Stigma and suicide warning signs

Future Well-Being Among U.S. Youth Who Attempted Suicide and Survived

To what extent does a suicide attempt impair a person's future well-being? We estimated the prevalence of future well-being (FWB) among suicide attempt survivors using a nationally representative sample of 15,170 youths. Suicide attempt survivors were classified as having high FWB if they reported (a) a suicide attempt at Wave I, (b) no suicidal ideation or attempts over the past year at Wave III (7 years after), and (c) a well-being profile at or above the top quartile of nonsuicidal peers. Seventy-five of 574 suicide attempt survivors (∼13%) met criteria for FWB at Wave III, compared to 26% of nonsuicidal peers. Wave I well-being levels, not depressive symptoms, predicted the likelihood of FWB at Wave III (OR = 1.23, 95% CI [1.05, 1.44], p < .05). In conclusion, a nonfatal suicide attempt reduced but did not preclude FWB in a large national sample. The observation that a segment of the population of suicide attempt survivors achieves FWB carries implications for the prognosis of suicidal behavior and the value of incorporating well-being into investigations of suicide-related phenomena.

Saving Lives: A Systematic Review on the Efficacy of Theory-Informed Suicide Prevention Programs

Suicide is a global epidemic. This review assessed the scope and effectiveness of suicide prevention programs. Systematic literature searches were conducted using PsycINFO, ERIC and MEDLINE to retrieve articles published between January 2007 and March 2017 and fulfilled inclusion criteria (studies evaluating the efficacy of theory/model-informed suicide prevention programs in increasing participant knowledge or skills when presented with a peer at risk of suicide). The review is informed by PRISMA guidelines. Of 1398 studies identified, 25 were reviewed and most: targeted professionals; were 1-4-day workshops; were underpinned by 21 different theories; taught less detail to the community than professionals; and improved target outcomes. Current programs, although effective, are limited by their inaccessibility, narrow content for the community and substantial variability in theory base. Future suicide prevention programs will benefit from being informed by a more specific theory, delivered through technology, targeting more of the community and improving methodological rigour.

Future Well-Being Among People Who Attempt Suicide and Survive: Research Recommendations

Over 48,000 people died by suicide in 2018 in the United States, and more than 25 times that number attempted suicide. Research on suicide has focused much more on risk factors and adverse outcomes than on protective factors and more healthy functioning. Consequently, little is known regarding relatively positive long-term psychological adaptation among people who attempt suicide and survive. We recommend inquiry into the phenomenon of long-term well-being after nonfatal suicide attempts, and we explain how this inquiry complements traditional risk research by (a) providing a more comprehensive understanding of the sequelae of suicide attempts, (b) identifying protective factors for potential use in interventions and prevention, and (c) contributing to knowledge and public education that reduce the stigma associated with suicide-related behaviors.

Enhancing Community Suicide Risk Assessment and Protective Intervention Action Plans Through a Bystander Intervention Model-Informed Video

Aim: The effects of a bystander intervention model (BIM)-informed intervention (video) for the general community on participant risk of suicide assessment ability (ROSAA) and protective intervention ability (PIA) were compared with an active control (non-BIM-informed video). Method: Video interventions with 628 participants (M_age = 47.99, SD_age = 17.34, range = 18-85 years) were conducted online. ROSAA and PIA were assessed immediately preintervention, postintervention, and at 2 months follow-up (n = 126). Results: Linear mixed model analyses indicated that the experimental and control conditions improved on both outcome variables postintervention/Time 2 (T2); however, the former yielded better outcomes than the latter (moderate ESs in both variables). Follow-up/Time 3 (T3) experimental ROSAA scores were higher than Time 1 (T1) and lower than T2 scores. Follow-up experimental PIA scores were higher than T1 and lower than T2 scores. Follow-up control ROSAA scores were higher than those of T1 and similar to T2. Follow-up control PIA scores were similar to T1 and T2 scores. Limitations: Limitations of the study include: sample homogeneity, small n at follow-up, self-report data only (no observable behavior was tested), fair inter-rater reliability, and a brief follow-up time frame. Conclusion: Current community information increased ROSAA and PIA. A BIM-informed intervention significantly enhanced these effects, which seemed to wane somewhat over time with the effect being lower at follow-up compared with postintervention. The BIM should be explored further as a basis for community suicide prevention interventions.

Factors Affecting Collaborations between a Tertiary-level Emergency Department and Community-based Mental Healthcare Centers for Managing Suicide Attempts

BACKGROUND

Community-based active contact and follow-up are known to be effective in reducing the risk of repeat suicide attempts among patients admitted to emergency departments after attempting suicide. However, the characteristics that define successful collaborations between emergency departments and community-based mental healthcare centers in this context are not well known.

METHODS

This study investigated patients visiting the emergency department after suicide attempts from May 2017 to April 2019. Patients were classified in either the successful collaboration group or the failed collaboration group depending on whether or not they were linked to a community-based follow-up intervention. Clinical features and socioeconomic status were considered as independent variables. Logistic regression analysis was performed to identify factors influencing the collaboration.

RESULTS

Of 674 patients, 153 (22.7%) were managed successfully via the targeted collaboration. Completion of hospital-based psychological counseling (adjusted odds ratio [aOR], 233.55; 95% confidence interval [CI], 14.99-3,637.67), supported out-of-pocket expenses (aOR, 11.17; 95% CI, 3.03-41.03), Korean Triage and Acuity Scale 1-3 (aOR, 4.31; 95% CI, 1.18-15.73), suicide attempt associated with mental disorder (aOR, 0.15; 95% CI, 0.04-0.52), and self-discharge against medical advice (aOR, 0.12; 95% CI, 0.02-0.70) were independent factors influencing the collaboration.

CONCLUSION

Completion of hospital-based psychological counseling was the most highly influential factor determining the outcome of the collaboration between the emergency department and community-based mental healthcare center in the management of individuals who had attempted suicide. Completion of hospital-based psychological counseling is expected to help reduce the risk of repeat suicide attempts.

Promoting the Community's Ability to Detect and Respond to Suicide Risk Through an Online Bystander Intervention Model-Informed Tool

Background: The public health sector has advocated for more innovative, technology-based, suicide prevention education for the community, to improve their ability to detect and respond to suicide risk. Emerging evidence suggests addressing the bystander effect through the Bystander Intervention Model (BIM) in education material may have potential for suicide prevention. Aims: The current study aimed to assess whether BIM-informed tools can lead to improved readiness, confidence and intent in the community to detect and respond to suicide risk in others. Method: A sample of 281 adults recruited from the community participated in a randomized controlled trial comprising a factsheet designed according to the BIM (intervention group) and a standard factsheet about suicide and mental health (control group). Participants' self-reported detecting and responding to suicide risk readiness, confidence, and intent when presented with a suicidal peer was tested pre- and postintervention and compared across time and between groups. Results: The intervention group had significantly higher levels of detecting and responding to suicide risk readiness, confidence, and intent than the control group at postintervention (all p < .001) with moderate-to-large effect sizes. Limitations: The study was limited by a homogenous sample, too low numbers at follow-up to report, and self-report data only. Conclusion: This study demonstrates BIM-informed suicide prevention training may enhance the community's intervention readiness, confidence, and intent better than current standard material. Further testing in this area is recommended. While results were statistically significant, clinical significance requires further exploration.

Public Stigma Toward Persons with Suicidal Thoughts-Do Age, Sex, and Medical Condition of Affected Persons Matter?

OBJECTIVE

Suicidal persons often face public stigmatization which affects help-seeking behavior and may lead to an additional suicide risk. There is not much known about differences in stigmatizing attitudes concerning characteristics of affected persons. The present study investigates public stigma toward suicidal persons in Germany by focussing on differences concerning sex, age, and medical condition of the affected person.

METHOD

A national telephone survey (N = 2,002) was conducted using case vignettes presenting a person with suicidal thoughts. Vignettes systematically varied in sex, age, and medical condition (depressive symptoms vs. cancer). Several components of stigma were assessed ("weakness of will" as a cause, separation, negative emotional reactions, and desire for social distance).

RESULTS

About 44% of the respondents agreed that a cause of suicidal thoughts is "weakness of will," and two thirds disagreed that they would feel and think the same as the described person. In terms of emotional reactions, fear was more pronounced than anger. Stigmatizing attitudes were particularly pronounced when the described person was female and depressive symptoms were presented.

CONCLUSIONS

Magnitude of public suicide stigma varies depending on the characteristics of the described person. Groups that are at special risk of being stigmatized should be considered in antistigma programs.

Australian R U OK?Day campaign: improving helping beliefs, intentions and behaviours

Background

Suicide is a major public health concern and has been recognised as a public health priority. R U OK?Day aims to prevent suicide by encouraging and empowering Australians to reach out to friends and family who might be experiencing personal difficulties. This study aims to update the evaluation of the public awareness campaign ‘R U OK?Day’ that was conducted using 2014 data.

Methods

Data from 2013 participants were collected via an online survey following the R U OK?Day campaign implemented in 2017. Outcome measures included campaign awareness and participation, past 12-month help-seeking, helping beliefs, helping intentions and helping behaviours. Data were analysed using z-tests, Chi square and regression analyses in SPSS.

Results

Both campaign awareness and participation have increased since 2014, from 66% and 19% to 78% and 32%. Campaign exposure was associated with stronger beliefs in the importance and the ease of asking “Are you okay?”, and increased the likelihood of intentions to use recommended helping actions by two to three times compared to those not exposed to the campaign. Participants who were exposed to the R U OK?Day campaign were up to six times more likely to reach out to someone who might be experiencing personal difficulties compared to those not exposed to the campaign. Interestingly, those who had sought help from a mental health professional in the past 12 months were more likely to be aware of, and participate in, the campaign, suggesting people experiencing mental health issues recognise the value of seeking—and giving—social support.

Conclusions

The R U OK?Day campaign continues to be relevant and effective in spreading key messages about the importance of reaching out to others and empowering members of the community to have conversations about life problems. The campaign’s impact is increasing over time through increased campaign awareness and participation, and improving helping beliefs, intentions and behaviours. Ongoing monitoring and evaluation of the campaign’s impact is vital and may inform potential changes needed to further enhance its impact.

Comparing the reasons for suicide from attempt survivors and their families in Ghana

Background

Family members are key in detecting early suicide warning signs. This study compared the reasons for suicidality as reported by attempt survivors with their family folks in Ghana.

Methods

A qualitative design was used to select a sample size of 20 (10 family members and 10 suicide attempt survivors). Thematic analysis was used to analyse the data.

Results

Analysis of the data showed two major themes: 1) Similar Reasons (where both families and attempt survivors consistently reported similar reasons for suicidality and 2) Different Reasons (where there were sharp divergences).

Conclusions

Findings from this study help to understand the readiness of attempt survivor family members to intervene early during suicidal crisis.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6743-z) contains supplementary material, which is available to authorized users.

What is the relationship between rejection and self-harm or suicidality in adulthood?

BACKGROUND

Rejection is an adverse experience that may help explain the heightened risk of self-harm and suicide amongst many societal groups. The aim of this systematic review was to determine the relationship between rejection experiences and self-harm and suicidal ideation.

METHOD

The databases PsychINFO, CINAHL, Medline and Web of Science were searched from inception until May 2017 using key search terms. Quantitative studies were included if they were; (i) mean sample age over 18; (ii) in the English language; (iii) and had a measure of self-harm or suicidal behaviour and a measure of rejection. The results were synthesised narratively.

RESULTS

Eighteen studies were identified for the review. Fifteen out of the eighteen studies found a significant positive association between rejection and self-harm. This association was identified within several marginalised groups known to be at risk of self-harm, including those from lesbian, gay or bisexual sexuality or those who identify as transgender.

LIMITATIONS

Heterogeneity between the measures of self-harm, suicidal behaviour and rejection, as well as the lack of longitudinal analyses made it difficult to draw firm conclusions.

CONCLUSION

Perceived rejection may leave some individuals at risk of self-harm and might account for the elevated risk in marginalised societal groups. Interventions focused on modifying rejection experiences may help reduce the risk of self-harm in this population.

Relations Between Thwarted Belongingness, Perceived Burdensomeness, and History of Suicide Attempts and Readiness for Mental Health Treatment in High-Risk Veterans, Reserves, and Active Duty Service Members

Suicide rates for service members and veterans are growing rapidly in the United States. Despite availability of evidence-based approaches, a large number of high-risk individuals are reluctant to seek out treatment. The present study used the interpersonal theory of suicide, involving 3 primary predictors of death by suicide to investigate treatment readiness in high-risk U. S. veterans, reserves, and active duty service members. Four hundred and two service members were recruited. Inclusion criteria involved (a) reporting active suicidal ideation and (b) denying active behavioral health treatment. All participants completed a self-report battery that assessed burdensomeness, thwarted belongingness, lifetime suicide attempts, and perceptions about treatment. Regression analyses revealed that thwarted belongingness was significantly predictive of treatment perceptions and readiness, in that higher or more severe scores on the thwarted belongingness scale were significantly related to lower or less likely treatment perceptions and readiness scores. The findings suggested that, in high-risk service members, thwarted belongingness is predictive of lower treatment readiness, and contributes to the growing literature on perceived stigmas, treatment barriers and readiness, and suicidal behaviors and risk factors.

Short- and Long-term Effects of Case Management on Suicide Prevention among Individuals with Previous Suicide Attempts: a Survival Analysis

BACKGROUND

This study examined the long-term preventive effects of a case management service on suicide reattempts, and clarified the factors related to suicide reattempts.

METHODS

We reviewed the medical records of suicide attempters who visited the emergency department of Ulsan University Hospital from August 28, 2013 to July 31, 2017. A 4-week case management service was provided to consenting participants, either face-to-face or by telephone. Using survival analysis, we analyzed differences in the time to the next emergency department visit for a suicide attempt according to whether participants completed the case management service. We also assessed which characteristics of participants were associated with suicide reattempts.

RESULTS

We found no overall difference in time to suicide reattempt between case-managed participants and controls over the entire observation period (median period: 19 months). However, in the first 24 weeks after the initial suicide attempt, the case-managed group showed a longer time to reattempt than did the control group (log-rank test = 4.243; P = 0.039). A higher risk of reattempt was found among participants with the medical benefit type of health insurance compared to those with national health insurance (hazard ratio [HR], 5.134; P < 0.001) and among participants aged 20-39 compared to those aged ≥ 60 (HR, 3.502; P = 0.05).

CONCLUSION

Case management had only short-term benefits (within 24 weeks of initial suicide attempt). Risk factors for suicide reattempts were having a medical benefit health insurance and being aged 20-39 years.

Awareness of Suicide Risk and Communication Between Health Care Professionals and Next-of-Kin of Suicides in the Month Before Suicide

Based on psychological autopsy data, the study compared awareness of suicide risk in the deceased among next-of-kin (NOK) and health care professionals (HCPs), and communication between these two groups in the month before death. The NOKs had significantly more knowledge about the decedent's suicide warning signs than the HCPs (90.5% vs. 44.6%). Contact between NOK and HCP was initiated more often by the family than the HCPs (29.4% vs. 5.9%). The study found communication gaps between HCPs and NOK and stresses the need for suicide prevention strategies strengthening communication between these two groups.

Intervention related reductions in perceived burdensomeness mediates incidence of suicidal thoughts

BACKGROUND

Interventions aimed at preventing suicidal thoughts target people at risk for suicide based on risk factor elevations. Based on the interpersonal psychological theory of suicide, elevated perceived burdensomeness (PB) and thwarted belongingness (TB) are potential targets for prevention of the occurrence of suicidal thoughts. PB is the belief that one is a burden to others. TB is the perceived lack of social connectedness.

METHODS

This study was designed to examine the effects of a preventative intervention targeting PB and TB on the 6-month incidence of suicide ideation in a sample of 138 people (M = 38.01 years, SD = 16.40; 50.7% female) with elevated levels of these variables but no current suicidal thoughts at baseline. The three-session intervention included psychoeducation and cognitive bias modification.

RESULTS

PB was reduced in the intervention condition, compared to the repeated contact control condition (B = 2.50, p < .05) and TB was not (B = 1.42, p = .43). The likelihood of a reported incident of suicidal thoughts was reduced for those in the active intervention compared to those in the repeated contact control condition, through reductions in PB (B = .12, 95% confidence interval [.01, .32]).

LIMITATIONS

There were two components of the intervention, cognitive bias modification and psychoeducation; thus, it is unclear whether one or both components contributed to these findings.

CONCLUSIONS

This intervention can be used as a preventative intervention for suicidal thoughts by targeting PB. These results further confirm PB as a causal risk factor for suicidal thoughts.

Insight into the Stigma of Suicide Loss Survivors: Factor Analyses of Family Stereotypes, Prejudices, and Discriminations

Families of individuals who die by suicide report public stigma that threatens their well-being. This study used a community-based participatory (CBPR) approach to describe a factor structure for the family stigma of suicide. Candidate items (n = 82) from a previous qualitative study were presented in an online survey format. Members of the public (n = 232) indicated how much they thought items represented public views and behaviors towards family members who lost a loved one to suicide. Factor analyses revealed two factors for stereotypes (dysfunctional, blameworthy), one factor for prejudice (fear and distrust), and three factors for discrimination (exclusion, secrecy, and avoidance).

Making Sense of the Public Stigma of Suicide

Abstract. Background: Research suggests that stigma is a barrier to care for individuals who have attempted suicide. While extensive work has examined the stigma of mental illness, less research has focused on the public stigma of suicide. Existing measures of suicide stigma have lacked a conceptual foundation or have failed to include the perspectives of suicide stakeholders. Aims: This research draws on previous qualitative research with suicide stakeholders to create a measure of public suicide stigma. Method: This study used a community-based participatory research (CBPR) approach to define a factor structure for suicide stigma. The CBPR team used focus groups to generate items for each component of stigma (stereotypes, prejudice, and discrimination). Two online surveys (N = 372; N = 243) asked members of the public to rate candidate items for stereotypes, prejudice, and discrimination. Results: Analyses revealed three factors for stereotypes (weak, crazy, distressed), two factors for prejudice (fear/distrust, anger), and three for discrimination (avoidance, disdain, coercion). Limitations: Results should be confirmed in other samples and further evidence gathered on convergent, divergent, and discriminant validity. Conclusion: The resulting 44-item Suicide Stigma Assessment Scale (SSAS) can be further validated and used to measure efficacy of stigma change interventions.

Stakeholder Perspectives on the Stigma of Suicide Attempt Survivors

Abstract. Background: Past scholarly efforts to describe and measure the stigma surrounding suicide have largely viewed suicide stigma from the perspective of the general public. Aims: In the spirit of community-based participatory research (CBPR), the current study brought together a diverse stakeholder team to qualitatively investigate the suicide stigma as experienced by those most intimately affected by suicide. Method: Seven focus groups (n = 62) were conducted with suicide attempt survivors, family members of those who died by suicide, and suicide loss therapists. Results: Themes were derived for stereotypes (n = 30), prejudice (n = 3), and discrimination (n = 4). People who attempted suicide were seen as attention-seeking, selfish, incompetent, emotionally weak, and immoral. Participants described personal experiences of prejudice and discrimination, including those with health professionals. Conclusion: Participants experienced public stigma, self-stigma, and label avoidance. Analyses reveal that the stigma of suicide shares similarities with stereotypes of mental illness, but also includes some important differences. Attempt survivors may be subject to double stigma, which impedes recovery and access to care.

The Validity of a Brief Risk Assessment Tool for Predicting Suicidal Behavior in Veterans Utilizing VHA Mental Health Care

Suicide risk among military veterans is an important and ongoing concern. The Veterans Administration (VA) mandates suicide risk screening of all veterans seen for mental health issues, but little is known about the effectiveness of this screening. A retrospective chart review to examine all suicide risk screens at VA San Diego between October and December 2012 (n = 3,365) was conducted to assess whether results were associated with suicidal behavior over the subsequent 12 months. Patients judged to be at increased risk for suicide were 3 to 16 times more likely to attempt suicide and 7 to 25 times more likely to engage in self-directed violence over the next 12 months compared with others. The screening tool may be a useful addition to clinical practice.

Clinical Characteristics of the Suicide Attempters Who Refused to Participate in a Suicide Prevention Case Management Program

Case management interventions for suicide attempters aimed at helping adjust their social life to prevent reattempts have high nonparticipation and dropout rates. We analyzed the clinical characteristics of the group who refused to participate in the suicide prevention program in Korea. A total of 489 patients with a suicide attempt who visited Uijeongbu St. Mary's Hospital, the Catholic University of Korea, from December 2009 to December 2013 were analyzed. All patients were divided into the participation group (n = 262) and the refusal group (n = 227) according to their participation in the case management program. Demographic and clinical characteristics of each group were examined. Results showed that the refusal group had low risks for suicide in terms of risk factors related with psychopathologies and presenting suicide behavior. That is, the refusal group had less patients with co-morbid medical illnesses and more patients with mild severity of depression compared to the participation group. However, the refusal group had more interpersonal conflict, more isolation of social integrity, and more impaired insight about suicide attempt. The results suggest that nonparticipation in the case management program may depend upon the patient's impaired insight about the riskiness of suicide and lack of social support.

The relationship between lifetime suicide attempts, serum lipid levels, and metabolic syndrome in patients with bipolar disorders

OBJECTIVES

To assess the relationship between lifetime suicide attempts (SAs), serum lipid values, and metabolic syndrome (MetS) in patients with bipolar disorders (BPD).

METHODS

Eighty patients with BPD took part in the study (M = 40.60 years). After psychiatric diagnosis, demographic data, SAs, and serum lipids were measured and MetS was calculated.

RESULTS

70% reported at least one suicide attempt. 52.5% suffered from MetS. Suicide attempters had higher cholesterol values. SAs were associated with a family history of suicide, current mood state, and lower educational level. SAs were unrelated to MetS.

CONCLUSIONS

In patients with BPD, against expectations, the occurrence of SAs was associated with higher cholesterol values. Serum lipid values are not suitable as a biological trait marker to predict SAs.

No evidence for metabolic syndrome and lipid profile differences in patients suffering from bipolar I disorder with and without suicide attempts

OBJECTIVE

The aim of the present study was to provide further evidence of (1) metabolic syndrome and blood lipid profile differences between suicide attempting and non-attempting patients with bipolar disorder (BPD) I and to assess these differences (2) as a function of acute depressive or manic phase.

METHODS

Fifty inpatients (mean age: 36.14 years 48% males) with BPD I took part in the study. After recruitment, patients were clustered in four groups: 13 suicide attempters (SAs) assessed during a manic phase, 12 SAs assessed during a depressive phase, 15 non-SAs assessed during a manic phase, and 10 non-SAs assessed during a depressive phase. Body mass index (BMI), metabolic syndrome, blood pressure, blood lipids (cholesterol, high- and low-density lipids, and triglyceride), and fasting blood sugar were assessed.

RESULTS

Neither metabolic syndrome, blood lipid values, fasting blood sugar, nor BMI or blood pressure differed between the SAs and non-SAs, or between patients in an acute manic phase and those in a depressed phase. The overall prevalence of metabolic syndrome was 26.0%.

CONCLUSION

Among patients with BPD I neither the occurrence of metabolic syndrome nor lipid values or fasting blood sugar are reliable biomarkers of suicidal behavior during either acute depressive or manic phase.

Re-development of mental health first aid guidelines for suicidal ideation and behaviour: a Delphi study

BACKGROUND

Suicide continues to be a leading cause of death globally. Friends and family are considered best positioned to provide initial assistance if someone is suicidal. Expert consensus guidelines on how to do this were published in 2008. Re-developing these guidelines is necessary to ensure they contain the most current recommended helping actions and remain consistent with the suicide prevention literature.

METHODS

The Delphi consensus method was used to determine the importance of including helping statements in the guidelines. These statements describe helping actions a member of the public can take, and information they should have, to help someone who is experiencing suicidal thoughts. Systematic searches of the available suicide prevention literature were carried out to find helping statements. Two expert panels, comprising 41 suicide prevention professionals and 35 consumer advocates respectively, rated each statement. Statements were accepted for inclusion in the guidelines if they were endorsed by at least 80% of each panel.

RESULTS

Out of 436 statements, 164 were endorsed as appropriate helping actions in providing assistance to someone experiencing suicidal thoughts or engaging in suicidal behaviour. These statements were used to form the re-developed guidelines.

CONCLUSION

The re-development of the guidelines has resulted in more comprehensive guidance than the earlier version, with the endorsement of 164 helping actions, compared to 30 previously. These guidelines will form the basis of a suicide prevention course aimed at educating members of the public on providing first aid to someone who is experiencing suicidal thoughts.

Risk and protective factors predicting multiple suicide attempts

This study compared demographical and clinical variables between first and multiple suicide attempters and investigated risk and protective factors predicting multiple attempts. 228 patients visiting emergency department after attempting suicide were divided into two groups: first attempter (n=148, 64.9%) and multiple attempter (n=80, 35.1%). Demographic variables, clinical characteristics, factors related with suicide behavior, and psychiatric resources between two groups were compared. Multivariate logistic regression analysis was conducted to investigate risk and protective factors predicting multiple attempts. The results showed that multiple attempters were younger, not married, more severe in psychopathology (e.g., psychiatric disorder, personality disorder, lower function, and suicide family history) and suicidality (e.g., repetitive/severe/continuous suicide ideation), and lower in psychiatric resources (e.g., interpersonal stress/conflict, conflicting interpersonal relationship, socially isolated, lower personal achievement, and lower ability to control emotion) than first attempters. Suicide ideation severity and conflicting interpersonal relationships predicted multiple suicide attempts, whereas past year's highest global functioning score and age over 45 protected against multiple suicide attempts. This study demonstrated that multiple suicide attempters have more severe clinical profile than first suicide attempters. Moreover, decreasing severity of suicide ideation, improving interpersonal relationships, and enhancing functioning level of suicide attempters might be important in preventing them from re-attempting suicide.