The Heterogeneity of Suicide Attempters: An Analysis of Single- and Repeat-Suicide Attempters Among People in Custody

• Date: 01 August 2021
• Published date: 01 August 2021
• DOI: 10.1177/0093854820983853
• Author: Bryce E. Stoliker
• Subject Matter: Articles

CRIMINAL JUSTICE AND BEHAVIOR, 2021, Vol. 48, No. 8, August 2021, 1127 –1147.

DOI: https://doi.org/10.1177/0093854820983853

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© 2020 International Association for Correctional and Forensic Psychology

1127

THE HETEROGENEITY OF SUICIDE

ATTEMPTERS

An Analysis of Single- and Repeat-Suicide Attempters

Among People in Custody

BRYCE E. STOLIKER

Simon Fraser University

Suicide attempters represent a heterogeneous group, whereby repeat-suicide attempters possess a differing risk profile com-

pared with single-suicide attempters. Using cross-sectional data from a nationally representative sample of 18,185 people in

custody in the United States, the current study compared repeat-suicide attempters (n = 1,549) to single-suicide attempters

(n = 1,146), and compared single- and repeat-suicide attempters to suicide ideators (n = 1,741), on a range of correlates.

Multiple suicide attempts were more commonly reported than a single attempt, especially among women. Several factors

differentiated repeat-suicide attempters from single-suicide attempters, with men and women exhibiting some similarities and

differences in correlates of repeat- versus single-suicide attempts. Several factors also differentiated single- and repeat-sui-

cide attempters from suicide ideators. Overall, repeat-suicide attempters exhibited greater vulnerability to respond to stress

through means of suicide as compared with single-suicide attempters. Discussion emphasizes the importance of acknowledg-

ing the heterogeneity of suicide attempters.

Keywords: repeat-suicide attempters; single-suicide attempters; suicidal ideation; prison; ideation-to-action

INTRODUCTION

A history of attempted suicide is a robust risk factor for subsequent suicide attempts

(Bille-Brahe & Jessen, 1994; Groholt & Ekeberg, 2009; Kapur et al., 2006; Owens et al.,

2002; Scoliers et al., 2009; Wang & Mortensen, 2006), with the probability of death by

suicide increasing with the number of attempts (Leon et al., 1990; Scoliers et al., 2009). In

light of this, it is generally accepted that suicide attempters are a heterogeneous group,

whereby repeat-suicide attempters (i.e., two or more attempts) are clinically distinct from

single-suicide attempters (i.e., one attempt only), with differing levels of psychopathology

AUTHOR’S NOTE: I would like to recognize the contributions of Dr. Simon Verdun-Jones (Professor

Emeritus, School of Criminology, Simon Fraser University), Dr. Martin Bouchard (Professor, School of

Criminology, Simon Fraser University), and Dr. Adam Vaughan (Assistant Professor, Criminal Justice, Texas

State University) who provided invaluable advice throughout various stages of this project. Correspondence

concerning this article should be addressed to Bryce E. Stoliker, School of Criminology, Simon Fraser

University, Saywell Hall Room 10120, Burnaby, British Columbia, Canada V5A 1S6; e-mail: bryces@sfu.ca.

983853CJBXXX10.1177/0093854820983853Criminal Justice and BehaviorStoliker / The Heterogeneity of Suicide Attempters

research-article2020

1128 CRIMINAL JUSTICE AND BEHAVIOR

and sociodemographic risk (see Hakansson et al., 2011; Mendez-Bustos et al., 2013; Monnin

et al., 2012; Pennel et al., 2018; Smith et al., 2014). Despite this understanding, repeat-

suicide attempters have not been adequately studied (Mendez-Bustos et al., 2013), espe-

cially in the context of incarcerated populations. While research on repeat-suicide attempters

has gained momentum in recent years (see Mendez-Bustos et al., 2013), and some research-

ers have examined the nature of repeated suicide attempts among people in custody (e.g.,

see Chapman et al., 2005; Hakansson et al., 2011; Smith et al., 2014), knowledge remains

limited on if, and how, repeat-suicide attempters differ from single-suicide attempters

among individuals who are incarcerated. Lack of knowledge in this regard is primarily

driven by the fact that suicide attempters are too often studied as a homogeneous group,

which is evident in both community- and prison-based research (see Mendez-Bustos et al.,

2013; Monnin et al., 2012; see also Favril & O’Connor, 2021; Favril et al., 2020). To that

end, the characterization of single- and repeat-suicide attempters is an important research

effort as these groups may exhibit differing risk profiles and, therefore, empirical evidence

could help inform risk assessment and treatment strategies to more effectively target and

address behavioral risk—especially risk for repetitive suicidal behavior (Mendez-Bustos

et al., 2013). This initiative is particularly relevant for incarcerated populations, as people

in custody exhibit elevated levels of suicidal thoughts, attempts, and completions as com-

pared with the general public (see Carson & Cowhig, 2020; Centers for Disease Control and

Prevention, 2020; Dye, 2010, 2011; Fazel et al., 2011; Jenkins et al., 2005).

THEORETICAL AND EMPIRICAL BACKGROUND

The stress-diathesis model of suicide (Mann, 2003) suggests that suicidal behavior is the

result of the interaction between stressful life experiences, along with an individual’s pre-

disposed vulnerability to respond to stress through means of suicide. Such vulnerability

might be elevated and more persistent among repeat-suicide attempters (Mendez-Bustos

et al., 2013). Indeed, data from several studies show that psychopathology is more complex

and severe among repeat-suicide attempters as compared with single-suicide attempters (for

review, see Mendez-Bustos et al., 2013; see also Monnin et al., 2012). For instance, repeat-

suicide attempters are more likely to meet criteria for depression (Andover et al., 2007; da

Silva Cais et al., 2009; Dougherty et al., 2004; Gibb et al., 2009), anxiety and anxiety dis-

orders (Dougherty et al., 2004; Lopez-Castroman et al., 2011; Monnin et al., 2012; Pagura

et al., 2008; Rudd et al., 2004), psychotic disorder(s) (Forman et al., 2004; Monnin et al.,

2012; Osváth et al., 2003), personality disorders (Osváth et al., 2003), and substance use

issues/disorders (Lopez-Castroman et al., 2011; Monnin et al., 2012; Osváth et al., 2003;

Wang & Mortensen, 2006). In terms of other relevant psychological factors, studies also

show that feelings of hopelessness (Forman et al., 2004; Kaslow et al., 2006) and psychiat-

ric comorbidity (Milos et al., 2004; Monnin et al., 2012; Pagura et al., 2008) are associated

with repeated suicide attempts. In accordance to the stress-diathesis model of suicide (Mann,

2003), research has also shown that exposure to stressful life events increases risk of repeti-

tive suicidal behavior (see Bradvik & Berglund, 2002; Kudo et al., 2010; Wong et al., 2008).

Specifically, repeat-suicide attempters are more likely than single-suicide attempters to

have histories of sexual abuse (Vajda & Steinbeck, 2000) and traumatic life events in child-

hood and adolescence (Forman et al., 2004; Kaslow et al., 2006; Pagura et al., 2008), as

well as have a chronic illness (Vajda & Steinbeck, 2000).