Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 https://doi.org/10.1186/s12888-022-04427-8 RESEARCH Open Access A comparison of medically serious suicide attempters admitted to intensive care units versus other medically serious suicide attempters Marta Quesada‑Franco1,2*, Mª Dolores Braquehais3,4,5,6, Sergi Valero7,8, Anna Beneria1,2,3, J. A. Ramos‑Quiroga1,2,3,5, Enrique Baca‑García9,10,11,12,13,14,15,16 and Luis Pintor‑Pérez17 Abstract Background: Medically serious suicide attempts (MSSA) represent a subgroup of clinically heterogeneous suicidal behaviours very close to deaths by suicide. A simple definition of an MSSA is a suicide attempt with life-threatening consequences, regardless of the severity of the attempter’s mental disorder. Few studies have specifically analysed the heterogeneity of MSSA. Therefore, the aim of this study is to describe the profile of individuals who made a highly severe MSSA and to compare those admitted to Intensive Care Units (ICU) – including Burn Units– with other MSSA admitted to other medical and surgical units. Methods: The study sample consisted of 168 patients consecutively admitted to non-psychiatric wards from two public hospitals in Barcelona after an MSSA during a 3-year period. In order to select more severe MSSA, the minimum hospital stay was expanded from Beautrais’ definition of ≥ 24 h to ≥ 48 h. Mean hospital stay was 23.68 (SD = 41.14) days. Patients needing ICU treatment (n = 99) were compared to other MSSArs (n = 69) that were admitted to other medical and surgical units, not requiring intensive care treatment, with an initial bivariant analysis followed by a logis‑ tic regression analysis using conditional entrance. Results: Medically serious suicide attempters (MSSArs) spent more time hospitalized, more frequently reported recent stressful life events, were more likely to have at least one prior suicide attempt (SA) and their current attempt was more frequently non-planned, compared to the profile of MSSArs reported in previous studies. The most frequent method was medication overdose (67.3%) and jumping from heights (23.2%). Among those who chose more than one method (37.6%), the most frequent combination was medication overdose and drug use. Affective disorders and personality disorders were the most frequent diagnoses. Higher educational level, history of previous mental disorders and prior lifetime suicide attempts were significantly more frequent among those admitted to ICU compared to other MSSArs. Patients needing admission to ICU less frequently used self-poisoning and cuts. *Correspondence: marta.quesada@vallhebron.cat 1 Department of Psychiatry, Hospital Universitari, Vall d’Hebron, Barcelona, Spain Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 Page 2 of 10 Conclusions: MSSA needing ICU admission can be regarded clinically as similar to attempts resulting in suicide. More research on this type of highly severe suicide behaviour is needed due to its serious implications both from a clinical and public health perspective. Keywords: Medically serious suicide attempts, Nearly lethal suicide attempts, Intensive care unit Background based on social-demographic and clinical factors con- More than 700,000 people die by suicide every year, ducted with 124 MSSA found that three major groups which is one person every 40 s and accounted for 1.3% of patients could be identified: 1) “impulsive-ambiva- of all deaths worldwide in 2019 [1]. Suicide occurs at all lent”, predominantly females, with a less severe suicide stages of life, being the fourth cause of death in people attempt, generally after a personal crisis and with low between 15 and 29 years [1]. scores on anxiety and depression; 2) “marked intent”, pre- Individuals who made an MSSA in the past are at dominantly males, with more lethal attempts compared higher risk of dying by suicide than those who make less to the first group, more violent suicidal methods (self- serious lethal suicide attempts [2, 3]. Studies have shown poisoning by pesticide and gas), and greater prevalence that survivors of MSSA are epidemiologically very similar of moderate and severe depressive disorders; and, 3) to those who die by suicide [4, 5]. Consequently, recent “aborted suicides”, with a higher risk of becoming deaths research has focused on subjects with MSSA, as the study by suicide: they could have died if there had not been a of this subgroup can best shed light on deaths by suicide medical intervention because their lethal means was [3]. Moreover, from the methodological perspective, the even more violent compared to the second group (fire- study of MSSA overcomes some problems related to the arms, hanging, being run over, etc.) and with the great- study of suicidal behaviour. In contrast to the psycho- est prevalence of severe depressive disorder. Therefore, logical autopsy conducted in suicides, in MSSA the main distinguishing between several clinical presentations of source of information is the survivor. patients admitted to a general hospital after an MSSA is However, criteria to define an MSSA are heterogene- a step beyond the simplistic notion that this subset of sui- ous. Broadly, a simple definition is suicide attempts with cide attempters is a homogeneous clinical group [26]. life-threatening consequences, regardless of the severity The characterization of MSSA subgroups according to of the attempter’s mental disorder. Beautrais and col- the severity of the medical consequences of the attempt laborators provide a specific clinical definition of MSSA: may help elucidate the heterogeneity of these nearly patients who require hospital admission for more than lethal suicide attempts. This is the main reason why we 24 h after the attempt and met one of the following treat- decided to compare the profile of patients with MSSA ment criteria: a) treatment in a specialized clinical unit who needed specialized medical care to other MSSA. (i.e.: intensive care, hyperbaric or burn units), c) need of We chose a more restrictive definition of MSSA, expand- surgery under general anaesthesia, c) need of medical ing Beautrais’ minimum hospital stay of ≥ 24 [4, 6–11] treatment beyond gastric lavage, activated charcoal, and/ to ≥ 48 h, in order to identify the most severe MSSA. The or routine neurological observations; and, d) patients concept of MSSA focuses on the medical consequences who require hospital admission for more than 24 h not of the attempt, regardless of its psychiatric severity. because of the aforementioned criteria but because of the Our main hypothesis was that there would be signifi- highly lethal suicidal methods (e.g.: hanging or gunshot) cant socio-demographic and clinical differences between [4, 6–11]. MSSA needing ICU admission and those who did not. Other studies define MSSA with psychometric scales This is also the first study conducted in Spain on MSSA such as: the Self-inflicted Injury Severity (SIISF) [12–14]; in urban areas and the characteristics of this suicidal sub- the Lethality Scale [15]; the Lethality of Suicide Attempt group are compared to findings from other studies on Scales II (LSARS-II) [16, 17]; the Lethality Rating Scale MSSA conducted to date. (LRS) [3, 18–21] or the Risk Rescue Rating Scales (RRRS) Patients requiring admission to intensive care units [22–24]. Other researchers refer to the time spent in (ICU) for the consequences of suicide attempts can be non-psychiatric wards after the MSSA. For instance, considered as those who come closest to dying [27, 28]. in certain studies the mean hospital length of stay was Thus, being able to identify the profile of patients whose 19 days [3, 20, 21] and 22.7 days in other studies [25]. attempts are nearly fatal could help develop more effec- Aside from the medical consequences of the MSSA, tive suicide prevention strategies. Moreover, in addition from a psychosocial analysis they can be conceptualized to the suffering and possible longer-term consequences as a heterogenous group [26]. A cluster analysis study faced by the individual patients, ICU admissions have Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 Page 3 of 10 a higher financial cost in comparison to those to other Beautrais’ 24 h to ≥ 48 h, in order to have a more restric- units [29]. tive inclusion criterion with respect to the severity of the attempt (see Table 1). We selected MSSA admitted to Method specialized care units (including Intensive Care and Burn Study design Units) because of the serious medical consequences of This cross-sectional study was conducted over a three- their suicide attempt and compared them to other medi- year period at two tertiary university affiliated general cally serious suicide attempters admitted in other medi- hospitals, with all the medical and surgical specialities cal and surgical wards and not requiring intensive care and services required for patients with unusually severe, treatment in ICU. complex, or uncommon health problems [30]. Both pub- lic hospitals are located in the metropolitan area of Bar- Procedure and assessment celona (Spain). Valld’Hebron University Hospital and MSSA were identified daily on Emergency Room data- Clinic Hospital provide medical coverage to catchment bases. In addition to medical assistance, psychiatric areas covering a population of 400,000 and 540,000 peo- assessment of MSSA is always performed during hos- ple respectively. In Spain, due to the universal coverage pitalization once the medical condition is sufficiently of its public health system, the majority of patients with stabilized. Researchers involved in the study evaluated MSSA are initially referred to public hospitals in order to the patient during the first week after the MSSA. It was stabilize their medical situation. independent of clinical assistance and provided by expert The study group consisted of one hundred and sixty- psychiatrists during hospitalization. eight patients consecutively admitted to the emergency Psychosocial, clinical and suicidiological variables units of both hospitals after an MSSA. Patients from related to suicide risk and protective factors [31] were Clinic Hospital (n = 100) were included from February recorded using an ad hoc questionnaire that included: 2007 to August 2010 while those from Vall d’Hebron Uni- versity Hospital (n = 68) were included from February ∙ Social-demographics: age, sex, nationality, marital 2010 to October 2012 (see Fig. 1). status, educational level, employment situation, and legal problems. Subjects ∙ Physical and/or sexual abuse during their child- The sample consisted of 168 adults with MSSA admit- hood or/and adulthood. ted to the Emergency Care Units of both hospitals. The ∙ Stressful life events the year prior to the Index Sui- definition of MSSA followed all Beautrais’ inclusion cri- cide Attempt (ISA). teria [4, 6–11], but hospital admission was extended from ∙ Current medical morbidity (not related to the ISA). Fig. 1 Study flow-chart. MSSA: Medically serious suicide attempts (needing to be hospitalized at a medical/surgical unit ≥ 48 h after the attempt) Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 Page 4 of 10 Table 1 Inclusion and exclusion criteria Inclusion Criteria Exclusion Criteria • ≥ 18 years old • Current moderate/severe cognitive impairment • Admitted via the Emergency Unit after a medically serious suicide attempt • Current severe psychomotor agitation (MSSA) • Patients admitted to the hospital for other reasons (not for a suicide • Need of hospital admission ≥ 48 h attempt) ✓ Need of specialized medical care unit • Definition of MSSA: at least 1 of the following: • Refusal to sign informed consent ✓ Need of surgery (superficial cuts excluded) ✓ Medical treatment beyond basic gastric lavage, activated charcoal and/or ✓ Highly lethal suicide methods with a high risk of fatality, especially hanging basic neurological assessment or gunshot who were hospitalized for ≥ 48 h, but did not meet the preceding criteria • Informed consent ∙ Psychiatric history: method of current SA; presence ranges from 0 to 30 points. In the scale’s validation of SA in the 5 years prior to the ISA; previous psychi- studies, the mean scores were 16.3 for highly serious atry emergency room or inpatient admissions; pre- suicide attempts; 10.1 for medium severity, and 6.7 for vious outpatient psychiatric or psychological treat- low severity. ment; and, family history of psychiatric disorders and suicide attempts. The SIS measures the individual’s intent to die by any suicide attempt. The scales were selected according to pre- Lethality of the attempt was evaluated using a simple existing evidence on a brief screening of suicidal behav- clinical criterion: those needing ICU treatment after the iours [2, 18, 20, 38] in order to capture the most important suicide attempt versus those MSSA whose medical con- information regarding the suicide attempt, whilst also sequences were not so severe. Diagnosis was conducted considering that the in situ evaluation was limited by the according to DSM-IV-TR criteria [32]. Psychometric patient’s condition. assessments included: Statistics ∙ The validated Spanish-language version of Beck’s Bivariate and multivariate analyses were executed. First, a Hopelessness Scale (BHS) [33, 34] is composed of 20 descriptive analysis of all variables as percentages, means, items that can be defined as true or false, evaluating and standard deviations was conducted. To compare the scope of negative expectations about the immedi- patients admitted in ICU with other MSSA patients, odds ate and long-term future. The items that indicate hope- ratio with 95% confidence intervals were used to analyse lessness score 1 point, while those that do not indicate the relationship between binary variables. Bonferroni cor- it score 0 points. The number of points measure the rection for multiples testing was used in variables found severity of hopelessness: 0–3 is minimum or normal, statistically significant at bi-variate analysis, in order to 4–8 is mild, 9–14 is moderate and 15–20 is severe. minimize the type I error. Finally, logistic regression anal- ∙ The validated Spanish-language version of Barratt’s yses were conducted using the variables that remained Impulsiveness Scale (BIS-11) [35] is composed of statistically significant after the Bonferroni correction. 30 self-report items scored between 0 to 4 (range of In order to avoid co-linearity related variables were not total score 0–120), with cognitive, motor and non- included in the multivariate analyses. The dependent vari- planning impulsiveness subscales. able was need of ICU (0 = non-ICU and 1 = ICU). A condi- ∙ The validated Spanish-language version of Beck’s tional entrance method was used to select variables in the Suicidal Intent Scale (SIS) [36, 37] is composed of 15 model. All statistical hypotheses were two-sided and con- items, with the first eight items measuring objective ducted with an alpha of 0.05. All analyses were performed aspects of suicide intent (including isolation, time, act- using the SPSS version 20. ing to get help, and suicide note) and the last seven items measuring patients’ self-reports of intent (such Results as alleged purpose, expectations of fatality, and attitude The sample included 168 patients with a mean age of toward dying) It is rated by summing up the scores 45 (SD = 17.21) years. Males were less prevalent than on each item (varying from 0 to 2), and the final score women (47.6%, n = 80), with 38% (n = 64) only achieving Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 Page 5 of 10 elementary education and almost a quarter of the sample the sample and 41% (n = 65) met criteria for an Axis I (20%, n = 34) living alone. Physical abuse was reported by and Axis II diagnosis. 13.7% (n = 23), while 7.1% (n = 12) had a history of sex- With regards to the features of their MSSA, 36.3% ual abuse during their childhood/adolescence. Stressful used violent suicide means (i.e., jumping from heights, life events were reported by 92% (n = 154) the year prior hanging, stabbing, burns and cuts). The different types the MSSA, with most of them reporting serious ongo- of suicide methods are depicted in Fig. 2. ing interpersonal difficulties (73.8%, n = 124) while 32.1% The majority of them only used one method (62.5%, (n = 54) reported work-related problems. Physical ill- n = 105), 31% (n = 52) combined two, and the rest used nesses before the attempt were present in 56.5% (n = 95) three or more methods (6.6%, n = 11). Alcohol was of the sample, the majority of which were cardiovascular present in 26.2% (n = 44) and 37.6% (n = 61) reported diseases. drug use before the attempt. While 43.5% (n = 73) MSSA were initially admitted to the Emergency Room reported that they had previously planned the attempt, (69.6% to the Medical Unit and 30.4% to the Surgi- 40.5% (n = 68) answered they had considered suicide cal Unit) and later referred to: 1) Intensive Care Units less than 3 h before the attempt. Differences in social- (56.0%); 2) Internal Medicine Hospitalization (28%); 3) demographic and clinical variables between groups are Orthopaedics / Trauma Units (10.7%); and, 4) Burn Units depicted in Table 2. (3%). Mean length of hospital stay was 23.68 (DT = 41.14) Higher educational level, history of previous psychi- days. After hospitalization, most patients were dis- atric disorders and of previous suicide attempts were charged to home (61.9%), but 29.8% required psychiatric more frequent among those admitted to ICU. After admission and 6.0% needed to be referred to a rehabilita- Bonferroni’s correction, individual history of psychiat- tion hospital. ric disorder and type of current suicidal method of the With respect to their psychiatric history, 90.5% MSSA remained statistically significant. (n = 152) of the subjects had a previous psychiatric No statistically significant differences between ICU disorder, 62.5% (n = 105) had at least one prior sui- and non-ICU attempters were found when comparing cide attempt and 42.3% (n = 71) of the sample required the mean scores of the BIS-11 (motor, non-planning temporary hospital admission after a previous suicide and cognitive subscales as well as the global score), the attempt. The majority (98.8%) of the sample currently SIS (conception, preparation, precautions and commu- met diagnostic criteria for at least one mental disor- nication subscales, and global scores) and the Beck’s der: affective disorders (41.9%), personality disorders Hopelessness scale (Table 3). (41.9%) and substance use disorders (36.9%). Concur- After multivariate analysis, MSSA needing intensive rent mental disorders were present in 43% (n = 72) of and specialized care less frequently used self-poisoning Fig. 2 Type of suicide method Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 Page 6 of 10 Table 2 Differences in socio-demographic and clinical variables Socio-demographic variables ICU MSSArs (n = 99) Other MSSArs (n = 69) Statistics Qualitative variables n (%) n (%) OR 95% CI Sex (male) 48 (48.5%) 32 (46.4%) 1.09 0.59–2.01 Immigrant 13 (13.3%) 9 (13.2%) 1.00 0.4–2.50 Living alone 19 (19.2%) 15 (21.7%) 0.86 0.4–1.83 High educational qualifications 65 (66.3%) 35 (50.7%) 1.91 1.02–3.60 Active working status:  - Unemployed 15 (16%) 6 (8.8%) 1.88 0.62–5.65 - Disability/work leave/retired 51 (54.3%) 41 (60.3%) 0.93 0.46–1.88 - Active 28 (29.8%) 21 (30.9%) Reference Reference Physical and/or sexual abuse (Childhood / adolescence) 19(21.1%) 10 (15.4%) 1.47 0.63–3.42 Stressful life events the year prior to the ISA 89 (90%) 65 (94%) 0.55 0.16–1.82 Quantitative variables Mean (SD) Mean (SD) Age (years) 44.42(16.9) 47.80 (17.59) 0.99 0.97–1.01 Clinical variables Personal mental health history 95 (96%) 55 (79.7%) 6.05 1.89–19.28 Family mental health history 59 (62.8%) 39 (59.1%) 1.17 0.61–2.22 Chronic medical condition 48 (48.5%) 41 (59.4%) 0.64 0.65–1.20 Acute medical condition 8 (8.1%) 9 (13%) 0.59 0.21–1.60 Discharge Further hospitalization 36 (36.4%) 28 (40.6%) 0.58 0.45–1.57 Inpatient treatment in prior 12 monthsa 30 (30.3%) 16 (23.2%) 1.44 0.71–2.91 Outpatient treatment in prior 12 monthsa 72 (72.7%) 43 (62.3%) 1.61 0.84–3.11 Current mental disorders-IV-TR Diagnoses Substance use disorder 35 (35.4%) 27 (39.1%) 0.85 0.45–1.61 Mild cognitive disorder 10 (10.1%) 2 (2.9%) 3.76 0.80–17.75 Psychotic disorder 13 (13.1%) 13 (18.8%) 0.65 0.28–1.51 Affective disorder 38 (38.4%) 31 (44.9%) 0.76 0.41–1.42 Personality disorder 44 (44.4%) 26 (37.7%) 1.27 0.68–2.38 Adjustment disorder 29 (29.3%) 20 (29%) 1.04 0.52–2.06 Quantitative variables Mean (SD) Mean (SD) Length of hospital stay (days) 27.57 (32.39) 18.10 (50.9) 1.01 0.99–1.02 a Psychiatric treatment; OR Odds ration, CI Confidence Interval, MSSArs Medically serious suicide attempters, ISA Index Suicide Attempt, ICU Intensive Care Units and cuts but were more likely to have a life history of Patients in our sample spent more time hospitalized, mental disorders (see Table 4). more frequently reported recent stressful life events and had higher rates of previous suicide attempts and more Discussion frequently reported non-planned suicide attempts. Dis- This is the first study conducted in Spain on MSSA using cordances with other studies could be related to our a highly restrictive definition of a nearly lethal suicide more restrictive definition of the MSSA. Given the high attempt. Notably, the definition of MSSA in our study rate of previous suicide attempts, our sample could be extended from 24 to 48 h the minimum a patient had to expected to have a high risk of dying by suicide, because remain hospitalized after the suicide attempt [4, 6–11], so as Probert-Lindström’s study shows, having previously they could be more accurately conceptualized as nearly attempted suicide is a risk factor for death by suicide lethal behaviours (closer to deaths by suicide). In fact, in even decades later [39]. our study mean hospital stay was 23.68 days thus con- Despite the fact that most MSSA studies assume they firming the severe medical consequences of the attempt. are a homogenous group, some authors have found Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 Page 7 of 10 Table 3 Differences in past and current suicide behaviour ICU MSSArs (n = 99) n (%) Other MSSArs (n = 69) n (%) Statistics OR IC 95% Family history of suicide behaviour 26 (25.5%) 20 (32.8%) 0.76 0.98–1.51 Previous suicide attempts 69 (69.7%) 37 (53.6%) 1.99 1.05–3.77 Current serious suicide attempt Violent means 39 (39.4%) 22 (31.9%) 1.39 0.73–2.65 Medication overdose 70 (70.7%) 43 (62.3%) 1.46 0.76–2.80 Poisoning 2 (2%) 12 (17.4%) 0.10 0.02–0.45 Jumping 28 (28.3%) 11 (15.9%) 2.08 0.95–4.53 * * Hanging 2 (2%) 0 (0%) Cuts 3 (3%) 11 (15.9%) 0.17 0.04–0.62 Stabbing 2 (2%) 2 (2.9%) 0.69 0.10–5.03 * * Burns 5 (5.1%) 0 (0%) Drug use 32 (32.3%) 20 (29%) 1.17 0.60–2.29 MSSArs Medically serious suicide attempters, ICU Intensive Care Unit * Statistical comparison tests were not performed due to low n in cross table cells Table 4 Multivariate analysis: logistic regression to higher costs both from a human and financial point of Variables Exp(B) Wald Sig Exp(B) (IC 95%) view. Poisoning 8.403 6.965 0.008 (1.73–40.83) Cuts 5.893 6.555 0.010 (1.52–22.91) Comparison of our sample with other studies on MSSA Previous psychiat‑ 0.274 4.097 0.043 (0.08–0.96) No great differences were found in comparison with pre- ric disorder vious studies on MSSA concerning prevalence of mental Constant 1.665 0.671 0.413 disorders (especially affective disorders) and main suicide Hosmer and Lemeshow test X2 = 0.55; p = 0.46 method (medication overdose). When comparing the pro- files of MSSA, women (52.4%) were slightly less represented than Beautrais’ research studies [4, 11], but higher than in distinctive patterns based on clinical [26] or suicidologi- others [42]. Deaths by suicide are said to be clearly more cal features [22]. Although to date few studies have spe- frequent among men while non-severe suicide attempts are cifically analysed MSSA admitted to an ICU [27, 40], we more frequent among women [43]. MSSA would be in the decided to divide the MSSA sample into two groups as medium of a continuum of gender-related suicidal behav- those in intensive care treatment could be categorized as iours as they are almost equally frequent in both sexes. aborted suicides. In fact, MSSArs admitted to ICU are Almost all patients met criteria for mental disorders more critically ill as they need to recover from life-threat- (98.8%), findings that are similar to those reported in ening conditions. other studies on MSSA [4, 6–9, 11, 44]. Affective disor- Hospitalization in an Intensive Care Unit was consid- ders were also the most frequent diagnosis in our sample ered a strong enough criterion to classify MSSA accord- [11, 20, 22, 45, 46] ing to their severity as patients admitted to this type of A large number of MSSA in our sample (66.7%) had unit are in a more serious and life-threatening condi- at least one previous suicide attempt. Our figures were tion. A sensibility analysis determining (other) different higher compared to other studies [27]. Rapeli and col- scenarios for medically serious suicide attempters, using leagues, when focusing on “aborted suicides”, reported other criteria to assess the seriousness of the attempt that 59% did not have prior suicide attempts [26]. such as the score in the Lethality Rating Scale [41], could The most frequent suicide method was medication be considered in future studies. overdose (67.3%), followed by jumping from heights MSSArs who needed intensive care spent more time (23.2%). The results for self-poisoning were similar to in hospital (27.57 days), compared to those admitted to other studies but prevalence of jumping was higher than other medical units (18.10 days). Although this differ- that reported by other studies: 18.6% [18], 14% [19] and ence did not reach statistical significance, which may be 16.7% [21]. Self-immolations amounted to 3% (n = 5). due to the small sample size, ICU-admitted MSSA lead Prevalence of this rare condition was higher than in Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 Page 8 of 10 other studies conducted in Western societies [21, 47], Both patients admitted to ICU and those admitted but lower than others [17]. Studies conducted in India to other medical and surgical units presented simi- have registered the highest prevalence of self-immolation lar SIS scores. Conversely, Rapeli’s study found higher 10% (n = 10), especially among women, a fact that can be scores on the suicide intentionality subscale amongst related to certain specific sociocultural factors [23, 24]. the attempted suicides of higher lethality [26], though it Very few studies on MSSA specifically inquire into the cannot be assumed that the higher lethality group were combination of different suicide methods. Only one study of sufficient medical severity to require ICU admission. conducted in a 13–34 years-old sample found that 5% of This being the case, the differences observed could have MSSA were the result of combining several lethal means resulted from the complex relationship between lethal- (i.e.: ingestion, cutting and hanging) [48]. One third of ity and intentionality, because the medical severity of an our sample chose more than one method. The most fre- attempt (“objective” lethality) can be independent of the quent combination was medication overdose and drug patient’s intention to die by suicide (“subjective” lethal- use, with alcohol being the most frequent drug of choice. ity). In this regard, some studies have found a relation Alcohol would help individuals feel more disinhibited to between them [24, 50], while others have not been able attempt suicide [48, 49]. to confirm it [51]. In our sample, the overall BIS average score was 26.52, Other authors refer to some variables modulating the much lower than that identified previously by Giner et al., relationship between intentionality and lethality, as is where the average scores were higher (between 62.5 and the case of the subject’s prior knowledge about the lethal 63.3), but similar for the three comparison groups: low potential of the method employed. While the expecta- lethality suicide attempts, serious suicide attempts and tions of death have been associated with a higher risk of violent suicide attempts [22]. They did not find differ- suicide, some authors note their low predictive value [52]. ences in the Hopelessness Scale between the low lethality Patients needing ICU admission were less likely to have SA, serious SA and violent SA subgroups [22], although chosen poisoning and cutting as their suicide method the average score was similar to our study. and were more likely to have had prior mental health problems, compared to those subjects admitted to other medical units. Attempters admitted to ICU more fre- Comparing MSSA admitted to ICU with other MSSA quently reported a history of prior mental disorders but not admitted to ICU only Beautrais [6–8] reported that patients with MSSA Subjects with higher educational level were more likely to were more likely to have a prior history of affective dis- need admission to ICU after their MSSA. Although there orders compared to controls and to those who had died are few studies focusing on MSSA needing admission to by suicide. ICU, Beautrais, in a 5-year follow-up study, found that subsequent suicide attempts were more frequent among Limitations patients with a higher educational level [2]. This finding The main limitations of this study are: a) its cross-sec- suggests that individuals with a higher educational level tional design that limits the knowledge of risk and pro- may have more skills to prepare and carry out a more tective factors related to MSSA; b) the sample size, severe lethal attempt. However, other researchers had especially in the subsample analysis; c) the fact that diag- previously found an association between lower educa- noses were not obtained after a structured interview; tional levels and MSSA [7, 18, 21, 46] and others failed and, d) the lack of more qualitative and phenomenologi- to find any relationship [6, 19]. Therefore, more insight is cal information with respect to MSSA. needed to ascertain the relationship between socio-edu- The lack of a structured diagnostic interview might cational level and serious suicidal behaviour. have influenced the results as there may be a moderate Current suicide attempt medical severity in our correlation between diagnoses conducted with and with- study was not related to the presence of a prior physi- out those types of instruments [53, 54]. However, individ- cal illness. In fact, no differences in this regard were uals requiring hospitalization after an MSSA usually have found between MSSA admitted to ICU and MSSA not serious injuries related to the suicide attempt limiting the admitted to ICU. History of previous suicide attempts feasibility to carry out a long semi-structured diagnostic were more frequent among MSSArs admitted to ICU interview psychometric assessment. compared to those admitted to other medical and sur- gical units. Although the differences did not remain Conclusions statistically significant after Bonferroni correction, it Despite its limitations, data on highly severe MSSA need- is known to be a risk factor that remains even decades ing intensive and specialized care treatment (admis- after the index attempt [39]. sion in ICU) reported in this study may help improve Quesada‑Franco et al. BMC Psychiatry (2022) 22:805 Page 9 of 10 strategies aimed at preventing future suicides. In situ de Catalunya (UIC), Barcelona, Spain. 7 Ace Alzheimer Center Barcelona, Uni‑ versitat Internacional de Catalunya, Barcelona, Spain. 8 Networking Research evaluation of patients after an MSSA may provide a val- Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos uable insight into the factors and reasons behind their III, Madrid, Spain. 9 Department of Psychiatry, University Hospital Jimenez Diaz behaviour. New ways of exploring the mental states lead- Foundation, Madrid, Spain. 10 Department of Psychiatry, University Hospital Rey Juan Carlos, Mostoles, Spain. 11 Department of Psychiatry, General Hospital ing to severe attempts should be incorporated in future of Villalba, Madrid, Spain. 12 Department of Psychiatry, University Hospital research. Infanta Elena, Valdemoro, Spain. 13 Department of Psychiatry, Madrid Autono‑ Preventing MSSA should be considered a public health mous University, Madrid, Spain. 14 CIBERSAM (Centro de Investigacion en Salud Mental), Carlos III Institute of Health, Madrid, Spain. 15 UniversidadCatolica del priority in order to reduce the negative impact on the Maule, Talca, Chile. 16 Department of Psychiatry, Centre Hospitalier Universitaire patient’s wellbeing and also to lessen the healthcare sys- de Nîmes, Nimes, France. 17 Department of Psychiatry, Hospital Clinic, CIBER‑ tem’s expenditure on this type of suicidal behaviours. SAM, Universitat de Barcelona, Barcelona, Spain. Findings from longitudinal studies on nearly lethal sui- Received: 28 July 2022 Accepted: 25 November 2022 cide attempts may enrich the conclusions from this study. Qualitative studies may also contribute to a wider com- prehension of the phenomenon. References 1. World Health Organization. Suicide Worldwide in. Global Health Esti‑ Abbreviations mates; Licence: CC BY-NC-SA 3.0 IGO; World Health Organization: Geneva. MSSA: Medically serious suicide attempts; MSSArs: Medically serious suicide Switzerland. 2019;2021:1–4. attempters; ICU: Intensive Care Units; SA: Suicide attempt; Index: Suicide 2. Beautrais AL. Further suicidal behaviour among medically serious suicide Attempt (ISA). attempters. Suicide Life Threat Behav. 2004;34(1):1–11. https://​doi.​org/​10.​ 1521/​suli.​34.1.​1.​27772. Acknowledgements 3. Levi-Belz Y, Gvion Y, Horesh N, Apter P. 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