ReviewImpulsive suicide attempts: A systematic literature review of definitions, characteristics and risk factors
Introduction
Suicide is often understood as a process that progresses in seriousness from death wishes to suicide ideation, then to planning and later to an attempt, with the risk increasing at each stage (Thompson et al., 2012). The results of a number of studies, however, are not consistent with this, indicating that in some cases the risk of attempting suicide develops quickly, with little prior premeditation or planning (Simon et al., 2001, Sveticic and De Leo, 2012, Wyder and De Leo, 2007). The proportion of these “impulsive” attempts is put as high as 80% in some studies (Cornelius et al., 1996, Gore-Jones and O׳Callaghan, 2012, Kleespies et al., 2011). These observations are countered by those who argue that “people do not attempt suicide impulsively” (e.g., P.N. Smith et al., 2008, p. 13) and that, in almost all cases, suicide can be foreseen (Van Orden et al., 2010). The lack of agreement about the impulsive character of some suicide attempts poses a challenge to current understanding of the suicide process and potentially hampers suicide assessment and prevention. If there are impulsive attempts, the single, linear, unfolding suicide process must be highly condensed in some cases; alternatively, there is no single process. If there is more than one process, different preventive strategies may be needed for each.
The term “impulsive suicide attempt” (ISA) was mentioned in the literature as early as the 1890s in Durkheim׳s work (Durkheim, 1897, 2005), while reports of impulsive suicide attempts (ISA) have appeared at least since the 1950 s (Finn, 1955, Kessel, 1965), but there has been little review of this literature. Gvion and Apter (2011), in revisiting the broader theme of aggression and impulsivity in suicide, considered the difficulties in defining impulsive or, as they referred to it, “unplanned” suicide, and noted the importance of distinguishing between impulsivity as a characteristic of the act and as a characteristic of the person involved. Conner (2004) focused on impulsive attempts and the differences from non-impulsive attempts. He concluded that impulsive suicide attempts are characterised by low lethality and low levels of depression and hopelessness, and become more probable when negative life events are close in time to the suicide attempt. Conner also suggested such impulsive suicide attempts are possibly linked to reactive (impulsive) aggression. The findings on this point, however, are not wholly consistent with data from neurobiological studies linking aggression and lethality, and contradict Gvion and Apter (2011), who claimed there is little support for a direct relationship between trait impulsivity of the attempter and impulsivity of the attempt itself.
To date, there has been no systematic review of the literature on impulsive suicide attempts. The present paper sought to address this gap. Its purpose was to examine how impulsive suicide attempts have been defined by researchers and to establish, as far as possible, the likely correlates of those attempts described as impulsive.
Section snippets
Method
The most frequently used term in the literature is “impulsive suicide attempt” (e.g., Bagge et al., 2013, Wyder and De Leo, 2007). Some authors used the term “unplanned suicidal behaviour” (Conner et al., 2007a, Conner et al., 2007b, Jeon et al., 2010, Kessler et al., 1999) and others “low-planned suicide” (Conner et al., 2005) or “non-planned suicide attempt” (Suokas et al., 2005). These were used to formulate a set of search terms: impulsive suicide attempt, impulsive suicidal behaviour,
Description of included studies
A breakdown of 179 included articles by year and country of the study is shown in Fig. 2 and Table 1 accordingly. The number of studies on suicide attempt impulsivity increased rapidly from 1980 onwards, the largest increase in the number of articles is seen from 2005. The majority of research effort is still concentrated only in the Western countries (USA, Western Europe). However, some representation of Asian, African and Latin American countries is visible.
Definitions of impulsive suicide attempts
The first question addressed was
Discussion
This systematic review identified 179 articles presenting both quantitative and qualitative data on impulsive suicide attempts and their risk factors. Such a large volume of research is not surprising, given the fact that the ISA construct has been used for more than one hundred years (Durkheim, 1897, 2005). However, substantial lack of agreement about the definition of impulsive suicide attempt hampers integration of the study findings.
Studies differ in whether they use proximal or distal
Role of funding source
The senior author is supported by an Australian Research Grant Scholarship.
Conflict of interest
We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.
Acknowledgements
None.
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Cited by (0)
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Number in brackets at the end of the citation refers to number of article in Table 2. Articles that just listed frequencies of impulsive suicide attempts marked with (L) at the end of the reference. Qualitative articles, case studies and case presentation on impulsive suicide attempts marked with (Q). Refer to Supplementary tables for full details.