Psychiatry Research 177 (2010) 55–59

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Psychiatry Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Suicide attempts at the time of first admission and during early course schizophrenia:
A population based study
Stephen Z. Levine ⁎, Shelly Bakst, Jonathan Rabinowitz
Bar Ilan University, Israel

a r t i c l e i n f o a b s t r a c t

Article history: This article examined suicide attempt rates at first psychiatric hospitalization and risk factors for subsequent
Received 21 September 2009 suicide attempts over the early course of schizophrenia in national population-based data. Data were
Received in revised form 5 January 2010 extracted from the National Psychiatric Hospitalization Case Registry of the State of Israel that contains all
Accepted 28 February 2010
first psychiatric admissions with schizophrenia 1989-1992 and were followed up to 1996 (N = 2293).
Attempted suicide rates were: 8.5% (n = 196) at the time of first psychiatric hospitalization and 6.6%
Keywords:
Epidemiology
(n = 151) over the follow-up period of 4 to 7 years. Of those with a suicide attempt at first admission, 31.6%
Suicidality (n = 62) made a subsequent suicide attempt during the follow-up period (OR = 10.44, 95% CIs = 7.22 to
Risk 15.09). Risk profiles were derived using recursive partitioning to predict sub-groups at risk of a subsequent
Premorbid suicide attempt. Those characterized by an attempt at the time of first admission were college educated,
Education female and not married (45.9% (17/37), OR = 13.46, 95% CIs = 6.89 to 26.3). The risk profiles together
Sex correctly classified 90.7% (137/151) of subsequent suicide attempts. Suicide attempts at first admission and
premorbid years of education have long-term prognostic utility and risk profiles are available.
© 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Suicide is the leading cause of premature death among people with
schizophrenia (Caldwell and Gottesman, 1990; Drake et al., 1984).
Reports based on samples of persons with chronic schizophrenia,
meta-analysis and mortality records have estimated that completed
suicide over the lifetime of persons with schizophrenia ranges from
6% to 13% (Brown, 1997; Caldwell and Gottesman, 1990; Harkavy-
Friedman et al., 1999; Inskip et al., 1998; Meltzer, 2002; Palmer et al.,
2005). During early episode, that figure drops to between 3% (Clarke
et al., 2006; Kuo et al., 2005; Palmer et al., 2005) and 6% in most
(Fenton, 2000; Jarbin and Von Knorring, 2004) but not all (Wester-
meyer et al., 1991) studies. Suicide risk among patients with
schizophrenia and related disorders has been estimated to be 20
times higher than control cases (Nordentoft et al., 2004). Suicide
attempts are estimated to occur in among 25% to 50% of people
with schizophrenia (Meltzer, 2001; Pompili et al., 2007). Meta-
analysis indicates that a prior history of suicide attempts is a
risk factor of future suicide (Hawton et al., 2005). Together this
highlights the relevance of understanding suicide and suicide
attempts in schizophrenia.
The period early in the course of schizophrenia is associated with
elevated risk of suicide, particularly among those with a history of
suicide attempts (Drake et al., 2006; Harkavy-Friedman et al., 1999;
⁎ Corresponding author. Bar-Ilan University, Ramat Gan, Israel, 52900.
E-mail address: levins@biu.ac.il (S.Z. Levine).
Hawton et al., 2005; Palmer et al., 2005; Scocco et al., 2008; Siris,
2001; Tandon, 2005; Westermeyer et al., 1991). Risk is also higher
among those with histories of multiple psychiatric hospital admis-
sions and discharges (Haw et al., 2005; Kuo et al., 2005; Qin, 2005).
Indeed psychiatric hospitalization appears to be associated with two
peaks of suicidal behaviors, risk that occur before first admission
(Addington et al., 2002, 2004; Ho, 2003; Qin, 2005), and shortly after
discharge (Craig et al., 2006; Pompili et al., 2005; Roy, 1982). For
instance, population-based research has indicated that the highest
risk period was after the first admission, during the first 5 days of in-
patient care and particularly immediately after discharge (Rossau and
Mortensen, 1997). This highlights the need for early episode studies
aimed towards suicide prevention programs (Addington et al., 2004;
Melle et al., 2006; Power et al., 2003).
Most schizophrenia suicide research focuses on chronic rather
than early illness despite the heightened risk associated with the early
period of illness (Clarke et al., 2006; Palmer et al., 2005). The follow-
up of early episode patients in suicide research is rare, particularly in
epidemiological cohorts (Craig et al., 2006; Harkavy-Friedman et al.,
1999). One study, the Suffolk County Mental Health Project
epidemiological study of early onset psychosis, documents suicide
related behaviors in early psychosis. Predictors of suicide ideation and
attempts over the 4 years following onset included: prior suicide
ideation or attempt, severe depressive symptoms at index admission,
lifetime substance abuse, and a younger age of hospitalization (b28,
attempts only) (Bakst et al., 2009). The suicide attempt rate at onset
was 9.3% at baseline of whom 40.8% made a subsequent attempt
during the 4 year follow-up period (Bakst et al., 2009). This highlights

0165-1781/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2010.02.019
56 S.Z. Levine et al. / Psychiatry Research 177 (2010) 55–59
the relevance of elevated risk of a suicide attempt in the years that
follow the onset of schizophrenia. Indeed, past case-control research
comparing living people with schizophrenia to those who completed
suicide in schizophrenia has emphasized the role of suicide attempt as
a predictor of completed suicide (Pompili et al., 2009). Also, in an
urban catchment study 10% of individuals with early episode
psychosis attempted suicide prior to presentation. Four years later,
18% made a suicide attempt and 3% completed suicide. Suicide
attempts prior to presentation related to a longer duration of
untreated psychosis (Clarke et al., 2006). This research indicates
that suicide behavior may be chronic among some attempters who
remain alive, possibly reflecting parasuicide. Clinical research into
persons with psychosis has used risk profiling to examine whether or
not a person made a suicide attempt (Mann et al., 2008). That study
showed that, for example, recent attempters were retrospectively
characterized by suicide ideation and comorbid borderline personal-
ity disorder. We are, however, unaware of national population-based
research that prospectively examines the prognostic utility of early
suicide attempts during first admission in schizophrenia on subse-
quent outcomes in an epidemiological cohort over an extensive time
period and produces risk profiles.
The current study uniquely aims to examine the correlates of
suicide attempts after first hospitalization in a national population
based epidemiological cohort. Specifically, we aim to examine (a)
incidence rates of suicide attempts at the time of first admission with
schizophrenia, (b) the extent to which suicide attempts at onset are
associated with a subsequent suicide attempt, and (c) risk factors of
suicide behaviors, extending past clinical research (Mann et al., 2008).
The current study examines key background factors that have been
shown by other research to influence the course of illness, including
sex (Caldwell and Gottesman, 1990), immigration and ethnicity
(Rabinowitz and Fennig, 2002) and premorbid years of education
(Levine and Rabinowitz, 2009).
2. Methods
2.1. Participants
2.1.1. Case registry
The Israeli National Psychiatric Case Registry is a complete listing of psychiatric
hospitalizations in Israel. For the years of the current cohort, it includes the ICD-9
admission and discharge diagnoses by an Israeli medical board-certified psychiatrist.
Diagnoses recorded in earlier ICD codes are routinely updated in the registry. All in-
patient or day hospital psychiatric admissions and discharges to either psychiatric or
non-psychiatric hospitals in Israel are legally required to be reported by the treating
facility to the registrar. Reporting is monitored by a dedicated unit of the Ministry of
Health that verifies reporting compliance, information consistency, and the complete-
ness and accuracy of the data registry. Registry diagnoses show acceptable levels of
sensitivity and specificity with research diagnoses (Weiser et al., 2005), and acceptable
reliability, as indicated by the stability of the diagnosis over time (Rabinowitz et al.,
Fig. 1. Percent attempted suicide by sex and age of first admission.
1994). Accordingly, by using the National Psychiatric Case Registry all first and
subsequent hospitalized cases of broadly defined schizophrenia were identified. These
include schizophreniform, schizoaffective, schizotypal, delusional disorders and non-
affective psychoses. These cases were hospitalized with a primary psychiatric diagnosis.
Like other registry studies (Olesen and Mortensen, 2002; Rabinowitz et al., 2006, 2007),
the last discharge diagnosis was used, and persons whose last diagnosis was other than
those mentioned above were removed. The registry also contains the treating
psychiatrist's judgment of whether a suicide attempt was made during the two
months preceding the admission. This study was approved by the local institutional
review board.
2.1.2. Population
The population consisted of all 2293 persons (n = 1444, 63% male) who were first
admitted to an Israeli psychiatric facility with a diagnosis of schizophrenia (ICD-9)
during the period between 1989 and 1992, and who maintained this diagnosis at their
last registry entry, either at admission or discharge. The cohort was followed in the
registry through 1996 for hospital admissions. Immigrants were excluded from the
study if they came to Israel after the age of 15 (see Rabinowitz and Fennig, 2002) to
preclude misclassifying persons as first admission who may have had a pre-
immigration admission. Regarding age first hospitalized, cases over 51 (n = 75) and
under 15 (n = 112) were removed. The rational for this is consistency with the ICD-9
and DSM-III-R diagnostic criteria, and follows past registry research (Rabinowitz et al.,
2007).
2.1.3. Statistical methods
For the purpose of the analysis we computed age of first hospitalization from the
date of birth and date of first hospital admission (Rabinowitz et al., 2006). To index the
first suicide attempt, we used the first psychiatric hospitalization with or without
suicide attempt within 2 months of hospital admission, coded as presence or absence of
suicide attempt. Similarly, a variable was created to indicate the presence or absence of
a subsequent suicide attempt.
There were 2911 cases with a first admission from 1989 to 1992. Cases were
removed due to missing data on years of education (n = 371), age at first admission
(n = 6), and suicide attempt (n = 13). Presence of missing values was not significantly
associated with death (23.5%, 20/85), or suicide attempt at first admission (8.7%, 47/
253). All cases that died were removed (n = 85), since it was not ascertainable as to
whether or not they completed suicide. Death was not significantly associated with
baseline suicide attempts (χ2 = 2.241, df = 1, P = .13). Regarding age first hospitalized,
cases over 51 (n = 75) and under 15 (n = 112) were removed. This left a total of 2293
cases with complete information available at first hospitalization with 4 to 7 years of
follow-up.
2.1.4. Analytic plan
The analysis consisted of two stages. First, incidence rates on aggregate and for each
sex by age of first admission were calculated. Second, to predict a subsequent suicide
attempt during follow-up and to derive risk profiles, binary logistic regression and
recursive partition modeling were used. Recursive partitioning algorithm used was the
conditional trees algorithm (Hothorn et al., 2006, 2004), implemented in the R
statistical software package. This has been previously used in schizophrenia research
(Rabinowitz et al., 2006). Recursive partitioning algorithms utilize splitting criteria that
are determined by the optimal statistical analysis. This algorithm is grounded in a
statistical theory of conditional inference procedures aimed at unbiased estimation. In
this analysis it was used to determine the cut-off points for groupings of the risk factors
(sex, age of onset, marital status, paternal country of birth, immigration status, and
years of education and presence of suicide attempt at first admission) that would show
the greatest differences between the groups on the outcome of subsequent suicide
 S.Z. Levine et al. / Psychiatry Research 177 (2010) 55–59 57

Table 1 of more formal education. Controlling for these protective factors, a first
Multivariate logistic regression modeling to predict the incidence of a suicide attempt psychiatric hospitalization with a suicide attempt was a significant
following first admission.
predictor of a subsequent suicide attempt.
Attempt rate: (6.6%, n = 151/2293) To develop risk profiles that account for contingencies among risk
% (n) P OR 95.0% CI factors we examined the data further with recursive partitioning
(Table 2). Each profile is presented with the percentage of cases with a
Sex (Female) 37 (849) .03 1.52 (1.05- 2.21)
Married 21.2 (486) .27 0.75 (0.45 1.25) subsequent attempt during the follow-up period and incidences of
Age first psychiatric hospitalization .45 accuracy. For instance, row 2 in Table 2 shows the most salient profile.
16 to 20 26.6 (610) .85 0.95 (0.60 1.52) People with this profile were females, had an attempt at first
21 to 25 25.3 (580) .48 0.82 (0.47 1.42) admission, college educated and not married. This profile had a
26 to 30 20.0 (459) .79 0.92 (0.50 1.70)
31 to 35 14.1 (323) .87 0.94 (0.45 1.98)
suicide attempt rate subsequent to first admission of 45.9% (17/37,
36 to 40 8.3 (190) .04 0.20 (0.04 0.90) OR = 13.46, 95%, CI = 6.89 to 26.3). Sensitivity was 46%, meaning that
Immigrant 18.7 (429) .76 0.92 (0.55 1.55) the probability that cases who belonged to this profile were predicted
Native born father 21.9 (503) .28 0.79 (0.52 1.21) to make a subsequent attempt was modest. Specificity was 94%
Premorbid education 23.2 (533) .01
implying that the probability of no subsequent suicide attempt was
High school attended without 17.1 (391) .04 0.56 (0.32 0.98)
graduating likely to be predicted correctly. Positive predictive power was 11%
High school completed 50.9 (1167) .03 0.64 (0.42 0.96) indicating that the probability of the predicted member of making a
Post High school studies 3.2 (73) .15 0.34 (0.08 1.49) subsequent attempt was low. Relative Improvement over Chance
BA graduation 5.6 (129) .01 0.06 (0.01 0.49) (RIOC) of 2.02 indicated increased improvement over chance levels of
First psychiatric hospitalization 196 (8.5) .00 10.96 (7.47 16.08)
suicide attempt
prediction. An advantage of the RIOC is that it takes into account the
Intercept .00 0.01 model's base rate and selection ratio, thereby allowing the assessment
of predictive efficiency in models with skewed distributions such as
suicide attempts. This indicated that although predictive accuracy was
attempt. It creates statistically significant splits among the predictor variables (i.e., the modest for other indices, this was possibly due to the low incidence at
risk factors), thereby producing contingencies between predictors.
first admission. Thus these results showed modest to strong
associations between belonging to a risk group and presence of a
3. Results suicide attempt following first admission (Table 2). The risk profiles
together correctly classified 90.7% (137/151) of subsequent suicide
Of the total 2293 patients, 196 (8.5%) attempted suicide at the time attempts.
of first admission, whereas the remaining 2097 (91.5%) did not. Fig. 1
presents the percents of those who attempted suicide at the time of 4. Discussion
first admission on aggregate and delineated by sex and age of first
hospital admission. Aggregate and male results approached, but did The current study uniquely examines suicide attempts in an entire
not meet, statistical significance. Among females results approached population based cohort over a considerable time period, focusing
statistical significance (χ2 = 10.83, df = 5, P = .06, Tau = .04). These exclusively on schizophrenia. The findings contribute to the literature
results illustrate that male suicide attempt rates peaked to 27% by providing population based data on incidence of suicide at time of
between the ages of 21 to 25. Among females attempts peaked to first and subsequent hospital admissions, data on the salience of a
26.1% between the ages of 16 to 20. Overall suicide attempts were suicide attempt at time of first admission as a risk factor for future
highest between age 16 and 20 (26.6%). During the 4 to 7 year follow- attempts and risk profiles of suicide attempts.
up period 151 (6.6%) had hospitalizations with suicide attempts and Unique risk profiles of suicide attempt based on readily ascertain-
2142 (93.4%) did not. In total 31.6% (n = 62/196) of those with an able information are available in the current study. Thus the current
attempt at first admission made a subsequent attempt (χ2 = 218.57, results provide supplementary information regarding suicide attempt
OR = 10.44, 95% CI = 7.22 to 15.09, P b .001). risk to existing risk scales (Ayer et al., 2008). The results also
supplement past clinical research that provides suicide risk profiles in
3.1. Prediction of subsequent attempt during follow-up psychosis (Mann et al., 2008). That study is extended in several ways,
including an extensive prospective follow-up period, and the use of
To examine risk factors for a suicide attempt prior to admission population-based data, thus circumventing selection bias. The
during the course of illness a binary logistic regression was conducted prevalence of initial and subsequent suicide attempts resemble past
(Table 1). Significant predictors that were protective factors of sub- epidemiological research suggests that the prevalence of subsequent
sequent attempts included being female, aged 36 to 40 and completion suicide attempts in psychosis generally is approximately 30% (Bakst

Table 2
Risk profiles of suicide attempt risk over the early course of illness.

Risk group Presence of subsequent OR 95% CI Sensitivity1 Specificity2 Positive predictive Relative Improvement
suicide attempt (%) (%) power3 (%) Over Chance4

Attempt at time of first admission

College educated and male 31% (36/116) 8.07 (5.22-12.48) 24 96 31 2.76
College educated , female & not married 45.9% (17/37) 13.46 (6.89-26.3) 46 94 11 2.02
College educated female & married 32.1% (9/28) 7.08 (3.15-15.94) 32 94 6 0.01
No attempt at time of first admission
Did not complete HS6, first hospitalized under 18, female 35.7% (5/14) 8.12 (2.69-24.53) 36 94 3 -2.44
Did not complete HS, first hospitalized over 265 4.1% (11/271) .57 (0.304-1.06) 4 93 7 -0.00
Completed HS through BA graduation, males 3.5% (32/923) .38 (0.25-0.56) 3 91 21 0.01
Completed HS through BA graduation, females 4.6% (27/583) .62 (0.40-0.95) 5 93 18 0.17

Note. All P values p b .001. Sensitivity1, the probability that an actual (outcome) observed event is predicted correctly. Specificity2- the probability that the actual non-occurrence of
an event is predicted correctly; Positive power of prediction, the probability that a prediction correctly predicted the occurrence of an outcome event RIOC 4 indexes the relative
improvement of prediction over chance using the risk profile, odds ratio is the ratio of the odds for two the risk factor and outcome. 5 (P = .07), 6 High school without graduation.
58 S.Z. Levine et al. / Psychiatry Research 177 (2010) 55–59
et al., 2009). The present study differs to the other study since no
clinical measures are available and it focuses only on schizophrenia.
The current findings suggest that more education was associated
with an increased risk of suicide, replicating recent early episode
research in psychosis (Bakst et al., 2010). One possible reason is that
persons with schizophrenia become demoralized and despondent
based on their insight into the illness (Drake and Cotton, 1986), and
that persons with more education may be more susceptible to this
given their higher levels of insight.
4.1. Limitations and conclusions
The current study is registry rather than clinically based, hence key
clinical indicators, such as presence of a suicide plan are absent from
the data. A number of social factors may influence the accuracy of the
data. For instance, it was not possible to assess out-migration, since it
was not available in our data. During the study period, however, there
were little or no changes in the health system that was hospital based,
free and equal to all (Mark et al., 1997).
The current study may have underestimated suicide attempts,
since the registry contains information pertinent to suicide prior to
hospitalization. Had clinical measures been available probably the
incidence of suicidality reported would have increased. Nonetheless,
it appears that hospitalization reflects symptom exacerbation and
thus possibly increased suicide attempts. Also past research suggests
that the likelihood of suicide behavior increases prior to psychiatric
hospitalization (Addington et al., 2002, 2004; Ho, 2003; Qin, 2005),
highlighting the relevance of these study findings.
The diagnoses used in this study are registry diagnoses that are
made by the treating psychiatrist based on signs, symptoms, and
history, and not a research diagnoses. Accordingly, concerns regarding
the validity and reliability of the diagnoses arise. Past research,
however, indicates registry and research diagnoses show considerable
correspondence and that registry diagnoses are highly stable over
time (Rabinowitz et al., 1994; Weiser et al., 2005). Also, the diagnoses
involved were at the "real world" level of applicability, reflecting a
measure of external validity and generalizibility. The current study,
however, defines schizophrenia broadly, since our data did not permit
the differentiation of different diagnoses. Thus, it is appropriate to
examine the relationship between onset and course by diagnosis in
future studies. Past epidemiological research has, however, found no
significant differences in risk between the different diagnostic groups
(Bakst et al., 2009; Craig et al., 2006; Ho, 2003).
It is noted that suicide has qualitative aspects that are not
considered in the current research. For instance, research indicates
suicide completers are younger who jump from heights (Reisch et al.,
2008). Similarly unfortunately, at present the registry contains no
information about the lethality of the suicide attempt or the methods
used. While a suicide attempt is often the reason for hospitalization,
we did not have data on the reason for psychiatric hospitalization.
Accordingly, future epidemiological research is warranted to provide
risk profiles depending on the method of suicide among people
hospitalized for a suicide attempt with schizophrenia. Future
epidemiological research is warranted to provide risk profiles
accounting for the method of suicide.
It is possible that some people attempted suicide, yet were not
hospitalized. Similarly, research indicates that males with schizophrenia
have higher rates of completed suicide as compared to females
(Caldwell and Gottesman, 1990; De Hert et al., 2001), particularly
early in the course (Kuo et al., 2005; Westermeyer et al., 1991). Men are
thought to attempt suicide with more violent or extreme methods
(Kelly et al., 2004; Pompili et al., 2005), and to die more frequently from
their suicide attempts than women. It is possible that such patients
would never have an opportunity to be examined in this study (a study
of suicide attempts at the time of hospitalization), since they would not
have lived long enough to be hospitalized. This may explain the finding
that female rather than male sex is a risk factor for subsequent suicide
attempt in this study.
In sum, the current study findings provide the first national suicide
attempt estimates over an extended period in schizophrenia. The
results suggest that suicide attempts are more common in early illness
than during follow-up (8.5% vs. 6.5%). The results show that suicide
attempts at onset and premorbid years of education have prognostic
utility in the identification of those at risk, and that suicide attempts in
illness have different antecedents for different risk groups. The
prognostic utility and generalizability of the findings require careful
testing in future prospective studies.
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