Risk factors for suicide reattempt: a systematic review and meta-analysis

Psychological Medicine cambridge.org/psm Review Article Cite this article: Pemau A et al (2024). Risk factors for suicide reattempt: a systematic review and meta-analysis. Psychological Medicine 54, 1897–1904. https://doi.org/ 10.1017/S0033291724000904 Received: 1 November 2023 Revised: 5 March 2024 Accepted: 15 March 2024 First published online: 16 April 2024 Keywords: meta-analysis; repetition risk; risk factors; suicide reattempt; suicide Corresponding author: Alejandro de la Torre-Luque; Email: af.dela[email protected] © The Author(s), 2024. Published by Cambridge University Press. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited. Risk factors for suicide reattempt: a systematic review and meta-analysis Andres Pemau1, Carolina Marin-Martin2, Marina Diaz-Marsa3,4, Alejandro de la Torre-Luque1,2 , Wala Ayad-Ahmed3, Ana Gonzalez-Pinto2,4,5, Nathalia Garrido-Torres2,6,7, Lucia Garrido-Sanchez6, Natalia Roberto8,9,10, Purificación Lopez-Peña2,4,5,11, Lorea Mar-Barrutia2,4,5,11, Iria Grande2,8,9,10, Marti Guinovart12,13, Daniel Hernandez-Calle14,15, Luis Jimenez-Treviño2,16,17,18,19, Clara Lopez-Sola2,8, Roberto Mediavilla2,20, Adrian Perez-Aranda21, Miguel Ruiz-Veguilla2,6,7,22, Elisa Seijo-Zazo16,17,18,19, Alba Toll13,23, Matilde Elices2,13,23, Victor Perez-Sola2,23,24,25, Jose Luis Ayuso-Mateos2,20 and the SURVIVE Consortium 1 Universidad Complutense de Madrid, Madrid, Spain; 2 Centre for Biomedical Research in Mental Health (CIBERSAM), Madrid, Spain; 3 San Carlos University Clinic Hospital, Madrid, Spain; 4 Araba University Hospital, Vitoria, Spain; 5 University of the Basque Country, Bilbao, Spain; 6 Virgen del Rocio University Hospital, Seville, Spain; 7 Seville Biomedical Research Institute (IBiS), Seville, Spain; 8 Bipolar and Depressive Disorders Unit, Hospital Clinic de Barcelona, Barcelona, Spain; 9 Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; 10 Departament de Medicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain; 11 BIOARABA, Vitoria, Spain; 12 Institut d’Investigacio i Innovacio ParcTauli (I3PT), Barcelona, Spain; 13 Autonomous University of Barcelona, Barcelona, Spain; 14 La Paz University Hospital, Madrid, Spain; 15 Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain; 16 Servicio de Salud del Principado de Asturias (SESPA), Oviedo, Spain; 17 Principado de Asturias Health Research Institute (ISPA), Oviedo, Spain; 18 University of Oviedo, Oviedo, Spain; 19 Principado de Asturias Neuroscience Research Institute (INEUROPA), Oviedo, Spain; 20 Autonomous University of Madrid, Madrid, Spain; 21 IIS Aragon Research Foundation, Zaragoza, Spain; 22 University of Seville, Seville, Spain; 23 Neurosciences Research Unit, IMIM-Institut Hospital del Mar d’Investigacions Mèdiques, Barcelona, Spain; 24 Hospital de Mar, Mental Health Institute, Barcelona, Spain and 25 Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain Abstract Background. Suicide is one of the main external causes of death worldwide. People who have already attempted suicide are at high risk of new suicidal behavior. However, there is a lack of information on the risk factors that facilitate the appearance of reattempts. The aim of this study was to calculate the risk of suicide reattempt in the presence of suicidal history and psychosocial risk factors and to estimate the effect of each individual risk factor. Methods. This systematic review and meta-analysis were conducted following the PRISMA- 2020 guidelines. Studies on suicide reattempt that measured risk factors were searched from inception to 2022. The risk factors studied were those directly related to suicide history: history of suicide prior to the index attempt, and those that mediate the transition from suicidal ideation to attempt (alcohol or drug misuse, impulsivity, trauma, and non-suicidal selfinjury). Results. The initial search resulted in 11 905 articles. Of these, 34 articles were selected for this meta-analysis, jointly presenting 52 different effect sizes. The pooled effect size across the risk factors was significant (OR 2.16). Reattempt risk may be increased in presence of any of the following risk factors: previous history, active suicidal ideation, trauma, alcohol misuse, and drug misuse. However, impulsivity, and non-suicidal self-injury did not show a significant effect on reattempt. Conclusion. Most of the risk factors traditionally associated with suicide are also relevant when talking about suicide reattempts. Knowing the traits that define reattempters can help develop better preventive and intervention plans. Introduction Suicide is one of the main external causes of death worldwide. The world health organization [WHO] has tracked suicide trends over the years and has pointed out the need to act urgently to tackle suicide impact worldwide (WHO, 2014). Thus, in their latest seminal report, the WHO reported that suicide accounted for more than 700 000 deaths in 2019 (WHO, 2023). Even then, deaths by suicide are just the tip of the iceberg. Other suicide-related behaviors, such as suicidal attempts or ideation (while not strictly a behavior) have much higher https://doi.org/10.1017/S0033291724000904 Published online by Cambridge University Press prevalence (Nock et al., 2008; WHO, 2014). Previous attempts are one of the most relevant risk factors for death by suicide (Mendez-Bustos, De Leon-Martinez, Miret, Baca-Garcia, & Lopez-Castroman, 2013). A recent meta-analysis suggests that one in five people who attempts suicide could repeat it (de la Torre-Luque et al., 2023). Risk factors for suicidal behavior represent a highly relevant line of work. Considering variables associated with suicidal history, the effect of ideation (at different levels of structuring) and the presence of multiple attempts are well established (De La Garza, Blanco, Olfson, & Wall, 2021; Mendez-Bustos et al., 2013). Other psychosocial aspects such as non-suicidal self-injury, trauma, or high impulsivity are also relevant (Daray et al., 2016; Hawton, Saunders, & O’Connor, 2012; Ng, Yong, Ho, Lim, & Yeo, 2018; Zatti et al., 2017). Socio-demographic factors have also been studied: with respect to sex, there are more deaths by suicide in men but more attempts in women. Regarding age groups, young people and the elderly represent special risk groups (WHO, 2014). However, despite knowing these suicide attempt risk factors, the knowledge is not directly transferable to reattempts (Mendez-Bustos et al., 2013). Some relevant risk factors in a first attempt may not be so when repeating. Studies in this regard are fewer, and there is a lack of clear evidence on the weight of each risk factor in successive attempts throughout life. In addition, the differences in terms of sample and methodology make it difficult to obtain clear conclusions (de la Torre-Luque et al., 2023). There are two groups of particularly interesting variables when talking about reattempt. On one hand, those related to the person’s own history of suicide. These variables have been associated with the so-called acquired capability for suicide. This concept is related to the habituation to suicide and the fearlessness of death or pain (Klonsky, Saffer, & Bryan, 2018). On the other hand, the volitional risk factors. This term refers to those variables that predict the transition from suicidal ideation to suicide attempt in the Integrated Motivational-Volitional Model (O’Connor & Kirtley, 2018). Further precise knowledge of how risk factors differ between first attempters and reattempters could help provide more personalized help. The study has two main objectives: 1) Calculate the risk of suicide reattempt in the presence of suicidal history and psychosocial risk factors. 2) Estimate the magnitude of the effect of each risk factor. Methods This study followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols 2020 (PRISMA 2020) statement (Page et al., 2021). Article selection criteria The PICOS (Population, Intervention, Comparison, Outcomes and Study) matrix guided the selection of the units of analysis. Starting with the population, studies with human participants of all ages who had attempted suicide (index attempt) and were admitted to a hospital department due to this attempt, were selected. Regarding intervention, participants had to be assessed with respect to suicidality. In terms of control criteria, studies should have either (a) a control group of individuals who engaged in a suicide attempt without reattempting; (b) a baseline assessment of reattempters in longitudinal studies. Regarding outcome criteria, studies had to include a measure of reattempt risk and information on at least one of these risk factors: –Those directly related to suicide history: previous suicide attempts (attempts prior to the index one) and suicidal ideation. –Those that facilitate the transition from suicidal ideation to attempt (whether related to impulse control or exposure to pain): alcohol misuse, drug misuse, non-suicidal self-injury, trauma, or impulsivity. Finally, regarding study criteria, longitudinal studies (both prospective and retrospective) published in Spanish or English until March 2022 were considered. Studies with cross-sectional measures were discarded. Search strategy and data extraction Studies were located following an ascendant approach. The consulted databases were: Web of Science, PubMed, PsycInfo, SCOPUS, CINAHL, and the Cochrane Library. The search was done by combining the following keywords: Suicide attempt and repetition. The exact searches can be found in online Supplementary Table S1 of the supplementary materials. Found papers were screened, collecting titles, abstracts, and keywords. Next, the papers selected in the first step were read in full, to decide if they were included. An independent peer reviewer endorsed the selection of every paper to be included. In case of discrepancies, they were resolved by discussion. Relevant data were extracted from each article using a coding manual, made purposely. Data collected from each study covered bibliometric features (i.e. year of publication, country), methodological features of the study (i.e. sample size, mean age of participants, sex ratio), suicide-related features (suicidal ideation, previous suicide history), and other relevant psychological traits (alcohol or drugs misuse, trauma, non-suicidal self-injury, and impulsivity). All risk factors were measured at baseline. The Newcastle –Ottawa Quality Assessment Scale (NOS) (Wells et al., 2000) was used to measure the methodological quality of the studies. Data analysis Multilevel mixed-effects meta-regression was used to estimate the overall repetition Odds Ratio (OR), derived from pooling risk estimates from each primary study. Heterogeneity among the individual effect sizes was analyzed by means of the Cochran’sQstatistic and the Higgins and Thompson I 2 statistic (Higgins & Thompson, 2002; Higgins, Thompson, Deeks, & Altman, 2003). Sensitivity analysis was conducted for each of the risk factors separately (the high variability between risk factors in each study prevented combined meta-regression techniques). OR was used as a measure of effect size for the individual factor effect size. The varying effect size estimates (relative risk, hazard ratio, or Cohen’sd) from the individual studies were transformed into a common metric (OR). When the same study included samples with several risk factors, all of them were included. If the study featured treatments, only the control groups were used. Finally, if there were several temporal follow-ups, only the longest one was considered. The restricted maximum-likelihood estimator was used to estimate overall effect size and variance (under the inverse variance 1898 Andres Pemau et al. https://doi.org/10.1017/S0033291724000904 Published online by Cambridge University Press method). The forest plot was used to visually display the individual effect sizes (presented for sensitivity analysis). Publication bias was studied by means of Egger’s regression asymmetry test. All the analyses were conducted using the software R (R Core Team, 2017) version 4.2.2, with packages meta and metaphor. Results The initial search resulted in 11 905 articles. After removing duplicates, 3672 abstracts were screened. Of those, 651 articles were read in full, and 34 papers presented data relevant to the study, jointly presenting 52 different effect sizes. Table 1 shows the characteristics of each of the studies. In cases where a study measured different risk factors, it appears several times, showing in each case the size of the relevant effect. Figure 1 shows the article selection flowchart. Most studies came from France (23.53%), followed by Taiwan (11.8%), Spain, and Sweden (8.8% in both cases). Almost 60% of the works were published after 2013. The follow-up period ranged from 3 to 328 months (M= 40.40, S.D. = 63.17, Median = 13). The articles considered a total sample size of 103 601 attempters (M= 3047.09, S.D. = 14 009.69, Median = 216.5). The mean age of participants was 34.33 years old (S.D. = 10.29, Median = 37.08). First, the multilevel mixed-effects model was carried out without introducing moderators (σ 2 = 0.28, OR 2.16, CI 95 [1.75–2.68], Z= 7.12, p= < 0.01). High heterogeneity was observed (Q= 652.87, p<0.01). Then, regarding the multilevel mixed-effects meta-regression, an analysis was carried out introducing the percentage of women in the sample, the follow-up period, and the mean age as covariates. This model showed a random-effects variance of σ 2 = 0.18; and Q M (3) = 3.03, p= 0.39. No covariate showed a significant loading in the model. Egger’s regression pointed to the possible existence of bias (Z= 3.17, p< 0.01). Since the diverse specific risk factors of each sample cannot be included in the same model (each study uses a different one, which would prevent joint analyses), we then opted for sensitivity analysis with the different risk factors. The sensitivity analyses focused on specific risk factors are presented below. The most studied risk factor in the literature was the history of suicide prior to the index attempt (k= 23). The effect of suicide attempt history on reattempt was significant (OR 2.85, CI 95 [2.19–3.71], Z= 7.78, p= < 0.01). Heterogeneity was significant (Q= 87.14, p< 0.01, I 2 = 78.24%). Regarding studies focused on the presence of active ideation at baseline (k= 7), a significant OR was found (OR 2.05, CI 95 [1.24– 3.40], Z= 2.78, p< 0.01). Between-study heterogeneity was high (Q= 45.18, p< 0.01, I 2 = 97.97%). Regarding alcohol misuse, seven studies analyzed its role as a risk factor for suicide reattempts. The analysis showed a significant OR for alcohol misuse (OR 2.16, CI 95 [1.63–2.86], Z=5.34, p< 0.01). Heterogeneity was, again, significant (Q= 20.87, p<0.01, I 2 = 61.72%). The studies that considered other drug use as a risk factor (k=4) are presented now. The OR for the samples with drug use was also significant (OR 2.29, CI 95 [1.33–3.93], Z= 2.99, p< 0.01). In this case, the heterogeneity was not significant (Q= 3.57, p= 0.31, I 2 = 20.72%). Lastly, the effect of trauma was significant when it came to suicide reattempt (k= 5, OR 1.58, CI 95 [1.12–2.24], Z= 2.58, p< 0.01). Cochran’sQwasn’t significant (Q= 3.36, p= 0.49, I 2 = 0%). It should be clear that all the included studies spoke of trauma as a lifetime experience of sexual trauma. The risk factors that did not show significant results are now discussed. Only one paper studied the relationship between nonsuicidal self-injury and suicide reattempt. This precludes the use of meta-analytic techniques. The only study that provided this data was that of Mirkovic et al. (2020). In their sample, an OR 1.15 was obtained. The effect was not significant. Five studies focused on the role of impulsivity. The analyses did not show a relevant role for this risk factor (OR 1.28, CI 95 [0.52–3.18], Z= 0.54, p= 0.59). Cochran’sQwas significant (Q= 26.52, p< 0.01, I 2 = 86.69%). A sensitivity analysis was performed eliminating the study by Aydin, Algin, Poyraz, and Kalenderoglu (2018) as it was the only one that had an Odds Ratio less than 1. In this way, a significant effect was found (OR 1.80, CI 95 [1.04, 3.11], Z= 2.09, p< 0.05). Cochran’sQwas not significant (Q= 6.31, p= 0.10, I 2 = 53.46%). The forest plot corresponding to each risk factor can be seen in the supplementary materials (online Supplementary Figs S1 to S6). Discussion Risk factors studied in first suicide attempts are partially replicated when we talk about repeat attempts. However, non-suicidal self-injury and impulsivity do not have the same relevance in reattempt. Our meta-analysis also reveals that there are various understudied risk factors in the field of suicide reattempt, for example, non-suicidal self-injury. This study aimed to find a robust global estimate of the effect of different suicide histories and psychological risk factors on suicide reattempts, and their individual contributions. For this, a robust methodology and a large number of studies were used (k= 34). The extensive initial search has allowed us to obtain results on a wide range of risk factors. Previous studies showed that an index attempt acts as the key single risk factor for suicide attempt repetition. In this regard, a previous meta-analysis stressed that one in five people will engage in another suicide attempt later in life (de la Torre-Luque et al., 2023). The risk factors studied here can help determine which profiles are more prone to reattempt. Our results indicate that people who present any of the studied risk factors have a double risk of suicide reattempt. The high variability between effect sizes makes it necessary to focus on which specific factors pose a greater risk. As can be seen, not all factors are equally relevant. Starting with the factors associated with the suicide history itself, the most studied risk factor is the presence of previous attempts. It should be noted that most studies consider the inclusion of a participant after an index attempt, the index attempt is not necessarily the first one. Those who made attempts prior to the index have an increased risk of repetition. This phenomenon could be related to the acquired capacity for suicide raised in the ideation to action framework. The concept of major repeaters could also be relevant (Blasco-Fontecilla et al., 2014; Irigoyen-Otiñano et al., 2018). Not all studies reported the exact number of lifetime attempts. The presence of active ideation at the time of the baseline measurement is also a relevant risk factor. From the action ideation models, the part related to ideation is considered relevant (O’Connor & Kirtley, 2018). Maintaining ideation even after the attempt could lead to new attempts in the future. However, there is some variability in the measures used and even in the Psychological Medicine 1899 https://doi.org/10.1017/S0033291724000904 Published online by Cambridge University Press Table 1. Features of studies Study Country Follow-up length (in months) Sample size Sex (% female) Sample age (mean) Risk factor OR Variance Aguglia et al. (2020) Italy 6 432 77.1 49.13 History 7.10 0.278 Ahmed et al. (2020) Saudi Arabia 36 157 76.4 17.84 Drugs 1.23 0.511 Trauma 2.57 0.265 Allard, Marshall, and Plante (1992) Canada 24 126 56 NA Drugs 3.29 0.288 Aydin et al. (2018) Turkey NA 103 70.9 27.86 Impulsivity 0.26 0.137 Azcárate-Jiménez et al. (2019) Spain 6 207 58.94 45.05 History 1.58 0.162 Batt et al. (1998) France 6 632 63 34.6 History 3.63 0.084 Alcohol 1.93 0.072 Impulsivity 1.50 0.085 Beautrais (2004) New Zealand 60 226 53.6 30.4 History 2.65 0.077 Trauma 1.80 0.078 Beckman et al. (2019) Sweden 6 176 73.3 40.2 Impulsivity 1.01 0.111 Chen et al. (2013) Taiwan 6 1056 68.4 38 History 2.27 0.038 Courtet et al. (2004) France 12 103 82.5 37.08 Impulsivity 3.90 0.431 De Beurs et al. (2016) UK 15 366 56.8 35.8 Ideation 4.51 0.234 de Beurs, van Borkulo, and O’Connor (2017) Netherlands 15 366 57.1 35 History 3.26 0.570 Demesmaeker, Chazard, Vaiva, and Amad (2021) France 6 972 63.6 38 Alcohol 2.92 0.050 Dieserud et al. (2003) Norway 18 50 66 41 History 3.89 1.247 Ideation 1.60 0.169 Espandian et al. (2020) Spain 12 319 74.3 41.5 History 1.52 0.156 Finkelstein et al. (2016) Canada 132 81 675 61.8 31 Alcohol 1.49 0.001 Fossi, Debien, Demarty, Vaiva, and Messiah (2022) France 6 10 666 58.7 40.6 History 2.93 0.006 Fridell, Öjehagen, and Träskman-Bendz (1996) Sweden 60 42 58.7 40.5 History 2.14 0.410 Garrido Romero et al. (2004) Spain 12 43 87 15.6 History 21.07 2.265 Groholt, Ekeberg, and Haldorsen (2006) Norway 109 78 90 16.9 History 4.76 0.247 Trauma 0.74 0.132 Huang et al. (2020) Taiwan 328.33 151 30.5 52.9 Alcohol 1.78 0.154 Drugs 1.54 0.146 Hultén et al. (2001) Sweden 46 1264 72.38 NA History 3.22 0.024 Jaar et al. (1998) Chile 84 92 100 37 History 3.83 0.224 Lee et al. (2012) Taiwan 12 102 68.6 39.9 History 30.40 1.091 Ideation 3.97 0.146 Impulsivity 2.90 0.142 Lee et al. (2019) Republic of Korea 13 691 57.4 46.02 Alcohol 2.56 0.071 (Continued) 1900 Andres Pemau et al. https://doi.org/10.1017/S0033291724000904 Published online by Cambridge University Press concepts measured. Some tests focus on suicidal ideation (e.g. De Beurs, Fokkema, & O’Connor, 2016;O’Connor, Smyth, & Williams, 2015) and others on suicidal intent (e.g. Dieserud, Røysamb, Braverman, Dalgard, & Ekeberg, 2003; Wei et al., 2021). It is necessary to systematize these measures to obtain more precise conclusions. Both alcohol and drug misuse are also a relevant risk factors for suicide reattempts. A previous meta-analysis already found similar results when considering full-blown substance disorders (de la Torre-Luque et al., 2023). This risk factor should not be confused with the involvement of substances during the attempt. Finally, the presence of trauma was also a significant risk factor for suicide reattempt. It is relevant to point out that the included studies can be interpreted as physical or sexual abuse throughout life (some studies considered only childhood and others lifetime). There may be differential functioning between trauma in adult life and that which occurs during childhood (Zatti et al., 2017). Studies in this regard seem necessary. All the factors mentioned have presented the expected relationship. They also coincide with the investigations on first attempts. However, the levels of impulsivity and non-suicidal selfinjury did not show a significant role in our study. Beginning with non-suicidal self-injury, only one study measured the relationship between it and suicide reattempt (Mirkovic et al., 2020). Therefore, meta-analytic analyses could not be carried out. The existing study does not find non-suicidal self-injury as a relevant risk factor. The scarce presence of this risk factor in the studies is striking. Regarding impulsivity, no significant OR was found when the full sample of studies was used. The literature focused on the first attempts finds that it is a relevant factor (Liu, Trout, Hernandez, Cheek, & Gerlus, 2017). In part, these discrepancies could be due to the high conceptual variability associated with impulsivity in the field of suicide (Rimkeviciene, O׳Gorman, &DeLeo,2015). In our case, we found studies that considered behavioral impulsivity compared to others that spoke of the impulsivity of the index attempt (the separate analyses were not significant either). When performing the sensitivity analysis, a relevant effect of impulsivity was found. The retrospective nature of the discarded study (Aydin et al., 2018)could explain this discrepancy. The temporal distance between the measure of impulsivity and the attempt could explain the nonappearance of a relationship (Liu et al., 2017). We can observe that there is a very high heterogeneity of terminology, methodology, and focus of study. Systematizing these aspects could help draw stronger conclusions that help guide future studies. The study has some limitations to be mentioned. First, only published articles were consulted. Second, there could be publication bias that affected the results. Third, it was necessary to group Table 1. (Continued.) Study Country Follow-up length (in months) Sample size Sex (% female) Sample age (mean) Risk factor OR Variance Ligier, Guillemin, Angot, Bourion, and Kabuth (2015) France 120 246 81 14.8 History 1.23 0.083 Trauma 0.89 0.158 Mirkovic et al. (2020) France 12 91 86.7 NA non-suicidal self-injury 1.16 0.208 Ideation 1.92 0.172 Monnin et al. (2012) France 24 273 69.2 37.6 History 1.92 0.083 Alcohol 2.34 0.127 Mouaffak, Marchand, Castaigne, Arnoux, and Hardy (2015) France 12 151 73.5 38.6 History 5.80 0.340 O’Connor et al. (2015) UK 15 367 56.7 34.19 History 1.42 0.009 Ideation 1.05 0.000 Vajda and Steinbeck (2000) Australia 12 112 67.86 18.05 History 1.01 0.255 Alcohol 4.47 0.215 Drugs 3.80 0.200 Trauma 1.79 0.210 Wang et al. (2016) Taiwan 3 64 73.4 37.5 History 9.50 1.428 Wei et al. (2021) China 93 1103 63.74 36.96 History 3.43 0.130 Ideation 1.06 0.003 Wong et al. (2008) USA 12 1099 33.3 14.61 History 12.61 0.213 Ideation 4.29 0.095 † Country of the correspondence author’s affiliation. Psychological Medicine 1901 https://doi.org/10.1017/S0033291724000904 Published online by Cambridge University Press many studies with definitions or measures of constructs that were not exactly the same (although equivalent). This could have masked some differences present, although attempts have been made to control for it using sensitivity analyses. Also, some variables were only considered in very few studies, making it difficult to draw strong conclusions. Given the variability between studies, analyses could not be carried out by taking different risk factors together. Finally, the heterogeneity between effect sizes was not completely covered by moderators in analysis. Specifically, there are relevant variables not studied in this work, such as diagnoses (for an in-depth work on this topic, consult the work of de la Torre-Luque et al., 2023). Not all people who made a first suicide attempt will reattempt. The presence of multiple previous attempts is the most relevant risk factors for suicide reattempt. There is a relevant overlap between the variables that facilitate the transition from suicidal ideation to act and those present in the reattempt. However, variables widely considered important in first suicide attempts are not so decisive when reattempting (i.e. impulsivity and non-suicidal self-injury). This study allows us to further define the risk profile for patients with several suicide attempts, which may facilitate the development of more effective interventions and preventive strategies. Supplementary material. The supplementary material for this article can be found at https://doi.org/10.1017/S0033291724000904 Acknowledgements. The following are members of SURVIVE: Beatriz Rodriguez-Vega, Patricia Diaz-Carracedo, Veronica Fernandez-Rodrigues, Elvira Lara, Itziar Leal-Leturia, Mireia Vazquez, Irene Canoso-Garcia, Lorenzo Bracco, Pilar Saiz, Teresa Bobes-Bascaran, Diego Palao, Narcis Cardoner, Anabel Cebria, Purificacion Lopez-Peña, Lide Rementeria, Benedicto Crespo-Facorro. Figure 1. Flow diagram of studies selected for this meta-analysis. 1902 Andres Pemau et al. https://doi.org/10.1017/S0033291724000904 Published online by Cambridge University Press Funding statement. This study was supported by the Instituto de Salud Carlos III-FIS research grants (PI16/00187, PI19/00236, PI19/00569, PI19/ 00685, PI19/00941, PI19/00954, PI19/01027, PI19/01256, PI19/01484, PI20/ 00229), co-funded by the European Regional Development Fund (ERDF) ‘A Way to Build Europe’integrated into the Plan Nacional de I + D + I and cofinanced by the ISCIII-Subdirección General de Evaluación y confinanciado por la Unión Europea (FEDER, FSE, Next Generation EU/Plan de Recuperación Transformación y Resiliencia_PRTR); the Instituto de Salud Carlos III; the CIBER of Mental Health (CIBERSAM); and the Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement (2021 SGR 01358), CERCA Programme / Generalitat de Catalunya as well as the Fundació Clínic per la Recerca Biomèdica (Pons Bartran 2022-FRCB_PB1_2022); the Government of the Principality of Asturias (grant ref.: PCTI-2018-2022 IDI/ 2018/235);. It was also supported by a FPU grant (FPU20/01651) from the Spanish Ministry of Universities and a Universidad Complutense de Madrid Predoctoral contract for research staff in training (CT82/20-CT83/20). Competing interests. IG has received grants and served as consultant, advisor, or CME speaker for the following identities: ADAMED, Angelini, CasenRecordati, Esteve, Ferrer, Gedeon Richter, Janssen Cilag, and Lundbeck, Lundbeck-Otsuka, Luye, SEI Healthcare Viatris outside the submitted work. She also receives royalties from Oxford University Press, Elsevier, Editorial Médica Panamericana. AGP has received grants from or served as a consultant, advisor, or CME speaker for the following entities: Almirall, AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, Glaxo-Smith-Kline, Janssen-Cilag, Ferrer, Johnson & Johnson, Lundbeck, Merck, Otsuka, Pfizer, Sanofi-Aventis, Servier, Shering-Plough, Solvay, the Spanish Ministries of Science and Innovation (through CIBERSAM) and of Science (through the Carlos III Institute of Health), the Basque Government, the Stanley Medical Research Institute, and Wyeth. VPS has been a consultant to or has received honoraria or grants from AB-Biotics, AstraZeneca, Bristol-Myers-Squibb, CIBERSAM, FISISCIII, Janssen Cilag, Lundbeck, Otsuka, Servier, and Pfizer. The remaining authors declare that they do not have any conflict of interest to disclose. References The works indicated with an asterisk are those used in the meta-analysis itself. *Aguglia, A., Solano, P., Parisi, V. M., Asaro, P., Caprino, M., Trabucco, A., … Serafini, G. (2020). Predictors of relapse in high lethality suicide attempters: A six-month prospective study. Journal of Affective Disorders,271(January 2020), 328–335. doi: 10.1016/j.jad.2020.04.006 *Ahmed, A. E., Alaqeel, M., Alasmari, N. A., Jradi, H., Al Otaibi, H., Abbas, O. A., …Al-Jahdali, H. (2020). Risk assessment of repeated suicide attempts among youth in Saudi Arabia. Risk Management and Healthcare Policy, 13, 1633–1638. doi: 10.2147/RMHP.S245175 *Allard, R., Marshall, M., & Plante, M-C (1992). Intensive follow-up does not decrease the risk of repeat suicide attempts. Suicide and Life-Threatening Behavior,22(3), 303–314. doi: 10.1111/j.1943-278X.1992.tb00735.x *Aydin, I., Algin, A., Poyraz, M. K., & Kalenderoglu, A. (2018). An analysis with rotter internal-external locus of control scale, Rosenberg self-esteem scale, and the Barratt impulsivity scale on patients who attempted to recurrent suicide. Eurasian Journal of Emergency Medicine,17(3), 109–112. doi: 10.5152/eajem.2018.39306 *Azcárate-Jiménez, L., López-Goñi, J. J., Goñi-Sarriés, A., Montes-Reula, L., Portilla-Fernández, A., & Elorza-Pardo, R. (2019). Repeated suicide attempts: A follow-up study. Actas Espanolas de Psiquiatria,47(4), 127–136. *Batt, A., Eudier, F., Le Vaou, P., Breurec, J. Y., Baert, A., Curtès, J. P., … Chaperon, J. (1998). Repetition of parasuicide: Risk factors in general hospital referred patients. Journal of Mental Health,7(3), 285–297. doi: 10.1080/09638239818102 *Beautrais, A. L. (2004). Further suicidal behavior among medically serious suicide attempters. Suicide and Life-Threatening Behavior,34(1), 1–11. doi: 10.1521/suli.34.1.1.27772 *Beckman, K., Lindh, A. U., Waern, M., Stromsten, L., Renberg, E. S., Runeson, B., & Dahlin, M. (2019). Impulsive suicide attempts among young people–A prospective multicentre cohort study in Sweden. Journal of Affective Disorders,243(May 2018), 421–426. doi: 10.1016/j.jad.2018.09.070 Blasco-Fontecilla, H., Jaussent, I., Olié, E., Béziat, S., Guillaume, S., Artieda-Urrutia, P., …Courtet, P. (2014). A cross-sectional study of major repeaters. The Primary Care Companion For CNS Disorders,16(4), 26183. doi: 10.4088/PCC.14m01633 Chen, W. J., Shyu, S. S., Lin, G. G, Chen, C. C., Ho, C. K., Lee, M. B., & Chou, F. H. C. (2013). The predictors of suicidality in previous suicide attempters following case management services. Suicide and Life-Threatening Behavior, 43, 469–478. doi: 10.1111/sltb.12031 *Courtet, P., Picot, M. C., Bellivier, F., Torres, S., Jollant, F., Michelon, C., … Malafosse, A. (2004). Serotonin transporter gene may be involved in shortterm risk of subsequent suicide attempts. Biological Psychiatry,55(1), 46–51. doi: 10.1016/j.biopsych.2003.07.004 Daray, F. M., Rojas, S. M., Bridges, A. J., Badour, C. L., Grendas, L., Rodante, D., …Rebok, F. (2016). The independent effects of child sexual abuse and impulsivity on lifetime suicide attempts among female patients. Child Abuse and Neglect,58,91–98. doi: 10.1016/j.chiabu.2016.06.011 *De Beurs, D. P., Fokkema, M., & O’Connor, R. C. (2016). Optimizing the assessment of suicidal behavior: The application of curtailment techniques. Journal of Affective Disorders,196, 218–224. doi: 10.1016/j.jad.2016.02.033 *de Beurs, D. P., van Borkulo, C. D., & O’Connor, R. C. (2017). Association between suicidal symptoms and repeat suicidal behaviour within a sample of hospital-treated suicide attempters. British Journal of Psychiatry Open, 3(3), 120–126. doi: 10.1192/bjpo.bp.116.004275 De La Garza, Á. G., Blanco, C., Olfson, M., & Wall, M. M. (2021). Identification of suicide attempt risk factors in a national US survey using machine learning. JAMA Psychiatry,78(4), 398–406. doi: 10.1001/ jamapsychiatry.2020.4165 de la Torre-Luque, A., Pemau, A., Ayad-Ahmed, W., Borges, G., Fernandez-Sevillano, J., Garrido-Torres, N., …Ayuso-Mateos, J. L. (2023). Risk of suicide attempt repetition after an index attempt: A systematic review and meta-analysis. General hospital psychiatry,81,51–56. doi: 10.1016/j.genhosppsych.2023.01.007 *Demesmaeker, A., Chazard, E., Vaiva, G., & Amad, A. (2021). Risk factors for reattempt and suicide within 6 months after an attempt in the French ALGOS cohort. The Journal of Clinical Psychiatry,82(1), 1–9. doi: 10.4088/jcp.20m13589 *Dieserud, G., Røysamb, E., Braverman, M. T., Dalgard, O. S., & Ekeberg, Ø (2003). Predicting repetition of suicide attempt: A prospective study of 50 suicide attempters. Archives of Suicide Research,7(1), 1–15. doi: 10.1080/ 13811110301571 *Espandian, A., González, M., Reijas, T., Florez, G., Ferrer, E., Saiz, P. A., … Bobes, J. (2020). Relevant risk factors of repeated suicidal attempts in a sample of outpatients. Revista de Psiquiatría y Salud Mental (English Edition), 13(1), 11–21. doi: 10.1016/j.rpsmen.2019.03.002 *Finkelstein, Y., Macdonald, E. M., Hollands, S., Sivilotti, M. L. A., Hutson, J. R., Mamdani, M. M., …Juurlink, D. N. (2016). Repetition of intentional drug overdose: A population-based study. Clinical Toxicology,54(7), 585– 589. doi: 10.1080/15563650.2016.1177187 *Fossi, L. D., Debien, C., Demarty, A. L., Vaiva, G., & Messiah, A. (2022). Loss to follow-up in a population-wide brief contact intervention to prevent suicide attempts - The VigilanS program, France. PLoS ONE,17(3 March), e0263379. doi: 10.1371/journal.pone.0263379 *Fridell, E., Öjehagen, A., & Träskman-Bendz, L. (1996). A 5-year follow-up study of suicide attempts. Acta Psychiatrica Scandinavica,93(3), 151–157. doi: 10.1111/j.1600-0447.1996.tb10622.x *Garrido Romero, R., Garcia García, J. J., Luaces Cubells, C., Fasheh Youssef, W., Pou Fernández, J., & Alda Diez, J. A. (2004). Factores predictivos de la reincidencia del intento de suicidio. Revista de psiquiatría infanto-juvenil, 21(3), 149–153. *Groholt, B., Ekeberg, Ø, & Haldorsen, T. (2006). Adolescent suicide attempters: What predicts future suicidal acts? Suicide and Life-Threatening Behavior,36(6), 638–650. doi: 10.1521/suli.2006.36.6.638 Hawton, K., Saunders, K. E. A., & O’Connor, R. C. (2012). Self-harm and suicide in adolescents. The Lancet,379(9834), 2373–2382. doi: 10.1016/ S0140-6736(12)60322-5 Psychological Medicine 1903 https://doi.org/10.1017/S0033291724000904 Published online by Cambridge University Press Higgins, J. P. T., & Thompson, S. G. (2002). Quantifying heterogeneity in a meta-analysis. Statistics in Medicine,21(11), 1539–1558. doi: 10.1002/sim.1186 Higgins, J. P. T., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring inconsistency in meta-analyses. BMJ,327, 557–560. doi: 10.1007/s10844-006-2974-4 *Huang, W. C., Yen, T. H., Lin, L., Lin, C., Juang, Y. Y., Wang, B. H., & Lee, S. H. (2020). Clinical characteristics of pesticide self-harm as associated with suicide attempt repetition status. Neuropsychiatric Disease and Treatment, 16, 1717–1726. doi: 10.2147/NDT.S258475 *Hultén, A., Jiang, G. X., Wasserman, D., Hawton, K., Hjelmeland, H., De Leo, D., …Schmidtke, A. (2001). Repetition of attempted suicide among teenagers in Europe: Frequency, timing and risk factors. European Child and Adolescent Psychiatry,10(3), 161–169. doi: 10.1007/s007870170022 Irigoyen-Otiñano, M., Puigdevall-Ruestes, M., Prades-Salvador, N., Salort-Seguí, S., Gayubo, L., de Leon, J., & Blasco-Fontecilla, H. (2018). Más evidencias de que los grandes repetidores se comportan como un subgrupo en la conducta suicida. Revista de Psiquiatría y Salud Mental,11(1), 60–61. doi: 10.1016/j.rpsm.2017.04.004 *Jaar, H,E, Gómez, C. A., Orellana, V,G, Núñez, M,C, Montino, R,O, & Lolas, S,F (1998). La conducta suicida en mujeres: Un estudio prospective. Revista Medica de Chile,126(8), 924–929. Klonsky, E. D., Saffer, B. Y., & Bryan, C. J. (2018). Ideation-to-action theories of suicide: A conceptual and empirical update. Current Opinion in Psychology,22,38–43. doi: 10.1016/j.copsyc.2017.07.020 *Lee, J., Chang, S. J., Kim, H., Kim, M. H., Ahn, J. S., Park, K. C., …Min, S. (2019). Prolonged risk of suicide reattempts in patients with alcohol use disorder and acute alcohol use: A register-based follow-up study (2010-2015). Psychiatry Investigation,16(2), 145–153. doi: 10.30773/pi.2018.11.22 *Lee, Y., Lin, P. Y., Yeh, W. C., Chiu, N. M., Hung, C. F., Huang, T. Y., … Chong, M. Y. (2012). Repeated suicide attempts among suicidal cases: Outcome of one-year follow-up. Asia-Pacific Psychiatry,4(3), 174–180. doi: 10.1111/j.1758-5872.2012.00189.x *Ligier, F., Guillemin, F., Angot, C., Bourion, S., & Kabuth, B. (2015). Recurrence of suicide attempt in adolescents lost to contact early by clinicians: The 10-year REPEATERS cohort of French adolescents. Journal of Adolescence,43, 111–118. doi: 10.1016/j.adolescence.2015.05.011 Liu, R. T., Trout, Z. M., Hernandez, E. M., Cheek, S. M., & Gerlus, N. (2017). A behavioral and cognitive neuroscience perspective on impulsivity, suicide, and non-suicidal self-injury: Meta-analysis and recommendations for future research. Neuroscience & Biobehavioral Reviews,83, 440–450. doi: 10.1016/ j.neubiorev.2017.09.019 Mendez-Bustos, P., De Leon-Martinez, V., Miret, M., Baca-Garcia, E., & Lopez-Castroman, J. (2013). Suicide reattempters: A systematic review. Harvard Review of Psychiatry,21(6), 281–295. doi: 10.1097/ HRP.0000000000000001 *Mirkovic, B., Cohen, D., Garny de la Rivière, S., Pellerin, H., Guilé, J. M., Consoli, A., & Gerardin, P. (2020). Repeating a suicide attempt during adolescence: Risk and protective factors 12 months after hospitalization. European Child and Adolescent Psychiatry,29(12), 1729–1740. doi: 10.1007/s00787-020-01491-x *Monnin, J., Thiemard, E., Vandel, P., Nicolier, M., Tio, G., Courtet, P., … Haffen, E. (2012). Sociodemographic and psychopathological risk factors in repeated suicide attempts: Gender differences in a prospective study. Journal of Affective Disorders,136(1–2), 35–43. doi: 10.1016/ j.jad.2011.09.001 *Mouaffak, F., Marchand, A., Castaigne, E., Arnoux, A., & Hardy, P. (2015). OSTA Program: A French follow up intervention program for suicide prevention. Psychiatry Research,230(3), 913–918. doi: 10.1016/ j.psychres.2015.11.024 Ng, Q. X., Yong, B. Z. J., Ho, C. Y. X., Lim, D. Y., & Yeo, W. S. (2018). Early life sexual abuse is associated with increased suicide attempts: An update meta-analysis. Journal of Psychiatric Research,99(December 2017), 129– 141. doi: 10.1016/j.jpsychires.2018.02.001 Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic reviews,30(1), 133–154. doi: 10.1093/epirev/mxn002 O’Connor, R. C., & Kirtley, O. J. (2018). The integrated motivational–volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society B: Biological Sciences,373(1754), 20170268. doi: 10.1098/ rstb.2017.0268 *O’Connor, R. C., Smyth, R., & Williams, J. M. G. (2015). Intrapersonal positive future thinking predicts repeat suicide attempts in hospital-treated suicide attempters. Journal of Consulting and Clinical Psychology,83(1), 169– 176. doi: 10.1037/a0037846 Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., …Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. International Journal of Surgery,88, 372. doi: 10.1016/j.ijsu.2021.105906 R Core Team. (2017). R: A language and environment for statistical computing. R Foundation for Statistical Computing. Rimkeviciene, J., O׳Gorman, J., & De Leo, D. (2015). Impulsive suicide attempts: A systematic literature review of definitions, characteristics and risk factors. Journal of Affective Disorders,171,93–104. doi: 10.1016/ j.jad.2014.08.044 *Vajda, J., & Steinbeck, K. (2000). Factors associated with repeat suicide attempts among adolescents. Australian & New Zealand Journal of Psychiatry,34(3), 437–445. doi: 10.1080/j.1440-1614.2000.00712.x *Wang, Y. C., Hsieh, L. Y., Wang, M. Y., Chou, C. H., Huang, M. W., & Ko, H. C. (2016). Coping card usage can further reduce suicide reattempt in suicide attempter case management within 3-month intervention. Suicide and Life-Threatening Behavior,46(1), 106–120. doi: 10.1111/ sltb.12177 *Wei, Y. X., Liu, B. P., Zhang, J., Wang, X. T., Chu, J., & Jia, C. X. (2021). Prediction of recurrent suicidal behavior among suicide attempters with Cox regression and machine learning: A 10-year prospective cohort study. Journal of Psychiatric Research,144(44), 217–224. doi: 10.1016/ j.jpsychires.2021.10.023 Wells, G. A., Shea, B., O’Connell, D., Peterson, J., Welch, V., Losos, M., & Tugwell, P. (2000). The Newcastle-Ottawa Scale (NOS)for assessing the quality of nonrandomized studies in meta-analyses. Retrieved from https://www3. med.unipmn.it/dispense_ebm/2009-2010/Corso%20Perfezionamento% 20EBM_Faggiano/NOS_oxford.pdf *Wong, J. P. S., Stewart, S. M., Claassen, C., Lee, P. W. H., Rao, U., & Lam, T. H. (2008). Repeat suicide attempts in Hong Kong community adolescents. Social Science and Medicine,66(2), 232–241. doi: 10.1016/ j.socscimed.2007.08.031 World Health Organization. (2014). Preventing suicide: A global imperative. Switzerland: World Health Organization. World Health Organization. (2023, September 14). Suicide. Retrieved from https://www.who.int/newsroom/fact-sheets/detail/suicide Zatti, C., Rosa, V., Barros, A., Valdivia, L., Calegaro, V. C., Freitas, L. H., … Schuch, F. B. (2017). Childhood trauma and suicide attempt: A meta-ana- lysis of longitudinal studies from the last decade. Psychiatry research,256, 353–358. doi: 10.1016/j.psychres.2017.06.082 1904 Andres Pemau et al. https://doi.org/10.1017/S0033291724000904 Published online by Cambridge University Press