Upwards of 20% of people who attempt suicide lack prior psychiatric illness

As many as one in five people who attempt suicide have no prior psychiatric condition, adding an extra challenge to prevention. A study showing significant numbers of people with no psychiatric diagnosis who attempt suicide raises questions around identifying harder-to-find people who are at risk, and issues related to screening. Yet, expanding screening may not work well in environments lacking resources to help patients, according to researchers in JAMA Psychiatry.Using a nationally representative U.S. population-based survey, results revealed that about 19.6% of people who attempted suicide did not meet criteria for any psychiatric disorders before their first attempt.“I was surprised that the rate of suicide attempts in those with no prior diagnosis was nearly 20%. I was expecting 5% or so,” said the study's lead author Dr. Maria Oquendo, a professor of psychiatry at the University of Pennsylvania.Generally, little is known about people who attempt suicide who are presumably psychiatrically healthy. Historically, some studies found about 58% of people who died by suicide in low- and middle-income countries had no evidence of psychiatric disorders.Other research, such as a study drawing on data from the U.K. Biobank found that 88% of people who reported self-harm, including suicide attempts, met criteria for at least one psychiatric disorder. However, this implied that 12% did not.“We had noticed in our lab's data on healthy volunteers who are screened to exclude those with psychiatric diagnoses that they reported suicidal ideation. So, we wanted to see if we could document the existence of suicidal behavior in samples representative of the U.S. population,” she told the Medical Post.The team conducted a cross-sectional study using data from the U.S. National Epidemiologic Study of Addictions and Related Conditions III (NESARC-III). In part of the study, participants were asked “In your entire life, did you ever attempt suicide?” For those who answer “yes” they were then asked, “How old were you the first time that happened?” Data were then correlated with data for psychiatric diagnoses.The goal was to estimate the percentage of people whose first suicide attempt happened before the onset of any psychiatric disorders.NESARC-III had 36,309 respondents, and of that a total of 1,948 had attempted suicide. Of these 66.8% were female while 33.3% were male. Of those who reported a previous suicide attempt, 128 (6.2%) were healthy individuals with no apparent antecedent psychiatric diagnoses.But, 261 (13.4%) had made a first suicide attempt before the onset of a psychiatric disorder. Some of these people did not meet the criteria for a disorder until several years after the suicide attempt.“Thus, an estimated 19.6% of respondents reported a lifetime suicide attempt with no evidence of a psychiatric disorder prior to their first attempt,” the study said.There were some differences by age and sex. For one, women were more likely to attempt suicide in the same year of onset of their first psychiatric disorder than men: 14.9% compared to 8.6% respectively. Men were about 10% more likely to make suicide attempts after the onset of a psychiatric diagnosis.That more women attempted suicide is consistent with trends found in other studies which show that, in general, women in western countries make more suicide attempts, and males are more likely to die by suicide. “We think it may be related to selecting more lethal means, overdose versus guns. However, women are more likely than males to have been physically or sexually abused as children, and we know that increases the risks for suicidal behavior, which could be an element,” she said.Did this part of the cohort have psychiatric conditions that hadn't been noticed yet? “They were screened in a very detailed fashion, so it is possible but not terribly likely,” Dr. Oquendo said. It was also found that people over age 50 were much less likely to have attempted suicide than people under 50. The rates for suicide attempts were 3.9% for those over 50, compared to 6.1% for those between 35 to 50 years, and 6.2% for those under 35 years.It's unclear why this is, but, “we believe that younger populations are more vulnerable to all sorts of mental health issues,” she said. They may have less resilience when it comes to facing challenges and intense stresses in life, but studies supporting this are lacking.At this point, there's no clear answer in terms of possible changes in screening. Dr. Oquendo stated that there are problems with figuring out what the right balance is when faced with limited mental health and medical resources. Many people can’t access mental health and social care services that could help.“I would advocate screening for suicidal ideation or attempts. A tool like PHQ-9 can help, although in many clinical settings the suicide item is avoided because of the lack of resources to help patients who are at risk,” she said.The high number of 20% found in the study comes as no surprise to David Klonsky, a suicide researcher and professor of psychology at the University of British Columbia—not involved with the study.“Psychological autopsy studies find that between 10%-to-40% of people who die by suicide have no mental disorder at the time of their death. The 20% figure in the article, though it is about suicide attempts, not death, is roughly in line with this figure,” he told the Medical Post. He noted that many people just assume all suicides and suicide attempts are driven by mental illness. “But I think it had been clear for decades that this perspective is not accurate.”In fact, a paper he co-authored in 2022 highlighted factors other than psychiatric illness that could drive attempts to suicide. It stressed that suicide may be “motivated by pain and hopelessness, and that pain and hopelessness can be caused not only by mental illness but by other factors such as overwhelming interpersonal struggles or loss, seemingly insurmountable financial problems, chronic medical conditions, and systematic discrimination and persecution.”

Upwards of 20% of people who attempt suicide lack prior psychiatric illness

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