The suicidal process; prospective comparison between early and later stages

Background: Mechanisms contributing to suicidal behaviour may differ according to how far individuals have progressed through the suicidal process. Methods: Lifetime and subsequent 12-month cumulative incidences were obtained of death ideation, death wishes, suicide contemplation and deliberate self-harm in a survey (n = 5618) of Dutch adults. Mokken's scale analysis was used to examine whether these were compatible with underlying lifetime and 12-month severity dimensions of suicidality. Sociodemographic details and personality traits, 12-month occurrence of negative life events, hopelessness and CIDI-generated DSM-III-R diagnoses were obtained. Ordered logistic regression was used to examine whether the effects of these on the 12-month incidence of suicidality differed by individuals' prior lifetime history of suicidality. Results: Mental illness was more strongly associated with 12-months' suicidality in the presence (ordered logistic regression coefficient 0.80, 95% confidence interval 0.48-1.12) than the absence of previous suicidality (0.49 [0.25-0.74]). The reverse obtained for negative life events (0.18 [0.08-0.29] vs. 0.40 [0.33-0.48], respectively) and a number of sociodemographic risk factors. Female gender was a risk factor for 12-months' suicidality (0.47 [0.28-0.66]) only when it was first-onset. Limitations: Completed suicides were not recorded. Self-report of lifetime suicidal behaviour may be biased. Conclusion: Environmental influences on suicidal behaviour are most pronounced early in the suicidal process which, after it has progressed, becomes more autonomous and intricately linked with mental illness and depression in particular. Men progress through the suicidal process faster than women. Management of suicidal behaviour depends on the stage of the process the person is at. (C) 2003 Elsevier B.V. All rights reserved.