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SUICIDAL BEHAVIOUR is one of the three most common causes of non-accidental death in people under 25 years of age. Every year, almost a million people commit suicide worldwide (World Health Organization [WHO], 2012). In Colombia, official reports indicate a higher suicide rate amongst individuals between the ages of 15 and 30. Indeed, close to 25% of the people who commit suicide in Colombia are young adults (Gómez-Restrepo et al., 2002; Ruiz & Chaves, 2017). Intoxication is the leading chosen method used to self-harm and women comprise the majority of suicide attempt reports (Cardona, Torres, González, & Portilla, 2019; Castillo, Rodríguez & Torres, 2020), though completed suicide cases are more frequently carried out by men (Carreño Tapias, Sierra Buelvas, & Yepes Pabón, 2018). For each completed suicide, many more suicide attempts are registered, and each attempt increases the probability to occur again with increased lethality (Borges et al., 2010).
A study conducted with 18,903 medical records across Colombia indicated that persistent suicidal ideation predicted multiple suicide attempts. Having a diagnostic of mental disorder, in particular depression, was also significantly linked with repeated suicide attempts (Arenas, Gómez-Restrepo, & Rondón, 2016; Castillo et al., 2020). In line with national data, analysis of samples from the Colombian northern region report that repeated suicide attempts are significantly likely within the context of mental disorders. Other variables as previous hospitalizations and the presence of chronic medical conditions also seem to increase the likelihood of incurring in more than one suicide attempt (Tuesca Molina & Navarro Lechuga, 2003).
Decades of research have identified suicide behaviour as the result of a multifactorial interplay of biological, psychological, and sociocultural factors (Chang et al., 2016; Franklin et al., 2017; Ribeiro et al., 2016). Nevertheless, the evidence is not conclusive as to what factors underpin the transition between suicidal ideas and suicidal acts, particularly in populations of low and middle-income countries (LMIC; Knipe et al., 2019). The integrated motivational-volitional framework (IMV; O'Connor, 2011) is a theoretical model composed of three phases that delimitates the pathways for the appearance ofsuicide behaviour and suicide ideation.
The pre-motivational phase explains the bio-psychosocial context where suicidal ideation (motivational phase), and subsequent suicidal behaviour (volitional phase; O'Connor & Kirtley, 2018) emerge. This phase comprises three factors in relation to suicide ideation and suicidal acts: diathesis, environment, and life events. Diathesis refers to the factors associated with the individual's background that increases the risk of suicide behaviour. A solid body of evidence supports that genetic (e.g., Hesselbrock et al., 2004), biological (e.g., serotonin neurotransmission; Lin & Tsai, 2004) and cognitive predisposition factors (e.g., dispositional optimism; Hirsch, Wolford, LaLonde, Brunk, & Morris, 2007) increase the risk of suicide ideation and behaviour. Complementarily, societal and environmental factors as stressful life events, interpersonal problems, financial issues, and inequality are known to increase the risk of suicidal behaviour (Baca-García et al., 2007; Beautrais, Joyce, & Mulder,1997; Chang, Yip, & Chen, 2019; Miller et al., 2005).
The motivational phase emphasizes the psychological processes underlying suicide ideation and intention formation. According to O'Connor and Kirtley (2018), the path towards suicide ideation initiates with feelings of defeat and humiliation in response to a life event stressor (e.g., a dispute with a partner). When the individual experiences these feelings of defeat and humiliation but lacks the psychological coping mechanisms to effectively manage them (Threat to Self-Moderators; TSM), feelings that there is no escape (entrapment) may appear.
The transition from feelings of entrapment to suicidal ideation are in turn moderated by Motivational Moderators (MM) that when present, increase or decrease the probability to progress from feelings of entrapment to suicidal ideation. In the absence of motivational moderators (e.g., belongingness, burdensomeness, resilience, or perception of social support, purpose) the risk for suicide ideation increases. The influence ofmotivational moderators, specifically burdensomeness (the idea that one is a burden for family and friends), and social isolation (belongingness), is widely supported by empirical data (see for a review; Chu et al., 2017).
The final phase proposed by O'Connor, 2011, comprises Volitional Moderators (VM) that are fundamental to transition from suicidal ideation to behaviour. Volitional motivators may be physiological (e.g., risk-prone, impulsivity; McGirr et al., 2008), psychosocial (Haw, Hawton, Niedzwiedz & Platt, 2013), or environmental in nature (Bilsen, 2018; Riblet, Shiner, Young-Xu, & Watts, 2017). The volitional phase also includes a history of self-harm attempts as a VM that increases the risk of swifting from suicide ideation to suicide behaviour. People that engage in self-harm behaviour once are signiicantly more likely to re-incur in suicide behaviour (Victor & Klonsky, 2014).
Other theoretical approximations to suicide ideation and behaviour, (i.e., interpersonal-psychological theory; Joiner, 2007), suggest that the transition from suicidal ideation to suicidal act depends on speciic psychological variables like impulse control, hopelessness, and mood disorders (Bebbington et al., 2010; Brezo, Paris, & Turecki, 2006; Mann et al., 2016; Steeg et al., 2016). Suicidal behaviour may occur as a reactive function in situations where the subject feels defeated and without hope, generating intolerable stress, non-acceptance of that emotional state, and limited access to effective strategies for resolution (Taylor, Gooding, Wood, & Tarrier, 2011).
Identifying and intervening risk factors in early stages is essential for suicide prevention (WHO, 2012; Wasserman & Wasserman, 2009). For instance, literature offers supporting evidence towards the effectiveness of suicide prevention protocols that prioritize key predictors, as history of previous suicide attempts, suicidal ideation, and psychiatric conditions (e.g., De Beurs, Ten Have, Cuijpers, & De Graaf, 2019; Harris & Barraclough, 1997), including personality disorders (Gerson & Stanley, 2002; Parra-Uribe et al., 2017; Rosenthal et al., 2008).
A large percentage of people that complete suicide had sought medical assistance in the month prior to passing (Luoma, Martin, & Pearson, 2002). Thus, when patients attend emergency services for self-harm may be a valuable moment of contact to intervene and reduce the risk of future suicide attempts (Deisenhammer, Huber, Kemmler, Weiss, & Hinterhuber, 2007), for instance, by screening for risk and protective factors during the assessment.
Medical bodies and international institutions as the International Association for Suicide Prevention (IASP) and the WHO advise that all individuals intentionally attempting to self-harm should undergo a psychiatric or psychological evaluation, regardless of the characteristics or severity of the suicidal act (WHO, 2014). However, while it is ideal to refer patients displaying suicide behaviour to mental health services, not all patients get to see a mental health professional (Stewart, Manion, & Davidson, 2002). The management of intentional self-harm should be informed by clinical evidence to improve the effectiveness ofprevention strategies (Ayuso-Mateos et al, 2012; Berman & Silverman, 2014). This study sought to identify the risk factors predicting repeated suicide attempts and also to conduct a descriptive analysis of the management given to patients attending an emergency service for suicide attempts in Northern Colombia.
Methods
Setting
The data used in this study was collected at a hospital in the city of Soledad, in Northern Colombia. The hospital has a capacity of 60 beds and serves a population of approximately 250,000 patients per year. As well as an emergency department, the hospital offers in and outpatient services in various medical fields as neurology, cardiology, occupational therapy, psychiatry, and psychology, amongst others.
Procedure
Routinely, patients attending the hospital's emergency department undergo an assessment conducted by nursing and medical staff. Details from this assessment are then documented in the medical records and patients receive a formal diagnostic according to the International Classification of Diseases (ICD-10). Management of patients attending the service for suicide attempts may be hospitalized, liaised with outpatient mental health services, or be sent home with recommendations.
This study comprised a retrospective audit of the emergency department database of a hospital in Northern Colombia. Out of the general database of the hospital, the records of patients seeking medical help for intentional self-inflicted injury within the period of January 2008 and June 2019 were selected (ICD-10 codes: X60-X84). After excluding those depicting accidental intentional self-inflicted injury, the remaining data were extracted for analysis. The final sample included all medical records that according to the ICD-10 categories for intentional self-harm, indicated a suicide attempt (e.g., by hanging, by poisoning).
Following the initial audit of the database, the remaining medical records underwent further examination of the patient's reported motivation to commit the self-harming act. The records were then classified as self-harm aimed to hurt oneself, or suicide attempt (e.g., "I did not want to live because my brothers threw me out of the house when they suspected I was pregnant", Medical record No. 14 ), and self-harming inflicted to cause an effect on others, or suicide gesture (Freeman et al., 2017; García-Nieto, Blasco-Fontecilla, de León-Martinez & Baca-García, 2014). Examples of suicide gestures found in the database included self-harming to attract someone's attention (e.g., "I did it to scare my husband, because of the family struggles we are having" Medical record No. 48), and to persuade a relative (e.g., "I drank the paint thinner to stop my husbandfrom abandoning me", Medical record No.5). Only the data categorised as suicide attempts were entered in the logistic regression (N=271). However, the description of management practices was performed with the dataset of suicide behaviour globally, including both suicide gestures and attempts (N=336). This study was approved by the hospital Ethics Committee and all included data were anonymized and handled according to its ethical procedures.
Study Variables
The variables utilized in the study included patients' sociodemographic details of gender, age, relationship status, and occupation (pre-motivational phase). Other factors hypothesized as predictors of single and repeated suicide attempts were suicide ideation before the episode of self-harm, use of recreational drugs (both self-reported), history of previous admissions for intentional self-harm, and record of prior psychiatric assessment, if available.
Data Analysis
Initially, descriptive statistics were used to identify differences between those who attempted to commit suicide for the first time and those with repeated attempts. Categorical and continuous variables were analysed using X 2 and T-Tests, respectively. Secondly, to assess the factors that significantly predicted repeated suicide attempts, a multivariate logistic regression analysis was conducted with the data of those meeting the criteria for suicide attempt (N=271). The dependent variable (history of suicide attempts) was dichotomized into 1 or 0 according to the presence or absence of previous suicide attempts within the medical record. The predicting variables utilised in the logistic regression were restricted to those available in the hospital database. Following the theoretical model of O'Connor (2011), two blocks of variables were introduced in the analysis: pre-motivational variables (age, gender, occupation status), and motivational variables (consumption of psychoactive substances, suicidal ideation prior the attempt, and history of a psychiatric disorder; see Table 2). In support to the second aim of this study, descriptive statistics were used to depict the management outcome of patients attending the emergency department for suicide behaviour. All data were analyzed using the statistical analysis software STATA 15 and SPSS version 26.
Results
A total of 336 cases from the hospital's database met the inclusion criteria for this study. The sample was composed of 269 females and 67 males (N=336). Females showed significantly more repeated attempts of self-harm (M=1.72, SD=.64), than their male counterparts M=29.2, SD (M=1.34, SD=1.08; t=2.73, P=.001). Patient's age ranged between 8-95 years and reached a mean of 27.68 (SD=13.9). Young adults (20-40 years old) were the largest age group within the sample. Over a third of the sample reported not having a partner (N=118), and being a student was the primary occupation reported (N=111), followed by formally employed (N=81) and homemakers (N=68; see Table 1).
Table 1 Demographic Details
| Factor | Total sample (N=336) | First time (N=200) | Repeated (N=136) | p |
|---|---|---|---|---|
| Age in years | .01 | |||
| Mean+/-SD | 28+/-14 | 29+/-15 | 25+/-11 | |
| Min-Max | 8-92 | 8-92 | 8-67 | |
| Gender (%) | .02 | |||
| Female | 269 | 151(56) | 118(44) | |
| Male | 67 | 49(73) | 18(27) | |
| Age group (%) | ||||
| <18 | 107 | 61(57) | 46(43) | |
| Adulthood | 175 | 101(58) | 74(42) | |
| Late adulthood | 52 | 38(73) | 14(27) | |
| Relationship status (%) | .28 | |||
| In partnership (e.g., civil partnership, married) | 72 | 40(56) | 32(44) | |
| < 16 | 64 | 34(53) | 30(47) | |
| In partnership with children | 73 | 49(67) | 24(33) | |
| Single | 118 | 74(63) | 44(37) | |
| Occupational status (%) | .26 | |||
| Homemaker | 68 | 39(57) | 29(43) | |
| Student | 111 | 60(54) | 51(46) | |
| Employed | 81 | 55(68) | 26(32) | |
| Not reported/Unemployed/Retired | 75 | 46(61) | 29(39) | |
| Suicidal ideation (%) | <.001 | |||
| No | 230 | 168(73) | 62(27) | |
| Yes | 105 | 31(30) | 74(70) | |
| Use of psychoactive substances (%) | .19 | |||
| No | 302 | 177(59) | 125(41) | |
| Yes | 32 | 22(69) | 10(31) | |
| Previous psychiatric assessment (%) | <.001 | |||
| Psychiatric or personality disorder alone | 141 | 72(51) | 69(49) | |
| Psychiatric disorder in comorbidity with personality disorders | 74 | 33(45) | 41(55) | |
| Psychiatric disorder in comorbidity with other psychiatric disorders | 30 | 18(60) | 12(40) | |
| Without record of psychiatric assessment | 91 | 77(85) | 14(15) |
Table 2 Odds Ratio Single vs Repeated Attempt
| Odds Ratio | Std. Err. | z | P>|z| | [95% Conf. Interval] | ||
|---|---|---|---|---|---|---|
| Female | 1.80 | .84 | 1.260 | .21 | .7215 | 4.4884 |
| Childhood/Adolescence | 4.93 | 3.18 | 2.470 | .01 | 1.3921 | 17.4726 |
| Early adulthood | 3.79 | 1.93 | 2.620 | .01 | 1.3978 | 10.2934 |
| Student | .51 | .24 | - 1.410 | .16 | .1972 | 1.3011 |
| Employee | .61 | .27 | -1.1 | .27 | .2551 | 1.4660 |
| Use psychoactive substances | 1.28 | .80 | .400 | .69 | .3749 | 4.3840 |
| Mental disorder | 3.26 | 1.55 | 2.500 | .01 | 1.2893 | 8.2626 |
| Personality disorder | 1.13 | 1.15 | 0.120 | .90 | .1539 | 8.3041 |
| Personality disorder and Mental disorder | 4.19 | 2.11 | 2.850 | 0 | 1.5622 | 11.2649 |
| With previous suicide idea | 10.88 | 3.88 | 6.700 | 0 | 5.4091 | 21.8777 |
| Constant | .02 | .01 | -5.47 | 0 | .0038 | .0715 |
The most-reported method utilized to self-harm was self-induced intoxication (N=289). Patients used a variety of substances, including poison (N=67; e.g., rat, termite poison), chemical solvents (N=45; e.g., bleach, paint thinner) and medications (N=177). It was observed that amongst the medications ingested by patients to self-harm, 42.3% (N=75) corresponded to over the counter medications (e.g., paracetamol, aspirin), 33% (N=59) reported ingesting medications with restricted sell (e.g., antipsychotics, benzodiazepine), and further 3% (N=5) did not specify the type of medication. Other types of methods utilized included cutting (N=32), firearms and hanging themselves (N=13). Intentional self-harming behaviour was mainly performed in the context of family (N=132) or relationship disputes (N=116), but some individuals reported triggers like financial concerns (N= 8).
It was documented that suicide attempters reported feelings of despair associated with the perception that there was no other way out for the situation they were experiencing (Feelings of entrapment and hopelessness). Excerpts from the database records included statements as: "things had already reached such a point that the only option was to attempt against my life" (Medical record No. 23); "I did not see any way out other than suicide because of the situation I was living with my partner" (Medical record No. 48).
In 105 records, the episode of self-harm was preceded by suicidal ideation, and 32 patients disclosed using psychoactive substances. A diagnostic of psychiatric disorder was reported in 245 cases. The most frequent diagnostic amongst suicide attempters were psychiatric disorders as mood disorders and psychosis (N=155), followed by diagnostic of a psychiatric disorder in comorbidity with a second or third diagnostic of personality disorder (N=73). A diagnostic of personality disorder was reported in 15 cases, and the remaining 91 reports did not have a psychiatric diagnostic within their medical history.
In 40% of cases (N=136), the patient had previously attempted to intentionally self-harm and the number of prior attempts ranged from 1-8 (M=1.64, SD=1.02). Repeaters were significantly younger (M=25.5, SD=11.37) than those with a single attempt registered in the database (M=29.2, SD=15.36), T=2.38 (333) P=.01. There were no significant differences in mean number of attempts between age groups, F(2,331)=.36, P=.70. Following the reviewing of motives behind the suicidal behaviour, it was identified 271 cases of suicide attempts and 65 suicide gestures.
Risk Factors for Repeated vs Single Suicide Attempt
Among the 271 patients who were treated at the hospital for suicide attempt, 67.5% had no history of previous attempts and the remaining 32% had one or more previous suicide attempts. It was found that females engaged in more attempts to self-harm than did their male peers; 35% females had history of one or more suicide attempts (as oppose to 65% first-timers), while amongst men 23% cases presented previous attempts (and 77% did not have previous attempts).
Over half suicide attempters (N=271) were young adults (52%), 30% were children or teenagers, and 17% were in intermediate or late adulthood. Patients reporting being single corresponded to 23% of the sample, 22% were in a relationship (both with or without children), and 15% were underaged. In terms of occupational status, 43% of patients reported to be unemployed, retired, or being a homemaker, 29% of cases corresponded to students, and 27% of suicide attempters were in formal employment. Approximately 72% of those who had one or more previous attempts reported having had previous suicidal thoughts (suicidal ideation), but only 8% of participants disclosed using psychoactive substances regularly. Previous psychiatric diagnoses were associated to 192 records. Diagnoses of mental disorders were observed in 40% of records, mental disorders in comorbidity with personality disorders in 26% records, and personality disorders alone in approximately 2%. Finally, 29% records of suicide attempts were not associated with a pre-existing diagnosis.
Results indicated that repeated attempts were significantly more likely to occur in patients that were underaged, odds ratio [OR]=4.93; 95% ci, 1.39-17.47, and in early adulthood, OR =3.79; 95% ci, 1.39-10.29. However, neither gender, nor occupational status appeared to predict repeated suicide attempts (p>.05). Findings regarding the motivational block of variables indicated that presenting suicidal ideation significantly predicted repeated suicide attempts, OR=10.88; 95% ci, 5.40-21.87. Conversely, self-reported consumption of psychoactive substances did not significantly predict the recurrence of suicide attempts (p>.05). However, repeated attempts were 3,26 (95% ci, 1.28-8.26) times more likely in patients with a previous diagnostic of mental disorders, and those with a history of mental disorders in comorbidity with personality disorders were 4,2 (95% ci, 1.56-11.26) times more likely to repeatedly incur in suicidal attempts.
Management of Self-Harm
Patients seeking medical help for intentional self-harm were commonly sent for further psychological or psychiatric assessment. In 108 (32.1%) cases, the management outcome was to grant appointments for outpatient psychiatric or psychological services and further 73 (21.7%) were hospitalized. 99 patients (30%) attending the emergency department for intentional self-harm were sent home with recommendations, and 50 (15%) patients were not compliant (see Table 3 for details).
Table 3. Management of Intentional Self-Harm; Method, Suicide Ideation, Psychiatric Assessment, and Prior Suicide Attempt
Amongst those attempting to self-harm by ingesting prescription medication (N=172), 90 (52%) were liaised with psychological or psychiatric services (hospitalization or transferred to outpatient services), further 55 (32%) were sent home with recommendations and 27(15%) were not compliant. Amongst those attempting to purposely poison themselves with paint thinner, bleach, or poison (N=112), management outcome included psychiatric hospitalization (N=28), transfer to outpatient mental health services (N=36), and to follow recommendations at home (n=29). Nineteen (N=19) patients were not compliant with the treatment offered at the service. The management of cases comprising cutting and other methods of self-harm (N=44) included mostly liaising the patient with mental health services (N=26), though 15 cases were discharged with recommendations, and three did not comply with the treatment.
The most frequent management outcome for cases with a previous psychiatric disorder diagnostic was to be sent home with recommendations (N=52), followed by being liaised with outpatient mental health services (N=51), and hospitalization (N=29). Likewise, 11 patients with a single diagnostic of personality disorder received mental health treatment, and further 4 were sent home with recommendations. Patients with a psychiatric disorder in comorbidity with a personality disorder were mainly transferred to mental health services (hospitalized or outpatient, N=43), but in 17 records the management outcome was to send the patient home with recommendations. Out of 87 patients without a formal psychiatric diagnostic 47 received mental health treatment, 26 were sent home with recommendations, and 14 did not comply with the medical treatment.
Record cases of intentional self-harm with a history of one or more previous attempts (N=136) mainly received mental health treatment (hospitalized or transferred to mental health services; N=68). In 49 cases displaying repeated suicide attempts, patients were sent home with recommendations and 19 reports showed that patients did not comply to receive attention. On the other hand, 113 patients attending an emergency department for intentional self-harm for the first time received mental health treatment, while 49 first time attempters were sent home with recommendations, and further 19 first time reports were non-compliant.
Discussion
Te present study aimed to identify the risk factors that predicted repeated suicide attempts in patients attending an emergency department for intentional self-harm. The study also sought to provide a descriptive account of the management given to these patients.
Echoing official Colombian and worldwide epidemiological data (WHO, 2012; Instituto National de Medicina Legal y Ciencias Forenses, 2018), most suicide attempts in this sample occurred amongst early and young adults. Moreover, descriptive analyses showed significant differences in number of previous episodes of intentional self-harm between age groups, and being a young adult was a significant predictor of repeated suicide attempts in the logistic regression analysis. Te evidence indicates that this age group is particularly vulnerable to engage in intentional self-harming behaviour repeatedly.
Mean rates of suicide attempts were significantly higher in females compared to males, however being a female did not predict the occurrence of multiple suicide attempts. In the body of literature, women have been found to be significantly likely to engage in self-harm repetitively and to display more medical seeking behaviour. Conversely, males employ more lethal means in the attempt and are more successful at completing the suicide act (Freeman et al., 2017; Ruiz & Chaves, 2017). There seems to be specific risk factors that affect women and men differently (Chang et al., 2019). However, the difference in gender ratios in the sample (80% females compared to 20%) does not provide the present study with enough statistical power to validate the representativeness of these results.
It was found that participants who reported suicidal ideation and those with a previous psychiatric diagnostic (compared with patients without diagnosis) were more likely to engage in suicide behaviour repeatedly. It is well established that suicidal ideation is a predictor of suicidal behaviour (Bebbington et al., 2010; Brezo et al., 2006; O'Brien, Nicolopoulos, Almeida, Aguinaldo, & Rosen, 2019), and it has been evident also in Colombian samples (e.g., Cardona et al., 2019; Castillo et al., 2020; Tuesca Molina & Navarro Lechuga, 2003). The presence of suicide ideation is a criterion transversely occurring in psychiatric disorders commonly linked to suicide behaviour (De Beurs et al., 2019) and thus, identifying these two risk factors may help prevent future, more severe, suicidal attempts. Similarly, other motivational factors as feelings of entrapment, and hopelessness may also help assess the level of risk in patients displaying intentional self-harm (O'Connor, 2011).
Other studies have identified having a mental disorder as a strong predictor of suicide attempts (Cardona et al., 2019; Castillo et al., 2020) and this was also the case in this sample. However, this study also revealed that individuals with a psychiatric diagnostic in comorbidity with a personality disorder were 12 times more likely to engage in repeated attempts compared to individuals with a single psychiatric diagnostic (e.g., mood or personality) or individuals without a diagnostic (Harris & Barraclough, 1997; Rosenthal et al., 2008). The influence of personality disorders in suicidal ideation and behaviour has been only partially covered by the literature. Borderline personality disorder in particular, has been identified as highly comorbid with other mental disorders and suicide behaviour (Gerson & Stanley, 2002; Parra et al., 2017; Rosenthal et al., 2008). This finding supports the need to further investigate suicidal behaviour in personality disorders, both to enhance the body of literature in this subject, and to develop strategies that help prevent suicide behaviour in these patients.
In this study, the management given to patients attending an emergency department for intentional self-harm mostly included mental health care attention in the form of hospitalization and outpatient services, which follows national guidelines in management of suicide attempts. However, for some patients it was not possible to see a mental health professional, being a missed opportunity to intervene the suicidal behaviour effectively. These results highlight the need to improve suicide risk assessments and monitoring practices of suicide behaviour within clinical practices and prevention programs (Deisenhammer et al., 2007; WHO, 2012, 2014).
Te introduction of evidence-based strategies to manage suicide behaviour in primary care settings are highly encouraged by global institutions preoccupied with suicide prevention. Intentional self-harm episodes are commonly associated with different levels of risk. Patients with high suicide risk are advised to undergo hospitalization in order to stabilize and receive adequate medical monitoring (Schmitz-Buhl et al., 2019; Berman & Silverman, 2014). On the other hand, medium and low-risk patients may benefit from an ambulatory mental health treatment, as isolation may not contribute to the recovery in these patients (Van Veen et al., 2019).
As well as early detection and treatment of risk factors, successful efforts to reduce suicide behaviour should include targeting psychosocial (e.g., change public's attitudes towards psychiatric disorders), and environmental (e.g., access to lethal means) risk factors (Riblet et al., 2017). In the present study, it was observed that amongst medication reportedly utilised, restricted sell items (e.g., antipsychotics and benzodiazepines) comprised over a third of cases of self-inflicted intoxication with medication. Te second most common self-intoxication method used was the ingestion of chemicals, some of which are subjected to legal restrictions (e.g., pesticides). While restrictions regarding these substances in Colombia are in place, it is possible that further preventive strategies, as awareness campaigns, need to be introduced to complement those policies.
Tere are limitations to this study that should be noted. Te study comprised a retrospective analysis of data collected at an emergency department and thus, the categorization and recording of data was not under control of the authors (with the exception of the classification between gesture and intent); results showcase a naturalistic observation of suicide attempts in this hospital. Furthermore, the dataset corresponded to that found in the archives of the hospital and there was no follow-up on the cases of intentional self-harm. These issues hinder generalisability of findings and casual relationships that could potentially be drawn from these results. Future literature would benefit from prospective studies of explicative designs measuring pre-motivational, motivational, and volitional factors interplaying underneath suicide behaviour.
Conclusion
Introducing recording practices in medical services helps create bodies of data that may be susceptible to analysis. It would be valuable for the literature and for the clinical practice to utilize this knowledge in the development and adaptation of management procedures that help respond to the patient's specific needs. This study's findings showed the predicting relationship between pre motivational (i.e., age), and motivational factors (i.e., psychiatric disorders, personality disorder, and suicidal ideation) in increasing the risk of repeated suicide behaviour. While further evidence is needed, it may be beneficial for the treatment of suicide behaviour to base management procedures upon known predictors, perhaps by including systematic protocols that ensure that patients in high-risk status receive the appropriate follow-up care. Complementary, further efforts should be directed to investigate suicide prevention strategies in the social realm, particularly in reinforcement of restrictions to people's access to lethal means.
