Research

JAMA Psychiatry | Original Investigation

National Trends in Suicide Attempts Among Adults

in the United States
Mark Olfson, MD, MPH; Carlos Blanco, MD, PhD; Melanie Wall, PhD; Shang-Min Liu, MS; Tulshi D. Saha, PhD;
Roger P. Pickering, MS; Bridget F. Grant, PhD

Editorial
IMPORTANCE A recent increase in suicide in the United States has raised public and clinical
interest in determining whether a coincident national increase in suicide attempts has
occurred and in characterizing trends in suicide attempts among sociodemographic and
clinical groups.

OBJECTIVE To describe trends in recent suicide attempts in the United States.

DESIGN, SETTING, AND PARTICIPANTS Data came from the 2004-2005 wave 2 National
Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and the 2012-2013
NESARC-III. These nationally representative surveys asked identical questions to 69 341
adults, 21 years and older, concerning the occurrence and timing of suicide attempts. Risk
differences adjusted for age, sex, and race/ethnicity (ARDs) assessed trends from the
2004-2005 to 2012-2013 surveys in suicide attempts across sociodemographic and
psychiatric disorder strata. Additive interactions tests compared the magnitude of trends in
prevalence of suicide attempts across levels of sociodemographic and psychiatric disorder
groups. The analyses were performed from February 8, 2017, through May 31, 2017.

MAIN OUTCOMES AND MEASURES Self-reported attempted suicide in the 3 years before the
interview.

RESULTS With use of data from the 69 341 participants (42.8% men and 57.2% women; mean
[SD] age, 48.1 [17.2] years), the weighted percentage of US adults making a recent suicide
attempt increased from 0.62% in 2004-2005 (221 of 34 629) to 0.79% in 2012-2013 (305 of
34 712; ARD, 0.17%; 95% CI, 0.01%-0.33%; P = .04). In both surveys, most adults with recent
suicide attempts were female (2004-2005, 60.17%; 2012-2013, 60.94%) and younger than
50 years (2004-2005, 84.75%; 2012-2013, 80.38%). The ARD for suicide attempts was
significantly larger among adults aged 21 to 34 years (0.48%; 95% CI, 0.09% to 0.87%) than
among adults 65 years and older (0.06%; 95% CI, −0.02% to 0.14%; interaction P = .04). The
ARD for suicide attempts was also significantly larger among adults with no more than a high
school education (0.49%; 95% CI, 0.18% to 0.80%) than among college graduates (0.03%;
Author Affiliations: Department of
95% CI, −0.17% to 0.23%; interaction P = .003); the ARD was also significantly larger among Psychiatry, College of Physicians and
adults with antisocial personality disorder (2.16% [95% CI, 0.61% to 3.71%] vs 0.07% [95% Surgeons, Columbia University, New
CI, −0.09% to 0.23%]; interaction P = .01), a history of violent behavior (1.04% [95% CI, York, New York (Olfson, Wall, Liu);
The New York State Psychiatric
0.35% to 1.73%] vs 0.00% [95% CI, −0.12% to 0.12%]; interaction P = .003), or a history of Institute, Columbia University, New
anxiety (1.43% [95% CI, 0.47% to 2.39%] vs 0.18% [95% CI, 0.04% to 0.32%]; interaction York, New York (Olfson, Wall, Liu);
P = .01) or depressive (0.99% [95% CI, −0.09% to 2.07%] vs −0.08% [95% CI, −0.20% to Division of Epidemiology, Services,
and Prevention Research, National
0.04%]; interaction P = .05) disorders than among adults without these conditions.
Institute on Drug Abuse, Rockville,
Maryland (Blanco); Division of
CONCLUSIONS AND RELEVANCE A recent overall increase in suicide attempts among adults in Biometry and Epidemiology, National
the United States has disproportionately affected younger adults with less formal education Institute on Alcohol Abuse and
Alcoholism, Bethesda, Maryland
and those with antisocial personality disorder, anxiety disorders, depressive disorders, and a (Saha, Pickering, Grant).
history of violence.
Corresponding Author: Mark Olfson,
MD, MPH, The New York State
Psychiatric Institute, Columbia
University, 1051 Riverside Dr,
JAMA Psychiatry. doi:10.1001/jamapsychiatry.2017.2582 New York, NY 10032
Published online September 13, 2017. (mo49@cumc.columbia.edu).

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 Research Original Investigation
P
reventing suicide is a leading public health 1 and
research2 priority. However, despite policy and clini-
cal initiatives aimed at reducing suicide, the rate of sui-
cide in the United States increased by approximately 2% per
year from 2006 to 2014.3 One recognized approach to prevent-
ing suicide involves improving the identification and treat-
ment of individuals at high risk, including those who plan or
attempt suicide.4
Suicide attempts are the most powerful known risk fac-
tor for completed suicide.5-7 During the first year after a sui-
cide attempt, the risk for completed suicide varies from 0.8%
to 3.0% for men and from 0.3% to 1.9% for women.6,8-10 In a
Swedish study,8 the rate of suicide among individuals in the
year after a suicide attempt was nearly 100-fold higher than
the corresponding suicide rate among age- and sex-matched
community control individuals. By 10 years, 5% to 10% of
adults making serious suicide attempts have completed
suicide.9-12 Because 15% to 25% of adults who die by suicide
have received treatment for a suicide attempt within the past
year,11,13,14 a substantial proportion of suicide deaths are po-
tentially subject to prior intervention that could be identified
with a suicide attempt.
Suicide attempts are important clinical events. They are a
major source of distress, morbidity, and economic burden. Most
adults who make suicide attempts have anxiety or mood dis-
orders and many have substance use disorders.15 In addition,
approximately 18% of individuals who attempt suicide make
a second attempt during the following year.16 In 2013, the total
annual estimated economic burden of suicide attempts in the
United States exceeded $8 billion.17
Population-based surveillance of suicide attempts could
help to assess progress in efforts to reduce suicidal behavior.
Several prior reports18-21 have characterized trends in delib-
erate self-harm events among individuals presenting for emer-
gency medical or mental health care. A limitation of these re-
ports is that they provide no information about self-harm
events that do not result in use of health care services. As a
result, relatively little is known about the underlying epide-
miology of suicide attempts and how it may have changed in
recent years. According to the National Longitudinal Alcohol
Epidemiologic Survey and National Epidemiologic Survey on
Alcohol and Related Conditions (NESARC), the lifetime preva-
lence of suicide attempts among US adults 18 years and older
remained unchanged from 1991 through 1992 to 2001 through
2002 at 2.4%.18 However, an analysis of the National Comor-
bidity Surveys15 revealed that the proportion of adults in the
United States who made a suicide attempt in the past year was
0.4% in 1990 through 1992 and 0.6% in 2001 through 2003.
More recently, the rate of past year suicide attempts was re-
ported as 0.5% among adults according to the 2008-2009 Na-
tional Survey on Drug Use and Health.22
Despite an increase from 2004 to 2014 in the US annual
suicide rate from 11.0 to 13.0 per 100 000 population,3,23
whether a corresponding coincident increase in suicide at-
tempts has occurred remains unknown. If an increase has oc-
curred, a characterization of which groups are at high and in-
creasing risk would help focus prevention and early
intervention initiatives. Therefore, the present report exam-
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National Trends in Suicide Attempts Among Adults in the United States
Key Points
Questions Has a national increase in suicide attempts occurred in
the United States in the decade since wave 2 of the National
Epidemiologic Survey on Alcohol and Related Conditions?
Finding In this national epidemiologic survey of 69 341 US adults,
the percentage making a recent suicide attempt increased from
0.62% in 2004 through 2005 to 0.79% in 2012 through 2013. The
adjusted risk differences for suicide attempts were significantly
larger among adults aged 21 to 34 years than among adults aged
65 years or older; adults with no more than a high school
education than among college graduates; and adults with
antisocial personality disorder, a history of violent behavior,
anxiety disorders, or depressive disorders than among adults
without these conditions.
Meaning A recent overall increase in suicide attempts among US
adults has disproportionately affected younger adults with less
formal education and those with antisocial personality disorder,
anxiety disorders, depressive disorders, and a history of violence.
ines trends in recent suicide attempts among nationally rep-
resentative general population samples collected from 2004
to 2005 and from 2012 to 2013. Because mental disorders24 and
socioeconomic disadvantage25 have been hypothesized to con-
tribute to the risk for suicide attempts, we sought to identify
whether recent trends in suicide attempt risk have differen-
tially affected subgroups with common mental disorders that
are often a focus of clinical efforts to reduce suicide risk. Be-
cause an economic downturn occurred during the period un-
der study, we also assessed whether adults with markers of so-
cioeconomic disadvantage, including lower levels of
educational attainment and lower family income, experi-
enced a disproportionate increase in suicide attempt risk dur-
ing this period.
Methods
Sources of Data
The wave 2 NESARC (2004-2005) and NESARC-III (2012-
2013) were separate nationally representative face-to-face in-
terview surveys of 34 653 and 36 309 adults, respectively, re-
siding in households and group quarters (eg, boarding and
group homes) that were conducted by the National Institute
on Alcoholism and Alcohol Abuse.26,27 Multistage probability
sampling was used to randomly select respondents. First, pri-
mary sampling units, which consisted of individual counties
or groups of contiguous counties, were selected. Next, sec-
ondary sampling units, which were groups of census-defined
blocks, were selected. In the third stage, households in the
sampled secondary sampling units were selected. This sample
involved random selection of eligible adults in sampled house-
holds. The analytic sample was restricted to all persons 21 years
and older. The 69 341 adult study participants included 34 629
in the 2004-2005 cohort and 34 712 in the 2012-2013 cohort.
The institutional review boards of the National Institutes of
Health and Westat approved the study protocols. All partici-
pants provided electronic informed consent.
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 National Trends in Suicide Attempts Among Adults in the United States
The overall survey response rate for the wave 2 NESARC
was 70.2%.27 For NESARC-III, the household screener re-
sponse rate was 72.0% with a person-level response rate of
84.0% to yield an overall response of 60.1%, comparable to
rates for other current US surveys.28,29 The samples were
weighted to adjust for nonresponse at the household and per-
son levels, selection of 1 person per household, and over-
sampling of young adults and Hispanic and African American
individuals. After weighting, the data were adjusted to be rep-
resentative of the US population for variables that included re-
gion, age, sex, and race/ethnicity based on the Decennial Cen-
sus and American Community Survey.30
Assessments
Sociodemographic measures included age, sex, race/
ethnicity, marital status, educational attainment, family in-
come, and current employment by self-report. The Alcohol Use
Disorder and Associated Disabilities Interview Schedule–
DSM-IV version (AUDADIS-IV) was used in NESARC,31 and the
AU DA D I S DS M - 5 ve r s i o n ( AU DA D I S - 5 ) w a s u s e d i n
NESARC-III.32 Past-year substance use disorders (alcohol use
disorders and drug use disorders, excluding nicotine depen-
dence), past-year anxiety disorders (panic disorder, general-
ized anxiety disorder, and social phobia), past-year depres-
sive disorders (major depressive disorders and dysthymic
disorder), and lifetime personality disorders (borderline, an-
tisocial, and schizotypal disorders) were assessed by struc-
tured diagnostic interviews. Test-retest reliability of AU-
DADIS-IV is good to excellent for substance use disorders
(κ = 0.51-0.74) and fair to good for other psychiatric disorders
(κ = 0.40-0.67),33-36 whereas reliability of the AUDADIS-5 is
good to excellent for substance use disorders (κ = 0.50-0.85)
and fair to good for other psychiatric disorders (κ = 0.35-0.54).37
A series of questions were also asked of respondents to
evaluate whether they had ever engaged in violence, includ-
ing starting a lot of fights, forcing a person to have sex against
their will, swapping blows with a partner, using a weapon in a
fight, hitting a person so hard that they required medical care,
physically hurting another person on purpose, or robbing or
mugging an individual.38 To evaluate suicide attempts, re-
spondents were first asked if they had ever attempted suicide
(“In your entire life, did you ever attempt suicide?”). Those who
responded affirmatively were asked their age at the first and
most recent times that they attempted suicide. Individuals who
indicated that their most recent attempt was within 3 years of
their current age were defined to have made a recent suicide
attempt. A history of suicide attempts was defined as report-
ing that the first suicide attempt occurred more than 3 years
before their current age.
Statistical Analysis
Proportions of 2012-2013 respondents with recent suicide at-
tempts were computed overall and stratified by demographic
and clinical subgroups. Because suicide attempt risk varies by
age, sex, and race/ethnicity,15 multivariable analyses were con-
trolled for these respondent characteristics. Because sociode-
mographic characteristics (educational attainment, marital sta-
tus, employment, and family income) were conceptualized as
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Original Investigation Research
being potentially in the causal pathway of trends in suicide at-
tempts, the multivariable analyses were not controlled for these
variables.
We used χ2 tests to evaluate group differences in demo-
graphic and clinical characteristics of the 2004-2005 and 2012-
2013 respondents with recent suicide attempts. Proportions
of individuals with a suicide attempt within the past 3 years
were then compared between the 2 surveys. Risk differences
adjusted for age, sex, and race/ethnicity (ARDs) assessed as-
sociations between the survey periods (2004-2005 vs 2012-
2013) and the risk for a recent suicide attempt. Adjusted risk
differences were obtained from SUDAAN (version 11.0; RTI In-
ternational) software using the predicted marginal approach
that back transforms the estimates from the logistic regres-
sion to the probability scale.39 The independent variable of in-
terest was the survey period effect, with the 2004-2005 sur-
vey as reference. Separate adjusted regression models using
the average marginal prediction approach39 tested whether the
ARDs significantly varied across different levels of each strati-
fication variable (additive interactions).40 All statistical analy-
ses were performed with SAS (SAS Institute; version 9.4) or
SUDAAN (version 11.0; RTI International) software to accom-
modate the complex sample design and weighting of obser-
vations.
Results
Correlates of Recent Suicide Attempt
Among the total sample of 69 341 study participants, 42.8%
were men, 57.2% were women, and the mean [SD] age was 48.1
[17.2] years. In the 2012-2013 survey, women (0.92%) were
more likely than men (0.64%) to have made a recent suicide
attempt (Table 1). In adjusted analyses, recent suicide at-
tempts were also significantly correlated with younger adults
(adjusted odds ratio [AOR], 12.65; 95% CI, 6.91-23.18); being
widowed, separated, or divorced rather than married or co-
habiting (AOR, 4.09; 95% CI, 2.68-6.24); lower educational at-
tainment (AOR, 4.05; 95% CI, 2.45-6.70); current unemploy-
ment (AOR, 3.37; 95% CI, 2.50-4.55); and a lower level of family
income (AOR, 5.71; 95% CI, 3.43-9.50). Each of the mental dis-
orders, especially borderline (AOR, 13.55; 95% CI, 10.29-
17.85), schizotypal (AOR, 7.12; 95% CI, 5.44-9.33), and antiso-
cial personality disorders (AOR, 6.67; 4.45-10.02), and a prior
suicide attempt (AOR, 23.54; 95% CI, 16.46-33.67) were strongly
associated with the risk for a recent suicide attempt.
Characteristics of Adults Reporting Recent Suicide Attempts
Adults with recent suicide attempts in both surveys were pre-
dominantly female (60.17% and 60.94%), white (67.89% and
68.92%), and not currently employed (58.30% and 59.37%).
Mental disorders were common. Approximately one-half of
adults with recent suicide attempts reported having made a
prior suicide attempt. In both surveys, nearly two-thirds of
those with recent suicide attempts had borderline personal-
ity disorder. Compared with adults from the 2004-2005 sur-
vey who had recently attempted suicide, those in the 2012-
2013 survey were younger (21 to 34 years of age, 49.98% vs
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 Research Original Investigation National Trends in Suicide Attempts Among Adults in the United States

with suicide attempts was significantly larger in the 2004-

Table 1. Recent US Suicide Attempt Prevalence and AORs of Recent
Suicide Attempts by Sociodemographic and Clinical Characteristicsa 2005 survey (43.24%) than in 2012-2013 survey (30.40%;
P = .02). In relation to their 2004-2005 counterparts, the adults
Suicide
Attempt, with suicide attempts in the 2012-2013 survey were also sig-
Weighted nificantly less likely to have an anxiety (45.36% vs 60.45%) or
Sample %
Characteristic (n = 34 712) AOR (95% CI) substance use disorder (49.15% vs 61.28%) (Table 2).
Sex
Men 0.64 1 [Reference] Stratified Trends in the Prevalence
Women 0.92 1.52 (1.14-2.00) of Recent Suicide Attempts
Age, y During the study period, the percentage of US adults who re-
21-34 1.48 12.65 (6.91-23.18) ported making a recent suicide attempt increased from 0.62%
35-49 0.87 7.24 (3.90-13.45) in 2004-2005 to 0.79% in 2012-2013 (ARD, 0.17%; 95% CI,
50-64 0.48 3.84 (1.92-7.67) 0.01%-0.33%; P = .04) (Table 3). In adjusted trends analyses,
≥65 0.13 1 [Reference]
significant risk differences in recent suicide attempts were ob-
served among adults aged 21 to 34 years (ARD, 0.48%; 95% CI,
Race/ethnicity
0.09%-0.87%; P = .02), non-Hispanic white (ARD, 0.24%; 95%
Non-Hispanic white 0.81 1 [Reference]
CI, 0.04%-0.44%; P = .02) and black (ARD, 0.28%; 95% CI,
Non-Hispanic black 0.75 0.77 (0.57-1.05)
0.01%-0.55%; P = .04) individuals, and adults with no more
Hispanic 0.75 0.71 (0.50-1.00)
than a high school education (ARD, 0.49%; 95% CI, 0.18%-
Other 0.70 0.71 (0.38-1.32)
0.80%; P < .002).
Marital status
We also tested whether the change across surveys in the
Married or cohabiting 0.43 1 [Reference]
percentages of adults who reported recent suicide attempts dif-
Widowed, separated, or 1.25 4.09 (2.68-6.24)
divorced
fered across strata (adjusted additive interaction P values). As
Never married 1.42 2.19 (1.47-3.26) an example, we considered whether the ARD for men (0.13%;
Educational attainment,
95% CI, −0.07% to 0.33%) was significantly different from that
highest grade for women (0.21%; 95% CI, 95% CI, −0.02% to 0.44%) (Table 3).
High school 1.01 4.05 (2.45-6.70) In these analyses, the ARD in suicide attempts was signifi-
Some college 0.97 2.99 (1.82-4.91) cantly larger for adults aged 21 to 34 years (0.48%; 95% CI,
College graduate 0.31 1 [Reference] 0.09% to 0.87%) than for 65 years or older (0.06%; 95% CI,
Present employment −0.02% to 0.14%). The increase in risk was also significantly
Employed 0.54 1 [Reference] larger for adults with no more than a high school education
Unemployed 1.15 3.37 (2.50-4.55) (0.49%; 95% CI, 0.18% to 0.80%) than for those who had gradu-
Annual family income, $ ated from college (0.03%; 95% CI, −0.17% to 0.23%).
0-19 999 1.67 5.71 (3.43-9.50) After controlling for potentially confounding demo-
20 000-34 999 0.83 2.80 (1.51-5.18) graphic characteristics, we found significant increases in re-
35 000-69 999 0.59 1.89 (1.11-3.23) cent suicide attempts among adults with a history of violent
≥70 000 0.32 1 [Reference]
behavior, antisocial personality disorder, substance use dis-
orders, depression disorders, and anxiety disorders and among
Past-year mental disorders
adults without anxiety disorders or substance use disorders
Depression 3.82 8.51 (6.50-11.15)
(Table 4). In adjusted models, the increase in suicide attempt
Anxiety 3.95 7.86 (5.66-10.91)
risk was significantly greater among adults with anxiety dis-
Substance use 2.58 4.52 (3.42-5.98)
orders (1.43% [95% CI, 0.47% to 2.39%] vs 0.18% [95% CI,
Borderline personalityb 4.57 13.55 (10.29-17.85)
0.04% to 0.32%]; interaction P = .01), depressive disorders
Antisocial personalityb 4.18 6.67 (4.45-10.02)
(0.99% [95% CI, −0.09% to 2.07%] vs −0.08% [95% CI, −0.20%
Schizotypal personalityb 4.28 7.12 (5.44-9.33)
to 0.04%]; interaction P = .05), antisocial personality disor-
Lifetime violent behavior 2.74 6.64 (5.03-8.76)
der (2.16% [95% CI, 0.61% to 3.71%] vs 0.07% [95% CI, −0.09%
Prior suicide attempt 9.17 23.54 (16.46-33.67) to 0.23%]; interaction P = .01), and a history of violent behav-
Abbreviation: AOR, adjusted odds ratio. ior (1.04% [95% CI, 0.35% to 1.73%] vs 0.00% [95% CI, −0.12%
a
Data from the National Epidemiologic Survey on Alcohol and Related to 0.12%]; interaction P = .003) than among adults without
Conditions III (2012-2013). Results are based on weighted sampling and these conditions (Table 4).
adjusted for age, sex, and race/ethnicity. Recent suicide attempts are in past
3 years, including year of the survey.
b
Indicates lifetime disorder.
Discussion
41.51%) and more likely have a depressive disorder (53.93% vs Between the 2004-2005 and 2012-2013 surveys, recent sui-
25.52%), antisocial personality disorder (22.90% vs 13.13%), cide attempts became increasingly prevalent in the United
and a history of violent behavior (55.05% vs 43.52%). In a post States. The increase was particularly evident among young
hoc analysis, the proportion of respondents aged 35 to 49 years adults and those with no more than a high school education.

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 National Trends in Suicide Attempts Among Adults in the United States Original Investigation Research

Table 2. Characteristics of US Adults With Recent Suicide Attemptsa

Survey Cohort With Suicide Attempt,
Weighted Sample %
2004-2005 2012-2013
Characteristics (n = 221) (n = 305) χ2 Test P Value
Sex
Men 39.83 39.06
0.02 .89
Women 60.17 60.94
Age, y
21-34 41.51 49.98
35-49 43.24 30.40
2.08 .10
50-64 13.30 16.57
≥65 1.95 3.05
Race/ethnicity
Non-Hispanic white 67.89 68.92
Non-Hispanic black 7.93 10.94
0.76 .52
Hispanic 14.47 13.71
Other 9.70 6.42
Marital status
Married or cohabiting 43.72 33.15
Widowed, separated, or divorced 27.56 32.86 1.50 .23
Never married 28.72 33.99
Educational attainment, highest grade
High school 35.99 42.93
Some college 51.52 45.25 0.88 .42
College graduate 12.49 11.81
Present employment
Employed 41.70 40.63
0.04 .84
Unemployed 58.30 59.37
Annual family income, $
0-19 999 41.75 46.20
20 000-34 999 19.11 20.19
0.32 .81
35 000-69 999 23.75 20.77
≥70 000 15.39 12.85
Past-year mental disorders
Depression 25.52 53.93 29.48 <.001
Anxiety 60.45 45.36 6.39 .01
a
Data are from the wave 2 National
Substance use 61.28 49.15 4.57 .03 Epidemiologic Survey on Alcohol
Borderline personalityb 62.95 65.09 0.16 .69 and Related Conditions (NESARC)
(2004-2005) and NESARC-III
Antisocial personalityb 13.13 22.90 4.45 .04
(2012-2013). Results are based on
Schizotypal personalityb 30.36 33.34 0.31 .58 weighted sampling. Recent suicide
Lifetime violent behavior 43.52 55.05 4.54 .04 attempts are in past 3 years,
including year of the survey.
Prior suicide attempt 52.47 53.65 0.04 .84 b
Indicates lifetime disorder.

The increase was also larger among individuals with antiso-
cial personality disorder, a history of violent behavior, anxiety
disorders, and depressive disorders than among those with-
out these conditions. In the 2012-2013 survey, the highest-
risk group consisted of adults with prior suicide attempts. Other
high-risk groups included persons with borderline, schizo-
typal, or antisocial personality disorders and those with anxi-
ety and depressive disorders. These findings highlight an in-
creasing prevalence of suicide attempts and underscore the
prominent role of mental disorders, including personality dis-
orders, in risks for suicide attempts at the population level.
The upward trend in suicide attempts coincided with a na-
tional increase in suicide, although the 2 trends varied across
demographic groups. For example, the risk difference in sui-
cide attempts was greatest among adults aged 21 to 34 years,
whereas the risk differences in suicide during this period were
largest among adults aged 45 to 64 years.3 Although demo-
graphic differences in the risk profiles for suicide attempts and

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 Research Original Investigation National Trends in Suicide Attempts Among Adults in the United States

Table 3. Percentage of Adults in the United States With a Recent Suicide Attempt, Total and Stratified by Sociodemographic Characteristicsa
No. of Observations Recent Suicide Attempt
by Survey Cohort by Survey Cohort, % Adjusted Risk Adjusted Additive
Adjusted Risk Difference, % Difference Interaction
Characteristic 2004-2005 2012-2013 2004-2005 2012-2013 (95% CI)b P Valueb P Valueb
Total 34 629 34 712 0.62 0.79 0.17 (0.01 to 0.33) .04 NA
Sex
Men 14 552 15 122 0.52 0.64 0.13 (−0.07 to 0.33) .18 .61
Women 20 077 19 590 0.72 0.92 0.21 (−0.02 to 0.44) .09 Reference
Age, y
21-34 8005 10 158 1.02 1.48 0.48 (0.09 to 0.87) .02 Reference
35-49 11 044 9816 0.87 0.87 0.01 (−0.30 to 0.32) .96 .06
50-64 8403 8932 0.34 0.48 0.13 (−0.10 to 0.36) .25 .14
≥65 7177 5806 0.06 0.13 0.06 (−0.02 to 0.14) .15 .04
Race/ethnicity
Non-Hispanic white 20 153 18 601 0.60 0.81 0.24 (0.04 to 0.44) .02 Reference
Non-Hispanic black 6580 7350 0.45 0.75 0.28 (0.01 to 0.55) .04 .83
Hispanic 6351 6556 0.78 0.75 −0.01 (−0.32 to 0.30) .93 .17
Other 1545 2205 0.94 0.70 −0.25 (−0.88 to 0.38) .44 .14
Marital status
Married or cohabiting 18 863 16 635 0.43 0.43 0.01 (−0.17 to 0.19) .90 Reference
Widowed, separated, 9149 9421 0.91 1.25 0.44 (−0.15 to 1.03) .15 .18
or divorced
Never married 6617 8656 1.04 1.42 0.30 (−0.03 to 0.63) .09 .16
Educational attainment,
highest grade
High school 13 691 12 765 0.59 1.01 0.49 (0.18 to 0.80) .002 .003
Some college 12 037 13 040 0.92 0.97 0.08 (−0.18 to 0.34) .56 .58
College graduate 8901 8907 0.29 0.31 0.03 (−0.17 to 0.23) .74 Reference
Employment status
Employed 21 884 20 341 0.40 0.54 0.13 (−0.01 to 0.27) .08 .49
Unemployed 12 745 14 371 1.04 1.15 −0.03 (−0.48 to 0.42) .89 Reference
Annual family income, $
0-19 999 8342 9863 1.33 1.67 0.19 (−0.36 to 0.74) .49 .56
20 000-34 999 6988 7571 0.63 0.83 0.19 (−0.26 to 0.64) .41 .50
35 000-69 999 10 642 9280 0.46 0.59 0.16 (−0.10 to 0.42) .23 .38
≥70 000 8657 7998 0.33 0.32 0.02 (−0.18 to 0.22) .81 Reference
a
Data are from the wave 2 National Epidemiologic Survey on Alcohol and 3 years, including year of the survey.
Related Conditions (NESARC) (2004-2005) and NESARC-III (2012-2013). b
Adjusted for age, sex, and race/ethnicity.
Results are based on weighted sampling. Recent suicide attempts are in past

completion exist, including age and sex, several clinical risk
factors are similar, including depression, anxiety, and sub-
stance use disorders41,42; genetic risk factors may also be
similar.43 Population-based suicide attempt data comple-
ment traditional suicide mortality as a measure of the na-
tional population burden of self-injurious behavior.
The risk for suicide attempts was elevated among adults
with high levels of economic insecurity, including those who
were unemployed and had low family income and low edu-
cational attainment.44,45 During the period when the NESARC-
III survey data were collected and the 3 prior years, the monthly
US unemployment rate (7.7%-10.1%) was considerably higher
than the unemployment rate period during and preceding col-
lection of the wave 2 NESARC survey (4.9%-6.3%).46 Young
adults and those with less formal education, 2 groups who ex-
perienced disproportionately large increases in suicide at-
tempt risk during this period, may have been particularly vul-
nerable to economic stress and psychological distress
associated with deterioration in the US economy.
Prior studies examining associations between economic
factors, most commonly unemployment, and suicide47,48
and suicidal behavior49,50 have yielded mixed results across
countries and periods. Contextual factors, such as the gen-
erosity of safety net programs and personal savings rates,
likely account for much of this variation. In the present
study, adults with no more than a high school educational
level experienced a significantly larger increase in suicide
attempt risk than did adults who had graduated from col-
lege. This pattern suggests that these socioeconomically
disadvantaged individuals have borne a disproportionate

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 National Trends in Suicide Attempts Among Adults in the United States Original Investigation Research

Table 4. Percentage of Adults in the United States, 2004-2005 and 2012-2013, With a Recent Suicide Attempt, Total and Stratified
by Clinical Characteristicsa
No. of Observations by Recent Suicide Attempt by
Survey Cohort Survey Cohort, %
Mental Disorders in Adjusted Risk Adjusted Risk Adjusted Additive
Past Year 2004-2005 2012-2013 2004-2005 2012-2013 Difference, % (95% CI)b Difference P Valueb Interaction P Valueb
Total 34 629 34 712 0.62 0.79 0.17 (0.01 to 0.33) .04 NA
Depression
Present 2179 4099 2.68 3.82 0.99 (−0.09 to 2.07) .07 .05
Absent 32 450 30 613 0.49 0.41 −0.08 (−0.20 to 0.04) .22 Reference
Anxiety
Present 5510 3095 2.50 3.95 1.43 (0.47 to 2.39) .004 .01
Absent 29 119 31 617 0.29 0.47 0.18 (0.04 to 0.32) .006 Reference
Substance use
Present 6895 5401 1.81 2.58 0.55 (0.00 to 1.10) .05 .18
Absent 27 734 29 311 0.31 0.47 0.17 (0.03 to 0.31) .01 Reference
Borderline personality
disorderc
Present 2226 4058 6.69 4.57 −1.49 (−2.82 to −0.16) .03 .02
Absent 32 403 30 654 0.25 0.31 0.07 (−0.03 to 0.17) .21 Reference
Antisocial personality
disorderc
Present 1222 1524 2.13 4.18 2.16 (0.61 to 3.71) .007 .01
Absent 33 407 33 188 0.56 0.63 0.07 (−0.09 to 0.23) .35 Reference
Schizotypal personality
disorderc
Present 1531 2287 4.82 4.28 −0.41 (−2.00 to 1.18) .62 .52
Absent 33 098 32 425 0.45 0.56 0.11 (−0.03 to 0.25) .12 Reference
Violent behavior
Present 5429 5555 1.77 2.74 1.04 (0.35 to 1.73) .003 .003
Absent 29 200 29 157 0.42 0.42 0.00 (−0.12 to 0.12) .97 Reference
Prior suicide attempts
Present 1135 1719 10.84 9.17 −0.86 (−3.47 to 1.75) .52 .49
Absent 33 494 32 993 0.31 0.38 0.08 (−0.04 to 0.20) .19 Reference
a b
Data are from the wave 2 National Epidemiologic Survey on Alcohol and Adjusted for age, sex, and race/ethnicity.
Related Conditions (NESARC) (2004-2005) and NESARC-III (2012-2013). c
Indicates lifetime disorder.
Results are based on weighted sampling. Recent suicide attempts are in past
3 years, including year of the survey.

share of risk associated with the recent increase in suicide
attempts. However, because trends in suicide attempt risk
did not significantly vary across family income level or cur-
rent employment status, the recent recession did not seem
to influence suicide attempt risk in a predictable manner.
Consistent with prior research on emergency department–
treated deliberate self-harm events,18-21 recent suicide at-
tempts in this nationally representative sample of community-
dwelling adults were more common among women than men
and decreased with age. During the study period, the risk for
attempting suicide increased for young adults but did not sig-
nificantly increase for middle-aged or older adults. Together
with a recently reported national increase in the prevalence
of major depressive episodes among young adults,51 the in-
crease in risk for suicide attempts among young adults sig-
nals the importance of focusing on early detection of mental
health risk factors of suicidal behavior and treatment initia-
tives in this age group.
In both surveys, nearly two-thirds of adults with recent
suicide attempts had borderline personality disorder. This
high proportion may in part reflect the broad spectrum of
self-harm behaviors captured by the suicide attempt survey
item. Adults with borderline personality disorder have been
previously found to be at increased risk for completed
suicide.52 Because borderline personality disorder is charac-
terized by “recurrent suicidal behavior, gestures, or
threats,”53(p663) the strong correlation with suicidal behavior
is not surprising. A high prevalence of suicide attempts com-
bined with a tendency of some front-line clinicians to hold
negative views of borderline personality disorder54 under-
scores the importance of developing clinician training pro-
grams to help improve the management of deliberate self-
harm among patients with this condition.55 One encouraging
finding is that although most adults in the 2012-2013 survey
who had recent suicide attempts had borderline personality
disorder, the risk of attempted suicide among adults with
borderline personality disorder significantly decreased dur-
ing the study period. This trend may reflect increasing
access to more effective interventions for impulsivity in bor-
derline personality disorder. A survey of US psychiatric resi-

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 Research Original Investigation National Trends in Suicide Attempts Among Adults in the United States

dency programs revealed that 40.8% of programs currently
offer training in dialectical behavior therapy for borderline
personality disorder.56
A substantial and increasing proportion of adults who at-
tempted suicide met criteria for antisocial personality disor-
der. Although individuals with antisocial personality disor-
der are often perceived as having a high risk for violent behavior
toward others,57 they also commonly have a history of sui-
cide attempts.58 In prospective research, adults with antiso-
cial personality disorder and other externalizing psychopatho-
logic features have been reported to be at increased risk for
attempting suicide.59 Antisocial behaviors may also be asso-
ciated with increased risk for suicide.60 Although suicidal be-
haviors are typically considered in relation to depression and
other internalizing disorders, associations between antiso-
cial personality disorder and attempted suicide challenge this
stereotype. Future clinical research is needed to clarify the so-
cial context, triggers, and motivation for suicidal behavior in
this population.
ence of changes in the effectiveness of life-saving emer-
gency management of suicide attempts. Fourth, the
NESARC does not survey homeless or incarcerated adults,
who have relatively high rates of suicidal behavior,61,62 nor
does it include an assessment of schizophrenia. Fifth, minor
modifications between DSM-IV and DSM-5 criteria may
have biased results of trends in suicide attempts among
adults meeting criteria for the various mental disorders,63
although these modifications do not influence the overall
trends in suicide attempts or associations with sociodemo-
graphic characteristics. Sixth, some important characteris-
tics, such as residence in a rural or urban location,64 were
not available. Seventh, to increase sample size, a 3-year
rather than a 1-year period was used to define recent suicide
attempts; this would be expected to attenuate associations
with past-year mental disorders. Finally, the surveys did not
collect data from individuals who died of suicide. This lack
may have led to an underestimation of suicide attempts in
each survey.65

Limitations
In interpreting these findings, several limitations apply.
First, the NESARC surveys rely on retrospective self-reports.
Responses may be affected by inaccuracies in the recall of
the timing of events or the intention of self-harm events.
However, we have no reason to believe that recall inaccura-
cies differentially affected the 2 surveys or that memory of
suicide attempts is easily perturbed by recall bias. Second,
suicide attempts were assessed with a single survey item
that likely captured a wide range of behaviors, including
interrupted, aborted, and potentially lethal and nonlethal
attempts. Third, we have no means of assessing the influ-
Conclusions
From the 2004-2005 to the 2012-2013 surveys, a national in-
crease in recent suicide attempts occurred. Because at-
tempted suicide is the greatest known risk factor for com-
pleted suicide,6,10 reducing suicide attempts is an important
public health and clinical goal. The pattern of suicide at-
tempts supports a clinical and public health focus on younger,
socioeconomically disadvantaged adults, especially those with
a history of suicide attempts and common personality, mood,
and anxiety disorders.

ARTICLE INFORMATION
Accepted for Publication: July 4, 2017.
Published Online: September 13, 2017.
doi:10.1001/jamapsychiatry.2017.2582
Author Contributions: Ms Liu had full access to all
the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data
analysis.
Study concept and design: Olfson, Blanco, Wall.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Olfson, Wall, Liu.
Critical revision of the manuscript for important
intellectual content: Olfson, Blanco, Wall, Saha,
Pickering, Grant.
Statistical analysis: Wall, Liu, Saha, Pickering.
Obtained funding: Grant.
Administrative, technical, or material support:
Pickering, Grant.
Study supervision: Olfson, Wall.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by
grants DA019606 and MH 107452 from the
National Institutes of Health (NIH) and The New
York State Psychiatric Institute (Drs Olfson and
Wall). The National Epidemiologic Survey on
Alcohol and Related Conditions was funded, in part,
by the Intramural Program, National Institute on
Alcohol Abuse and Alcoholism, NIH (Dr Grant).
Role of the Funder/Sponsor: The sponsors had no
additional role in the design and conduct of the
study; collection, management, analysis, and
interpretation of the data; and preparation, review,
or approval of the manuscript; and decision to
submit the manuscript for publication.
Disclaimer: The opinions expressed in this article
are the author's own and do not reflect the view of
the NIH, the Department of Health and Human
Services, or the US government.
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