enrollement) suicide attempt, SAD = substance abuse disorder; S = suicide; SA = suicide attempt; BHS = Beck
Hopelessness Scale; BDHI = Buss-Durkee Hostility Inventory; BIS = Barratt Impulsiveness Scale; SASS = Social Adaptation Self-evaluation Scale; SLE = Stressful Life
Events Scale.

attempters, 31.33% of individuals with a suicide attempt reattempted
suicide within a 2.8 year follow-up period and had increased risk for up
to 2 years (i.e., 27% made a suicide reattempt) and after two years of
follow-up, risk reduced and remained constant for the remainder of the
follow-up period (Christiansen and Jensen, 2007). Similar findings have
been found in studies with a longer follow-up period. For example, in a
prospective 10-year follow-up study of 150 suicidal patients, 25% of the
initial cohort made a suicide re-attempt and 12% died by suicide during
the follow-up period; death by suicide was highest during the first two
years of follow-up (Tejedor et al., 1999). In another follow-up study
among 3690 individuals hospitalized for a suicide attempt, 28.1% were
readmitted for a suicide attempt, and 4.6% died by suicide during a 10-
year follow-up period, and rates of readmission and death by suicide
were highest during the first 2 years after the index attempt (Gibb et al.,
2005). Consistent with these findings, our study highlights the im-
portance of the first two-years following hospitalization for SB. Taking
into account risk for repeated SB is highest during the first two years
after hospitalization (Christiansen and Jensen, 2007; Owens et al.,
2002) and risk is particularly high immediately after discharge (Angst
et al., 2002; Kan et al., 2007), careful and intense monitoring following
hospitalization for SB is warranted.
The study of suicide risk factors is limited, given the many suicide

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L.N. Grendas, et al. Journal of Affective Disorders 258 (2019) 144–150

Fig. 1. Survival estimates (unfavorable events). Fig. 2. Survival estimates (unfavorable events) considering child sex abuse.

factors are associated with repeated SB (Beghi et al., 2013). This, in
part, is due to the limited studies examining the interaction between
variables associated with SB (Devries et al., 2014; Hillberg et al., 2011).
In the present study, numerous interactions were evaluated, and only
the interaction between CSA and psychosocial functioning predicted
suicide reattempts. Childhood sexual abuse independently increased
the risk of a suicide reattempt, and the risk was significantly higher
among patients who also endorsed low psychosocial functioning, as
compared to those with CSA and high psychosocial functioning. Child
sexual abuse is a severe form of childhood trauma that increases the risk
for lifetime suicide attempts (Afifi et al., 2016; Daray et al., 2016;
Hoertel et al., 2015; Turecki and Brent, 2016). Rates of suicide among
victims of CSA (Bostwick and Pankratz, 2000; Koola et al., 2018) are
particularly concerning. However, the interaction between CSA and
social impairment in the prediction of suicide risk is unclear. Social
impairment may be measured by an individual's perceived psychosocial
functioning (Bobes et al., 1999). The perception of low psychosocial
functioning is similar to the concept of thwarted belongingness in the
framework of the interpersonal theory of suicidal behavior (Van Orden
et al., 2010). According to the interpersonal theory of suicidal behavior,
thwarted belongingness is a psychologically painful mental state that
results when the person does not experience social connectedness

Table 2
Estimated hazard ratio HR among reattempters and non-reattempters during the follow-up period.
Variable Comparison HR (CI 95%) p

Socio-demographic
Age One year increase 0.98 (0.97–1.00) 0.066
Age at first SA One year increase 0.99 (0.97–1.00) 0.117
Sex Men vs. women 1.20 (0.70–2.03) 0.516
Marital status Partenership/cohabiting vs. separated/divorced 1.30 (0.84–2.02) 0.240
Educational level Complete primary vs. Complete high school 0.68 (0.34–1.37) 0.562
Complete primary vs. College 0.99 (0.48–2.02)
Complete high school vs. College 1.45 (0.84–2.50)
Diagnosis
MDD No vs. Yes 0.77 (0.51–1.16) 0.219
BD No vs. Yes 0.99 (0.56–1.79) 0.995
Schizophrenia and related disorders No vs. Yes 1.04 (0.62–1.74) 0.877
Other No vs. Yes 2.13 (0.53–8.66) 0.289
Co-occurring disorders
BPD No vs. Yes 0.98 (0.64–1.49) 0.921
SAD No vs. Yes 1.37 (0.79–2.37) 0.268
Suicidal history
Previous SA 1 o 2 vs. 0 2.13 (1.19–3.79) 0.023
1 o 2 vs. ≥3 1.01 (0.65–1.56)
≥3 vs. 0 2.11 (1.18–3.76)
Lethality index High vs. low 0.71 (0.39–1.27) 0.464
High vs. very low 0.84 (0.44–1.59)
Low vs. very low 1.19 (0.75–1.87)
Rating scale scores
Hopelessness (BHS) High vs. low 0.90 (0.59–1.36) 0.604
Hostility (BDHI) High vs. low 1.25 (0.82–1.89) 0.300
Impulsiveness (BIS) High vs. low 1.08 (0.71–1.66) 0.721
Psychosocial functioning (SASS) High vs. low 0.91 (0.60–1.38) 0.643
Number of recent stressors (SLE) Low vs. high 0.94 (0.62–1.44) 0.786
Impact of recent stressors (SLE) Low vs. high 1.00 (0.66–1.52) 0.997
Family history of S or SA No vs. yes 1.18 (0.79–1.77) 0.409
Child sexual abuse Yes vs. no 1.53 (1.03–2.28) 0.037

Ref.: MDD = major depressive disorder; BD = bipolar disorder; BPD = borderline personality disorder; SAD = substance abuse disorder; S = suicide; SA = suicide
attempt; BHS = Beck Hopelessness Scale; BDHI = Buss-Durkee Hostility Inventory; BIS = Barratt Impulsiveness Scale; SASS = Social Adaptation Self-evaluation
Scale; SLE = Stressful Life Events Scale.

148
L.N. Grendas, et al.
Table 3
Multivariate analysis for unfavorable events.
Without a history of sexual abuse
Psychosocial functioning (SASS) Low vs. High 0.63
Sex Women 1.96
Previous SA 1 or 2 vs. 0 2.30
1 or 2 vs. ≥3 0.96
≥3 vs. 0 2.40
Age One year increase 0.98
Ref.: SASS = Social Adaptation Self-evaluation Scale; SA = suicide attempt.
(Van Orden et al., 2012). Thwarted belongingness is thought to be as-
sociated with suicidal desire (Ma et al., 2016) and child sexual abuse
(Van Orden et al., 2010). These data together may explain the increased
risk for suicide reattempts among patients with CSA and low psycho-
social functioning. The present findings provide empirical support for
the interaction between CSA and low psychosocial functioning in pre-
dicting future SB among patients with a history of suicidal thoughts and
behaviors. These results provide the support that clinical assessment
regarding psychosocial functioning may be particularly important
among patients with CSA and previous SB.
In accord with prior findings, previous suicide attempts predicted
risk for a future suicide attempt among our high-risk sample. A history
of previous suicide attempts is the most significant predictor for future
SB (Artieda-Urrutia et al., 2014; Beghi et al., 2013; Finkelstein et al.,
2015; Turecki and Brent, 2016). Risk for future SB increases as the
frequency of previous suicide attempts increases (Buron et al., 2016).
The lethality of an index suicidal episode has also been shown to predict
lethality of a future suicide attempt (Rojas et al., 2018). In fact, in-
dividuals with repeated SB are at a 42% higher risk for suicide
(Finkelstein et al., 2015). Moreover, the estimate of the lifetime suicide
prevalence among individuals hospitalized for SB is 8.6% (Bostwick and
Pankratz, 2000). For these reasons, suicide-specific interventions after a
suicide attempt are essential to prevent suicide reattempts
(Ghanbari et al., 2015). . Given suicide attempts are considered a proxy
for suicide (Saiz and Bobes, 2014), continued study of patients with a
previous suicide attempt is important when planning preventive inter-
ventions for suicide.
In terms of demographic variables, gender and age were associated
with marked differences in predicting suicide reattempts. Women were
two-times more likely to make a suicide re-attempt as compared to men
regardless of other risk factors. This finding is consistent with previous
work (Hawton, 2000; Oquendo et al., 2007, 2001a). Across different
diagnostic presentations, rates of suicidal ideation and suicide attempts
are higher among women as compared to men (Borges et al., 2010;
Mann et al., 1999; Nock et al., 2008). For example, among subjects with
depression, women, as compared to men, had a higher risk for suicide
attempts and a sixfold higher risk for a future suicide attempt if they
had a previous suicide attempt (Oquendo et al., 2007). Our results also
indicated that young age increases the risk of re-attempting suicide.
This result is similar to findings from the Danish registry-based survival
analysis (Christiansen and Jensen, 2007) and another global multi-
center study (Borges et al., 2010) were younger age were a risk factor
for re-attempting suicide. Taking into account that suicide is the second
leading cause of death among individuals aged 15–29 years
(WHO, 2018), young subjects with suicidal risk is especially relevant.
5. Limitations
Limitations should be considered when interpreting these findings.
First, the patients included in the current were hospitalized for a SB. As
such, the results should be extended to patients of similar severity.
Second, it is unclear if recent hospitalization influences patients' per-
ceived psychosocial functioning or whether lower psychosocial func-
tioning scores were present prior to hospitalization. Third, CSA was
Journal of Affective Disorders 258 (2019) 144–150
History of sexual abuse p-value
(0.34–1.15) 2.01 (1.11–3.62) 0.021
(1.12–3.44) 0.019
(1.21–4.37) 0.023
(0.61–1.52)
(1.24–4.65)
(0.96–0.99) 0.019
determined by a semi-structured interview, which included an assess-
ment of other demographic data. Nonetheless, this method is similar to
other methods used across multiple studies and that have demonstrated
high agreement between a series of similar semi-structured screening
questions and validated scales for CSA (Brodsky et al., 2008; Goodwin
et al., 2004).
6. Conclusions
In the current study, we observed a high rate of suicide re-attempts
and suicide over a 2 year follow-up period among patients hospitalized
for suicide risk. To date, there is not a specific psychological or biolo-
gical marker sufficiently sensitive to predict short-term suicide or sui-
cide attempt repetition. As such, the study of clinical variables that can
help predict SB is still needed. The current findings indicated female
gender, previous suicide attempt, younger age, and CSA were asso-
ciated with increased risk of suicide attempt repetition. The interaction
between CSA and psychosocial functioning may be considered for fur-
ther evaluation and planning of preventive strategies. In order to im-
prove prevention of SB and suicide, it is important to increase our
understanding of high-risk patients and the present work adds to this
body of literature.
Contributors
The work presented here was carried out in collaboration between
all authors. FMD and LG contributed to the concept and design. LG, DR,
SP, PV and AP participated in the interview of the patients and acqui-
sition of data. FMD, LG, SR and LC analyzed the data and interpreted
the results. All authors participate in drafting the article and revising it
critically for important intellectual content. All authors have con-
tributed to seen and approved the final version of the manuscript.
CRediT authorship contribution statement
Leandro N. Grendas: Conceptualization, Data curation, Formal
analysis, Writing - original draft. Sasha M. Rojas: Data curation,
Writing - review & editing. Soledad Puppo: Data curation. Patricia
Vidjen: Data curation. Alicia Portela: Data curation. Luciana
Chiapella: Formal analysis, Writing - original draft, Writing - review &
editing. Demián E. Rodante: Data curation. Federico M. Daray:
Conceptualization, Funding acquisition, Project administration,
Supervision, Formal analysis, Writing - review & editing.
Declaration of Competing Interest
No coauthor or any immediate family members have financial re-
lationships with any commercial organizations that might represent the
appearance of a conflict of interest in the material reported here.
Acknowledgments
This project was supported by a grant of the University of Buenos
Aires (UBACYT 2013–2016: 20020120300022BA code Exp-UBA
149
L.N. Grendas, et al.
17,064/2012) and a grant from Ministry of Science, Technology and
Productive Innovation of Argentina (PIDC-2012-0064) (to FMD).
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jad.2019.07.071.
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