Risk factors for attempted suicide in non-psychotic patients with suicidal ideation

Mikhail Zinchuk1, Alla Avedisova1,2, Ettore Beghi3, Massimiliano Beghi4, Elisa Bianchi3, Cesare Maria Cornaggia5, Daniele Piscitelli5, Lina Urh5, Chiara Crotti5, Alexander Yakovlev1,6, Alla Guekht1,7

1Moscow Research and Clinical Center for Neuropsychiatry of the Moscow Healthcare Department, Moscow, Russian Federation; 2Serbsky National Research Centre for Social and Forensic Psychiatry, Russian Federation; 3Department of Neurosciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy; 4Department of Mental Health, AUSL Romagna, Cesena, Italy; 5School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; 6Institute of Higher Nervous Activity and Neurophysiology of Russian Academy of Sciences, Russian Federation; 7Department of Neurology, Neurosurgery and Medical Genetics, Pirogov Russian National Research Medical University, Russian Federation.

Summary. Objective. In Eastern European countries, suicide rate are among the highest in the world and suicide attempts are among the most important risk factors. The aim of this study is to identify factors associated with suicide attempt (SA) in non-psychotic patients with suicidal ideation (SI). Methods. Among 6204 consecutive adult patients (residents of Moscow) with non-psychotic mental disorders (NPMD), 361 individuals aged 18-77 years (median 24 years) were enrolled in the study after screening for lifetime SI with the Self-Injurious Thoughts and Behaviors Interview (SITBI). All participants were assessed for sociodemographic variables, psychiatric diagnosis, family history of mental disorders, history of abuse, sexual behavior, psychiatric treatments, suicide plan, SA, and nonsuicidal self-injury (NSSI). Results of multivariable analyses (MV) are presented as odds ratios (OR) with 95% confidence intervals (CI). Results. 166 patients (46%) reported lifetime SA. In MV, variables associated with SA included smoking (OR 2.1; 95% CI 1.2-3.7), having made a suicide plan (OR 3.4; 95% CI 2.0-5.7), and scars covered by tattoos (OR 5.2; 95% CI 1.5-17.9). History of law violation (OR 2.0; 95% 1.0-4.2) was of borderline significance. Conclusions. Transition from SI to SA in patients with NPMD was associated with smoking, suicide planning, history of law violation and presence of tattoos covering scars.

Key words. Ideation-to-action framework, predictors, Russia, suicidal ideation, suicide attempt.

Fattori di rischio assiciati al tentativo di suicidio in pazienti non psicotici con ideazione suicidaria.

Riassunto. Scopo. Nei paesi dell’Europa Orientale i tassi di suicidio sono tra i più elevati nel mondo e il tentato suicidio è tra i fattori di rischio più importanti. Lo scopo di questo studio è di identificare i fattori associati a un tentativo di suicidio (SA) in pazienti non psicotici con ideazione suicidaria (SI). Metodi. In un campione di 6204 pazienti adulti (residenti a Mosca) con disturbi mentali non psicotici (NPMD), 361 individui di età compresa tra 18 e 77 anni (mediana 24 anni) sono stati arruolati nello studio in seguito a uno screening per ideazione suicidaria lifetime effettuato con il Self-Injurious Thoughts and Behaviors Interview (SITBI). In tutti i partecipanti sono state investigate: variabili sociodemografiche, diagnosi psichiatrica, storia familiare di disturbi mentali, storia di abusi, comportamento sessuale, trattamenti psichiatrici, pianificazione di suicidio, SA e autolesionismo non suicidario. I risultati dell’analisi multivariata (MV) sono stati presentati come odds ratio (OR) e intervalli di confidenza (CI) al 95%. Risultati. 166 pazienti (46,0%) hanno riportato almeno un SA lifetime. Nella MV, le variabili associate a SA erano: il fumo (OR 2,1; IC 95% 1,2-3,7), la pianificazione di suicidio (OR 3,4; IC 95% 2,0-5,7) e le cicatrici coperte da tatuaggi (OR 5,2; IC 95% 1,5-17,9). L’anamnesi positiva per violazione di legge (OR 2,0; 95% 1,0-4,2) era di significatività borderline. Conclusioni. La transizione da SI a SA nei pazienti con NPMD era associata a fumo, pianificazione del suicidio, anamnesi positiva per storia di violazione di legge e alla presenza di tatuaggi che coprono le cicatrici.

Parole chiave. Ideazione suicidaria, predittori, quadro ideazione-azione, Russia, tentativo di suicidio.


In many countries, suicide remains one of the leading causes of injury-related death, particularly among young people1,2. Suicide is a preventable cause of death, but its prevention is hampered by the lack of reliable predictors3. Despite a steady downward trend in suicide mortality over the past decade, suicide rates in the post-Soviet states are among the highest in the world, with an average incidence almost double that of most other European regions4.

The lifetime prevalence of suicide attempt (SA) in European adults is approximately 1.3%5, although according to the World Health Organisation, this prevalence varies considerably (0.4%-4.2%) between countries6. A previous SA is one of the most reliable predictors of both non-fatal and fatal SA in the future7-9.

Suicidal ideation (SI) appears to be quite common in the general population, with Nock et al.10 reporting a rate of 9.2% in a representative cross-national sample.

The risk of SA in people with SI varies considerably between populations. For example, people with mental disorders are on average 7 times more likely to have an unfavorable SI outcome than the general population11,12. Fortunately, only a minority of those who have thought about killing themselves will attempt suicide in their lifetime, so the prevalence of SI is several times higher than that of SA6,13. This renders the use of SI as a sole predictor of suicide ineffective due to its low specificity14. Despite this well-established fact, it is still common practice in suicide studies around the world to lump together people with SI only and people who have already attempted suicide together. In the last decade, many suicidologists have stressed the importance of studying so-called “ideators” and “attempters” separately. A comparison between these two groups is the only way to identify the factors involved in the transition from SI to SA. This is supported by the findings of the literature review conducted by Klonsky et al.15, who reported that traditional risk factors for suicide (e.g. depression, hopelessness, impulsivity, most psychiatric disorders) robustly predict SI, but poorly predict SA among ideators.

Over the past several decades, researchers have identified numerous risk factors for suicide that can be divided into two types: distal and proximal16. Distal risk factors include family history of suicide and genetic load, early life adversities and epigenetic modifications, personality traits and cognitive styles. Proximal risk factors include conditions that act as precipitants: psychiatric and physical disorders, psychosocial crises, recent life events causing acute stress, and availability of resources. Some sociodemographic factors are considered modifiers of the relationship between distal and proximal risk factors, such as gender, age, education, religious and spiritual beliefs, family structure, employment and income, social support, and quality of the social environment. At the same time, many of these parameters were found in studies that did not separate “suicide ideators” from “suicide attempters” and should be re-evaluated from this perspective in future studies.

Integrative theories of suicide, such as the Three-Step Theory14, can be incredibly valuable in this regard, allowing us not only to separate ideators from attempters, but also to take into account factors such as lack of resilience and capacity for suicide. These parameters may be significantly influenced by the social characteristics and cultural milieu of a particular country. Research on the factors involved in the transition from SI to SA in countries with different socio-economic and cultural contexts is needed to assess the mechanisms of this influence. To the best of our knowledge, no previous study has addressed this issue in Russian patients. With this in mind, our primary aim was to identify variables associated with SA in Russian non-psychotic inpatients with SI, following the ideation-to-action framework17,18.

Materials and methods

This is a retrospective cohort study conducted at the Moscow Research and Clinical Center for Neuropsychiatry between November 2017 and May 2019. The study population consisted of all patients aged 18 and over who were admitted to the inpatient ward of the centre for any psychiatric problem requiring medical intervention. It should be noted that any person with permanent registration in Moscow who needs medical care for psychiatric problems can receive it free of charge in this type of centre. The first step in the study was to conduct a structured interview using the Self-Injurious Thoughts and Behaviour Inventory (SITBI)19 to identify those who had experienced SI in their lifetime. The tool is a valid screening instrument with strong interrater and test-retest reliability, and its short and long forms have been widely used by researchers in different countries20-22. The SITBI-long form contains 169 questions and provides comprehensive information on SI, suicide plans, suicide gestures, SA, thoughts of nonsuicidal self-injury (NSSI). Each section is preceded by a question about the presence of the variable being studied, and if the answer is negative, the researcher moves on to the next section. Therefore, the duration of the interview did not exceed 5 minutes if the patient had no current or past history of suicidality.

We excluded patients who met criteria for disorders listed in the “Schizophrenia Spectrum and Other Psychotic Disorders” chapter of DSM-5, as well as those who met criteria for disorders coded F2x, except for F21.8 [Schizotypal personality disorder] of the Russian variant of ICD-10 Chapter V. Another exclusion criterion was inadequate knowledge of the Russian language and a manifest cognitive impairment that impeded the understanding of the interviewer’s questions.

After written informed consent was obtained, the patient underwent a structured interview to collect demographic and clinical data. A detailed ad hoc questionnaire was used for inclusion variables based on data from previous suicide research, such as: family history of self-injurious behavior23, previous traumatic events like physical and sexual abuse, witnessing domestic violence, bullying24, sexual habits25, body modifications26, substance abuse27, self-injurious behaviors (suicide plans, suicide gestures, SA, age at first suicidal thoughts, NSSI), history of psychiatric disorders, and hospital admissions. Family history was assessedin the ancestors and siblings, but not in the offspring. A detailed psychiatric diagnosis was made using the ICD-10 codes. All interviews were conducted by the same two clinical researchers (MZ, AA).

All variables were entered into a database and analyzed using the SAS software (version 9.4; SAS Institute, Cary, NC, USA). The significance level was set at 5%. Descriptive statistics were performed on all data. All variables were compared in subjects with and without SA. Data are presented as counts and percentages for categorical variables and as means with standard deviation (SD) or median, range and interquartile range for continuous variables. The association between each variable and SA was assessed using chi-squared or Fisher’s exact test. All variables found to be statistically significant were then included in a multivariable logistic regression model. Results are presented as odds ratios (OR) with 95% confidence intervals (95% CI).

The study was approved by the Ethics Committee of the Moscow Research and Clinical Centre.


Out of 6204 consecutive patients, 361 (5.8%) fulfilled the inclusion criteria and were enrolled in the study. The sample consisted of 315 (87%) participants assigned female at birth and 46 assigned male, aged 18-77 years (median 24 years), of whom 202 (56%) were younger than 25 years, 120 (33.2%) were 25-44 years, and 39 (10.8%) were 45 years or older. Alternative gender identity was reported by 36 patients (10%), all of whom were assigned female at birth.

The general characteristics of the sample are shown in table 1.

Patients were mostly highly educated: 95% a had secondary-level, incomplete or complete higher education. One hundred and 64 patients were unemployed (45.4%) and a significant proportion of patients (29%) were still studying at university at the time of the research. One hundred and 71 patients (47.4%) received financial support from their families. Only 174 patients (48.2%) were in a liaison at the time of the interview, while 41 (11.4%) had never been in a relationship. One hundred and 93 (53.5%) had a complete family structure during childhood.

While 205 patients (56.8%) had only heterosexual experience during their lifetime, 10 (2.8%) had only homosexual experience and 84 (23.3%) reported having partners of both sexes.

Current smoking was reported by 205 (56.8%) and alcohol consumption in the past 12 months by 296 (82%). One hundred and 69 patients (46.8%) had used illegal drugs at least once in their lives, and 49 (13.6%) had behavioural problems suggesting law-breaking. One hundred and 24 (34.3%) had at least one tattoo, 25 (6.9%) had tattoos covering scars from previous self-harm and 122 (33.8%) had body piercings. One hundred and 70 (64.6%) reported mental disorders in at least one of their parents/siblings. SA among family members was reported by 66 patients (18.3%) and death by suicide among close relatives by 34 patients (9.4%). Two hundred and 14 (59.3%) patients had been exposed to physical abuse, 126 (34.9%) had witnessed domestic violence, and 111 (30.7%) had been sexually abused. A history of eating disorders (anorexia and/or bulimia only) was reported by 130 patients (36%). The majority of patients had a primary diagnosis of mood disorder (41.2%), followed by personality disorder (23.5%) and schizotypal disorder (19.7%). During their lifetime, a total of 217 patients reported at least one episode of NSSI, 203 (56.2%) had a suicide plan and 166 patients (46%) reported one or more SA.

Univariate analysis

Patients with a history of SA were more likely to have relatives with SA and NSSI and to have had traumatic experiences such as witnessing domestic violence, physical abuse, or sexual abuse. SA was associated with a number of behavioral characteristics (lack of romantic relationships, bi-sexual experience, tattoos covering scars, smoking, experience of illegal drug use, history of law breaking) and a number of clinical variables including eating disorders, NSSI, suicide planning (table 1). SA was more prevalent in patients with schizotypal, mood, and personality disorders (the three most common primary diagnoses).

Multivariate analysis

In the multivariable model (table 2), the only variables significantly associated with SA were smoking (OR 2.1; 95% CI 1.2-3.7), having made suicide plans (OR 3.4; 95% CI 2.0-5.7), and having scar-covering tattoos (OR 5.2; 95% CI 1.5-17.9). A history of law violation (OR 2.0; 95% 1.0-4.2) was of borderline significance.


The percentage of individuals with SI in our sample (5.8%) was lower than in other studies. In line with Sørlie et al.28, suicide-related stigma in Russia may reduce both patient reporting and clinician recognition of suicidality, especially among men. In addition, in the Russian Federation, people with relatively mild symptoms of non-psychotic mental disorders, such as mild depression, mixed anxiety and depressive disorder, and people with organic emotional lability may also receive inpatient treatment. For these reasons, the severity of psychiatric symptoms and related distress appears to be lower than in previous studies. The patients in our sample were predominantly young and middle-aged women. SI rates are usually higher in women than in men5,29, but the difference is generally smaller compared to our findings. Our data may be explained by the fact that women are more likely to seek psychiatric treatment than men. The high percentage of unemployed participants was associated not only with a mental disorder that impedes career advancement, but also with the fact that a significant proportion of patients (29%) were still pursuing a university education at the time of the study. Almost half of the patients received financial support from their families.

In terms of psychiatric diagnoses, the high prevalence of schizotypal disorder in our sample is consistent with other reports. A meta-analysis30 found that self-harm and suicidality were highly prevalent in individuals at risk of psychosis, while Bang et al.31 found that these individuals had significantly greater SI and more severe depressive symptoms than healthy controls. In our study, the transition from SI to SA was reported by 46% of patients. These figures are higher than in previous reports32, which found that one-third of ideators had a plan and one-fifth had made an attempt. Our data are from an inpatient setting and represent a psychiatric sample rather than the general population. According to some studies, the prevalence of mental disorder among those who have attempted suicide may be as high as 80%33. However, while most patients with SA have a mental disorder, it is worth remembering that two-thirds of patients with major depressive disorder have never attempted suicide in their lifetime34.

Three factors were significantly associated with SA in our study: smoking, having formulated a suicide plan, and the presence of scar-covering tattoos. Smoking has been associated with SI35, suicide planning36,37, and SA, including fatal SA38. In a meta-analysis of 63 studies, smokers had a 2.05 risk of SI, a 2.36 risk of suicide planning, and a 2.84 risk of SA27. The mechanism by which tobacco smoking affects the risk of SA may be explained by nicotine decreasing serotonergic activity in the hippocampus39 and by nicotine activating the hypothalamic-adrenal-pituitary axis, which has been associated with suicidal behavior40. Currently, there is controversy regarding the relationship between tattoos and mental illness. There is some evidence that tattooing appears to be more common in some mental disorders, such as borderline personality disorder41. The prevalence of tattooing is influenced by various cultural factors, such as social attitudes towards people with tattoos. In recent decades, tattooing is no longer a marginal practice in the Russian Federation, but its prevalence is still lower than in other European countries42. The association between psychopathology and tattoos may weaken as tattoos become more prevalent in the population, although poorer outcomes may be associated with specific characteristics of tattoos, such as patient motivation43. Tattooing is common among individuals with NSSI and correlates with the severity of self-harm44,45, possibly indicating altered pain thresholds in individuals with a propensity to tattoo. In addition, the pain experienced during tattooing may increase suicidality by reducing the fear of pain46. In our study, tattoos used to cover scars from previous self-harm were associated with SA. In our study, a structured interview was used to identify suicide plans and their characteristics. The results obtained confirm that in patients with non-psychotic mental disorders, the presence of a suicide plan is associated with SA. While some authors believe that most SAs are impulsive47, others suggest that many attempts can be predicted and that the development of a suicide plan is a sign of high suicide risk48. Suicide planning is common among patients with mental disorders29,36,37. According to Dong et al.34, the lifetime prevalence of suicide planning among patients with major depressive disorder is approximately 17.5%. Several studies29,36,37 described a continuum between SI, suicide planning, non-fatal and fatal SA. The results of our study are consistent with previous findings and underscore the importance of identifying the presence of a suicide plan when SI is reported.

Many variables found to predict SA in previous studies were significant only in univariate analysis in our research, so they could not be considered as independent predictors of SA in studied population. The first explanation could be that they are involved in the development of SI but not in the transition from SI to SA. Another reason for these results could be some peculiarities of the Russian population, and repeated cross-national research is warranted to test this hypothesis. Our findings may also be influenced by some characteristics of studied cohort, which consists mainly of young adults (almost exclusively female) with non-psychotic mental disorders. As the number of men and older patients in our study is relatively small, the study may not be sufficiently powered to reveal the importance of some factors involved in the transition from SI to SA, if these factors are specific to this subpopulation.

Our study has both strengths and limitations. The main strength is the study of a large cohort of patients with SI at high risk of suicide. Another strength is the enrolment of consecutive patients to minimise selection bias. As we used a screening tool (the SITBI) that has been validated in many countries and the full version of our questionnaire is available19, the research methodology is easily reproducible. Such studies will make it possible to compare data from different populations and provide an understanding of the specific cultural features of the transition from SI to SA.

However, there are some limitations. The first is the retrospective design. The data cannot be extrapolated to persons with mental disorders whose first SA was fatal, so they are limited to cases of first non-lethal SA. However, a prospective study in this context has not been carried out as it would require a much larger sample size and a long follow-up period.

A second limitation is the baseline characteristics of the cohort. Our patients were admitted to the Center for Neuropsychiatry because of psychiatric symptoms, so they do not represent the entire population of people with suicidal thoughts. However, the purpose of our study was to provide data that could be used for patients with mental disorders.

A third limitation is the age and gender structure of our sample. The patients were predominantly young and middle-aged women, and this may be important for the interpretation of the results, as men and people in the older group are at higher risk of a lethal suicide attempt. With this in mind, the results of our study should not be extrapolated to the general population until additional studies are conducted in samples with higher numbers of men and older people to verify our results. The final limitation is the sample size. Although it is quite large, we cannot exclude that our study was underpowered for some variables that were found to be of borderline significance in our study (such as family history of SA and law violation).


Smoking, scar-covering tattoos, and suicide plan are associated with the transition from SI to SA in Russian patients with NPMD. Measures to prevent non-fatal and fatal SA should be taken in patients with SI and these behavioral characteristics.

Acknowledgements: the authors would like to thank the following people for their technical assistance: Nadezhda Voynova, Anastasiia Lavrishcheva.

Disclosures: this research has not received any specific grant from the public, commercial or not-for-profit sectors; the authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

Ethical publication statement: all subjects gave their informed consent for inclusion before they participated in the study; the study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the Moscow Research and Clinical Centre.


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