Risk factors for suicidal ideation and attempts may diverge both qualitatively and in terms of dose response. When effects of risk factors from multiple domains are concurrently examined, proximal clinical characteristics remain the most robust. All risk factors cluster into the group of repeated attempters.

Risk factors for suicide in depression inFinland: first-hospitalized patients followed up to 24 years Aaltonen KI, Isomets€ a E, Sund R, Pirkola S. Risk factors for suicide in depression in Finland: first-hospitalized patients followed up to 24 years Objective: To examine longitudinally risk factors for suicide in depression, and gender differences in risk factors and suicide methods. Method: We linked data from (i) The Finnish Hospital Discharge Register, (ii) the Census Register of Statistics Finland, and (iii) Statistics Finland's register on causes of deaths. All 56 826 first-hospitalized patients (25 188 men, 31 638 women) in Finland in 1991-2011 with a principal diagnosis of depressive disorder were followed up until death (2587 suicides) or end of the year 2014 (maximum 24 years). Results: Clinical characteristics (severe depression adjusted hazard ratio [AHR] 1.19 [95% CI 1.08-1.30]; psychotic depression AHR 1.45 [1.30-1.62]; and comorbid alcohol dependence AHR 1.26 [1.13-1.41]), male gender (AHR 2.07 [1.91-2.24]), higher socioeconomic status and living alone at first hospitalization were long-term predictors of suicide deaths. Highest risk was associated with previous suicide attempts (cumulative probability 15.4% [13.7-17.3%] in men, 8.5% [7.3-9.7%] in women). Gender differences in risk factors were modest, but in lethal methods prominent. Conclusion: Sociodemographic and clinical characteristics at first hospitalization predict suicide in the long term. Inpatients with previous suicide attempts constitute a high-risk group. Despite some gender differences in risk factors, those in lethal methods may better explain gender disparity in risk. Significant outcomes• This national study of risk factors for suicide in depression is the largest cohort study published thus far in terms of sample size and number of suicide deaths. Of 13 risk factors, male sex, previous suicide attempts, severe or psychotic depression, comorbid alcohol dependence, higher family income, and higher education predicted future suicide.• During the long-term follow-up, a substantial proportion of patients hospitalized for depression with a history of suicide attempt eventually died by suicide.• Some gender differences in risk factors for suicide in depression were found to exist. However, there are marked gender differences in lethal methods used, which more likely explain the gender disparity in risk of suicide. Limitations• The cohort comprised first-hospitalized psychiatric inpatients. Generalizability of findings pertaining to risk factors among psychiatric outpatients or primary care patients remains to be confirmed.• Some risk factors remained uninvestigated in the study.• The study is based on clinical diagnoses. Diagnostic imprecisions likely exist in assessment of severity of depression, in poor recognition of delusional hopelessness of psychotic depression, and missed diagnoses of comorbid alcohol dependence.