Temporal architecture of suicide: Interacting immediate and long-term action regulation with history of medically severe suicide attempt

Imminent suicide is difficult to predict. Suicide usually occurs on the first attempt. Suicide may consist of suicidal crises, with fluctuating and unpredictable risk, superimposed on long-term latent susceptibility. Risk characteristics are consistent with interacting long-term (sensitization) and short-term (impulsivity) mechanisms: sensitization to stress/trauma perceived as inescapable, or to addiction, can increase latent action-impulsivity, disinhibiting high-risk behavior including suicidal ideation and aggression. Survived medically severe suicide attempts are associated with severe morbidity and premature death. Therefore, it is necessary to identify characteristics that may predict a first attempt. We used Bayesian logistic regression and path analysis to identify direct and indirect (via suicidal ideation-worst (SSI-W)) predictors of MSSA in 28 adult survivors of MSSA and 23 symptomatically and demographically similar non-attempters (NA). SSI-W increased odds ratio (OR) for MSSA; Cumulative Adversity and action-impulsivity increased OR for MSSA independent of SSI-W. SSI-W mediated increased MSSA by aggression, alcohol use, and depression. Childhood Trauma Minimization/Denial increased MSSA directly but correlated negatively with SSI-W. MSSA required latent aggression or impulsivity combined with stress-sensitization and increased action-impulsivity. These interacting characteristics are potential targets for identification and preventive treatment of risk for suicide regardless of attempt history.