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Original Investigation
February 27, 2019

Severity and Variability of Depression Symptoms Predicting Suicide Attempt in High-Risk Individuals

Author Affiliations
  • 1Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 3Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 4Department of Psychiatry, Columbia University, New York, New York
  • 5Department of Statistics, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Psychiatry. 2019;76(6):603-613. doi:10.1001/jamapsychiatry.2018.4513
Key Points

Question  What are the most important clinical predictors of suicide attempt?

Findings  In this longitudinal study of 663 offspring of parents with mood disorders, the trajectory of depression symptoms showing the highest mean scores and variability over time predicted suicide attempt above and beyond psychiatric diagnoses. Additional predictors were younger age (≤30 years), mood disorders, childhood abuse, and personal and parental history of suicide attempt.

Meaning  Predictors were identified that clinicians already assess during routine psychiatric evaluation; clinicians should especially monitor and treat depression symptoms to reduce the risk for suicidal behavior.


Importance  Predicting suicidal behavior continues to be among the most challenging tasks in psychiatry.

Objectives  To examine the trajectories of clinical predictors of suicide attempt (specifically, depression symptoms, hopelessness, impulsivity, aggression, impulsive aggression, and irritability) for their ability to predict suicide attempt and to compute a risk score for suicide attempts.

Design, Setting, and Participants  This is a longitudinal study of the offspring of parents (or probands) with mood disorders who were recruited from inpatient units at Western Psychiatric Institute and Clinic (Pittsburgh) and New York State Psychiatric Institute. Participants were recruited from July 15, 1997, to September 6, 2005, and were followed up through January 21, 2014. Probands and offspring (n = 663) were interviewed at baseline and at yearly follow-ups for 12 years. Lifetime and current psychiatric disorders were assessed, and self-reported questionnaires were administered. Model evaluation used 10-fold cross-validation, which split the entire data set into 10 equal parts, fit the model to 90% of the data (training set), and assessed it on the remaining 10% (test set) and repeated that process 10 times. Preliminary analyses were performed from July 20, 2015, to October 5, 2016. Additional analyses were conducted from July 26, 2017, to July 24, 2018.

Main Outcomes and Measures  The broad definition of suicide attempt included actual, interrupted, and aborted attempts as well as suicidal ideation that prompted emergency referrals during the study. The narrow definition referred to actual attempt only.

Results  The sample of offspring (n = 663) was almost equally distributed by sex (316 female [47.7%]) and had a mean (SD) age of 23.8 (8.5) years at the time of censored observations. Among the 663 offspring, 71 (10.7%) had suicide attempts over the course of the study. The trajectory of depression symptoms with the highest mean scores and variability over time was the only trajectory to predict suicide attempt (odds ratio [OR], 4.72; 95% CI, 1.47-15.21; P = .01). In addition, we identified the following predictors: younger age (OR, 0.82; 95% CI, 0.74-0.90; P < .001), lifetime history of unipolar disorder (OR, 4.71; 95% CI, 1.63-13.58; P = .004), lifetime history of bipolar disorder (OR, 3.4; 95% CI, 0.96-12.04; P = .06), history of childhood abuse (OR, 2.98; 95% CI, 1.40-6.38; P = .01), and proband actual attempt (OR, 2.24; 95% CI, 1.06-4.75; P = .04). Endorsing a score of 3 or higher on the risk score tool resulted in high sensitivity (87.3%) and moderate specificity (63%; area under the curve = 0.80).

Conclusions and Relevance  The specific predictors of suicide attempt identified are those that clinicians already assess during routine psychiatric evaluations; monitoring and treating depression symptoms to reduce their severity and fluctuation may attenuate the risk for suicidal behavior.