Risk factors for suicide reattempt: a systematic review and meta-analysis.

BACKGROUND: Suicide is one of the main external causes of death worldwide. People who have already attempted suicide are at high risk of new suicidal behavior. However, there is a lack of information on the risk factors that facilitate the appearance of reattempts. The aim of this study was to calculate the risk of suicide reattempt in the presence of suicidal history and psychosocial risk factors and to estimate the effect of each individual risk factor. METHODS: This systematic review and meta-analysis were conducted following the PRISMA-2020 guidelines. Studies on suicide reattempt that measured risk factors were searched from inception to 2022. The risk factors studied were those directly related to suicide history: history of suicide prior to the index attempt, and those that mediate the transition from suicidal ideation to attempt (alcohol or drug misuse, impulsivity, trauma, and non-suicidal self-injury). RESULTS: The initial search resulted in 11 905 articles. Of these, 34 articles were selected for this meta-analysis, jointly presenting 52 different effect sizes. The pooled effect size across the risk factors was significant (OR 2.16). Reattempt risk may be increased in presence of any of the following risk factors: previous history, active suicidal ideation, trauma, alcohol misuse, and drug misuse. However, impulsivity, and non-suicidal self-injury did not show a significant effect on reattempt. CONCLUSION: Most of the risk factors traditionally associated with suicide are also relevant when talking about suicide reattempts. Knowing the traits that define reattempters can help develop better preventive and intervention plans.

Decreased oxytocin levels related to social cognition impairment in borderline personality disorder.

INTRODUCTION: Dysfunctions in the oxytocin system have been reported in patients with borderline personality disorder (BPD). Deficits could be related to interpersonal hypersensitivity, which has been previously associated with failures in social cognition (SC) in this disorder, especially in Theory of Mind (ToM) skills. The aim of this work is to study the links between the oxytocin system and SC impairments in patients with BPD. METHOD: Plasma oxytocin levels (OXT) and protein expression of oxytocin receptors in blood mononuclear cells (OXTR) were examined in 33 patients with a diagnosis of BPD (age: M 28.85, DT = 8.83). Social cognition was assessed using the Movie for the Assessment of Social Cognition (MASC). Statistical associations between biochemical factors and different response errors in MASC were analyzed through generalized linear regression controlling for relevant clinical factors. RESULTS: Generalized linear regression showed a significant relationship between lower OXTR and overmentalization in BPD patients (OR = 0.90). CONCLUSIONS: This work supports the relationship between alterations in the oxytocin system and ToM impairments observed in BPD patients, enhancing the search for endophenotypes related to the phenotypic features of the disorder to improve current clinical knowledge and address more specific therapeutic targets.

Anxious and depressive symptoms and health-related quality of life in a cohort of people who recently attempted suicide: A network analysis.

BACKGROUND: Suicide is an international health concern with immeasurable impact from the perspective of human and social suffering. Prior suicide attempts, anxious and depressive symptoms, and relatively lower health-related quality of life (HRQoL) are among the most replicated risk factors for suicide. Our goal was to visualize the distribution of these features and their interconnections with use of a network analysis approach in individuals who recently attempted suicide. METHODS: Individuals with a recent suicide attempt were recruited from nine University Hospitals across Spain as part of the SURVIVE cohort study. Anxious and depressive symptoms, and perceived HRQoL were included in the network analysis. Network structures were estimated with the EBICglasso model. Centrality measures and bridge symptoms connecting communities were explored. Subnetworks comparing younger and older individuals, and women and men were analyzed. RESULTS: A total of 1106 individuals with a recent suicide attempt were included. Depressed mood was the symptom with the greatest influence in the overall network, followed by anxiety symptoms such as feeling nervous, worrying, restless, and having difficulties to relax. Perceived general health was associated with increased suicidal ideation in the whole sample. Older people showed a specific connection between perceived general health and depressed mood. LIMITATIONS: The cross-sectional design does not allow determination of established causality. CONCLUSIONS: Depressed mood was the core network's symptom and, therefore, an important target in the management and prevention of suicide. HRQoL had more influence on the network of older populations, in which it should be a primary focus.

Psychiatric profiles in suicidal attempters: Relationships with suicide behaviour features.

BACKGROUND: Suicide constitutes a major health concern worldwide, being a significant contributor of death, globally. The diagnosis of a mental disorder has been extensively linked to the varying forms of suicidal ideation and behaviour. The aim of our study was to identify the varying diagnostic profiles in a sample of suicide attempters. METHODS: A sample of 683 adults (71.3% females, 40.10±15.74 years) admitted at a hospital emergency department due to a suicide attempt was recruited. Latent class analysis was used to identify diagnostic profiles and logistic regression to study the relationship between comorbidity profile membership and sociodemographic and clinical variables. RESULTS: Two comorbidity profiles were identified (Class I: low comorbidity class, 71.3% of attempters; Class II: high comorbidity class, 28.7% of attempters). Class I members were featured by the diagnosis of depression and general anxiety disorder, and low comorbidity; by contrast, the high comorbidity profile was characterized by a higher probability of presenting two or more coexisting psychiatric disorders. Class II included more females, younger, with more depressive symptoms and with higher impulsivity levels. Moreover, Class II members showed more severe suicidal ideation, higher number of suicide behaviours and a greater number of previous suicide attempts (p<.01, for all the outcomes), compared to Class I members. CONCLUSIONS: Psychiatric profiles may be considered for treatment provision and personalized psychiatric treatment in suicidal attempters as well as tackle suicide risk.

Inflammatory profiles in women with eating disorder: Linking inflammatory biomarkers to clinical phenotypes.

INTRODUCTION: Eating disorders (ED) represent a group of very complex and serious diagnoses characterized by emotional dysregulation and impulsivity. New approaches are necessary to achieve effective diagnosis and treatments. Shifting biomarker research away from the constraints of diagnostic categories may effectively contribute to a dimensional differentiation across disorders according to neurobiology (e.g., inflammatory biomarkers). Thus, the aim of our study was to identify inflammatory profiles in patients with ED. METHODS: A sample of 100 women with an ED (23.4 ± 8.55 years) and 59 healthy controls (HC) (20.22 ± 4.18 years) was used. K-means cluster analysis was followed to identify inflammatory clusters considering seven blood biomarkers (iNOS, TNFα, COX2, p38, ERK, TBARS and PPARγ). Moreover, a wide assessment of clinical features was conducted. RESULTS: Two distinct clusters were identified. Cluster 1 patients were characterized by higher inflammatory levels of TNF-α, COX2, p38, and ERK, and had more restrictive anorexia diagnosis than cluster 2. Cluster 2 participants showed higher inflammatory levels of iNOS and were older than cluster 1 and controls and had lower BMI than HC. In addition, they had higher levels of bulimic symptoms than those from the cluster 1 and HC, and higher impulsivity than HC. All ED patients (regardless of cluster) showed higher ED symptoms and more trauma than HC. CONCLUSIONS: Our study revealed that inflammatory dysfunction may be linked with clinical endophenotypes in ED, one more restrictive (cluster 1) with an inflammation/oxidative endophenotype more cytokine and MAPK/ERK mediated, and the other more impulsive, with more bulimic symptoms (cluster 2) with NO free radical high output source iNOS. Trauma seems to be a vulnerability factor for both endophenotypes.

Social cognition deficits in borderline personality disorder: Clinical relevance.

Interpersonal difficulties in borderline personality disorder (BDP) have been suggested to be related to impairments in Social Cognition (SC), mainly due to deficits in Theory of Mind (ToM). However, literature is scarce and ambiguous. This work aims to study the SC impairments in BPD patients, by the specific assessment of ToM deficits, and to investigate the relationship between these SC impairments and clinical variables. 82 BPD patients with BPD and 47 control subjects were assessed with the Movie for the Assessment of Social Cognition (MASC). Clinical variables of severity, chronicity, functionality and anxious-depressive symptomatology were recorded. BPD patients had fewer correct mentalization responses and more overmentalization, undermentalization, and absence of mentalization errors than controls. Chronicity was negatively correlated with overmentalization and positively correlated with undermentalization and absence of mentalization errors. Functionality was indirectly correlated with absence of mentalization. These results confirm previous reports of alterations in SC in BPD patients. Furthermore, this study shows that SC impairments in patients with BPD are dependent on characteristics such as chronicity or degree of functionality. The different ToM profiles in patients with BPD indicate the necessity of developing variants of mentalization therapy depending on the deficits of each patient.

Neurocognitive profile associated with borderline personality disorder: building specific indices of executive function.

The objective of this work is the creation of specific indices of the different executive functions (EF).

Oxidative stress and inflammatory pathways in female eating disorders and borderline personality disorders with emotional dysregulation as linking factors with impulsivity and trauma.

BACKGROUND: Borderline personality disorder (BPD) and eating disorders (ED) are both disorders with emotional dysregulation that may share some similar biological underpinnings, leading to oxidative/inflammatory alterations. Unfortunately, to date, no studies have assessed the relationship between clinical features, inflammatory alterations and childhood trauma across these disorders. Our aim was to identify the potential common and disorder-specific inflammatory pathways and examine possible associations between these dysregulated pathways and the clinical features. METHODS: We studied a sample of 108 women (m = 27.17 years; sd = 7.64), divided into four groups: 23 patients with a restrictive ED (ED-R), 23 patients with a bingeeating/ purging ED (ED-P) and 26 patients with BPD; whereas the control group included 23 healthy subjects. Several inflammatory/oxidative parameters: tumor necrosis factor alpha (TNFα), Thiobarbituric Acid Reactive Substances (TBARS), inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX2), p38 mitogenactivated protein kinases, ERK mitogen-activated protein kinases and c-Jun NH2- terminal kinase (JNK), and some antiinflammatory antioxidant elements: glutathione peroxidase (GPx), superoxide dismutase (SOD), catalase (CAT), Kelch-like ECHassociated protein (Keap1) were determined in plasma or peripheral blood mononuclear cells. Furthermore, clinical, impulsivity, trauma and eating behavior questionnaires were administered. RESULTS: Three main inflammatory/oxidative components were extracted using principal component analysis (59.19 % of biomarker variance explained). Disorder-specific dysfunction in the inflammatory and oxidative pathways in patients with BPD and ED were revealed by means of relationships with specific principal components (p < .01). BPD patients showed higher levels of a component featured by elevated levels of JNK and lower of GPx and SOD. ED-R and impulsivity were associated with a component featured by the activation of ERK and negative influence of Keap1. The component featured by the suppression of catalase and COX2 was associated with both ED subtypes and trauma exposure. CONCLUSION: Several risk factors such as trauma, impulsivity and eating disorder symptoms were transdiagnostically associated with some inflammatory alterations regardless of diagnosis. These findings suggest that the clinical profile comprising trauma exposure and an emotional dysregulation disorder might constitute a specific endophenotype highly linked with inflammatory alterations.

Altered emotional response pattern related to complex trauma in patients with borderline personality disorder.

INTRODUCTION: This work aims to demonstrate, through the International Affective Picture System (IAPS) responses, an altered emotional pattern in borderline personality disorder (BPD) patients and to find a specific emotional response pattern by understanding their relationship with traumatic experiences and attachment bonds towards their primary caregivers. METHOD: A total of 50 BPD patients and 39 control patients were evaluated using the IAPS, and its assessment was carried out through the Self-Assessment Manikin (SAM). Paternal and maternal attachment bonds as well as traumatic experiences in BPD patients were evaluated. Statistical associations were analysed in the different variables. RESULTS: Significant differences between BPD and control patients were found in all emotional response components for pleasant, unpleasant and neutral images (p < .01), with one exception, the arousal in pleasant images. Patients' experience of traumatic experiences was positively related to scores on the happiness component of pleasant imagery (p = .057) and on the arousal component of unpleasant imagery (p = .058). Poorer maternal bonding in BPD patients was significantly related to lower scores on happiness (p < .01) and dominance (p < .05) components of pleasant imagery and all emotional response components for unpleasant imagery (p < .01). CONCLUSIONS: The results of the study confirm an impaired emotional response pattern in patients with borderline personality disorder (BPD), showing an emotional response to pleasant images similar to that of depression, while the pattern found to unpleasant images could be related to the complex trauma observed in these patients, which includes PTSD experiences such as sexual abuse and attachment trauma experiences.

Transdiagnostic Study of Impulsivity and Self-Injurious Behaviour in Unstable and Impulsive Disorders.

High comorbidity between borderline personality disorder (BPD) and eating disorders (ED) shows the necessity of developing transdiagnostic models, where impulsivity could play a relevant role in the manifestations of self-injurious behaviour.

Pathways to eating disorder care: A European multicenter study.

BACKGROUND: The aim of this study was to assess barriers and facilitators in the pathways toward specialist care for eating disorders (EDs). METHODS: Eleven ED services located in seven European countries recruited patients with an ED. Clinicians administered an adapted version of the World Health Organization "Encounter Form," a standardized tool to assess the pathways to care. The unadjusted overall time needed to access the ED unit was described using the Kaplan-Meier curve. RESULTS: Four-hundred-nine patients were recruited. The median time between the onset of the current ED episode and the access to a specialized ED care was 2 years. Most of the participants did not directly access the specialist ED unit: primary "points of access" to care were mental health professionals and general practitioners. The involvement of different health professionals in the pathway, seeking help for general psychiatric symptoms, and lack of support from family members were associated with delayed access to ED units. CONCLUSIONS: Educational programs aiming to promote early diagnosis and treatment for EDs should pay particular attention to general practitioners, in addition to mental health professionals, and family members to increase awareness of these illnesses and of their treatment initiation process.

Narcissism as a protective factor against the risk of self-harming behaviors without suicidal intention in Borderline Personality Disorder.

The spectrum of suicidal behavior is a core factor of the prognosis and care of Borderline Personality Disorder (BPD). The aim of this study is to identify possible BPD specific personality traits that could act as protective factors of nonsuicidal self-injuries (NSSI.

Antisocial traits and neuroticism as predictors of suicidal behaviour in borderline personality disorder: A retrospective study.

INTRODUCTION: The spectrum of suicidal behaviour (SB) is nuclear in the clinic and management of borderline personality disorder (BPD). The pathological personality traits of BPD intervene as risk factors for SB in confluence with other clinical and sociodemographic variables associated with BPD. The objective of this work is to evaluate the specific personality traits of BPD that are related to SB. METHODS: A cross-sectional, observational and retrospective study was carried out on a sample of 134 patients diagnosed with BPD according to DSM-5 criteria. The Millon-II, Zuckerman-Kuhlman and Barrat questionnaires were used to assess different personality parameters. Variable comparisons were made using the χ2 test and the Student's t-test. The association between variables was analysed using multivariate logistic regression. RESULTS: Statistically significant differences were observed between SB and related factors and the neuroticism-anxiety dimension in the Zuckerman-Kuhlman test. It is also significantly related to the phobic and antisocial subscale of the Millon-II. Impulsivity measured with the Zuckerman-Kuhlman and Barrat tests does not appear to be related to SB. CONCLUSIONS: The results presented raise the role of phobic, antisocial and neuroticism traits as possible personality traits of BPD related to SB, suggesting an even greater importance within the relationship between BPD and SB than that of impulsivity. Looking to the future, longitudinal studies would increase the scientific evidence for the specified findings.

Neighborhood Vulnerability and Disability in First Episode of Psychosis: A Multilevel Study.

Objective: Neighborhood socioeconomic status seems to be related to functioning in patients with first episode of psychosis (FEP). The present study aimed to assess if neighborhood vulnerability and risk of social exclusion could predict functional outcomes in people with FEP after controlling for other key variables identified in previous literature.Methods: A total of 137 patients with FEP (DSM-IV-TR criteria) and 90 controls comprised the study sample from February 2013 to May 2019. Functioning was assessed with the WHO Disability Assessment Schedule. Neighborhood vulnerability was measured using a multidimensional socioeconomic deprivation index; data for the index were collected by the Madrid City Council and based on the participant's home address. Multilevel mixed-effects regression analyses were conducted to estimate the effects of neighborhood vulnerability on functioning.Results: Our results show that FEP patients could be more vulnerable to the effects of neighborhood-level characteristics than healthy controls (B = 1,570.173; z = 3.91; P < .001). In addition, our findings suggest that higher neighborhood vulnerability is related to greater functional disability in people with FEP, after controlling for other relevant confounders (B = 1,230.332; z = 2.59; P = .010).Conclusions: These results highlight the importance of incorporating contextual factors into assessment of patients with FEP, since psychosocial difficulties observed in these patients could be partially related to the quality of neighborhood social-related resources.

Rasgos antisociales y neuroticismo como predictores de conducta suicida en trastorno límite de la personalidad: un estudio retrospectivo

Introducción: El espectro de la conducta suicida (CS) es nuclear en la clínica y el tratamiento del trastorno límite de personalidad (TLP). Los rasgos patológicos del TLP intervienen como factores de riesgo de CS en confluencia con otras variables clínicas y sociodemográficas asociadas con el TLP. El objetivo del presente trabajo consiste en evaluar los rasgos de personalidad específicos del TLP que se relacionan con la CS. Métodos: Se realiza un estudio transversal, observacional y retrospectivo, de una muestra de 134 pacientes con diagnóstico de TLP según los criterios del DSM-5. Se utilizan los cuestionarios de Millon-II, Zuckerman-Kuhlman y Barrat para valorar distintos parámetros de la personalidad. Se realizan comparaciones por variables mediante las pruebas de la x2 y de la t de Student. La asociación entre variables se analiza mediante regresión logística multivariada. Resultados: Se objetivan diferencias estadísticamente significativas entre la CS y relacionadas y la dimensión neuroticismo-ansiedad en el test de Zuckerman-Kuhlman. Asimismo se relaciona de manera significativa con la subescala fóbica y antisocial del Millon-II. La impulsividad medida con las pruebas de Zuckerman-Kuhlman y Barrat no aparece relacionada con la CS. Conclusiones: Los resultados presentados plantean el papel de los rasgos fóbicos, antisociales y del neuroticismo como posibles rasgos de personalidad del TLP relacionados con la CS. Incluso se propone una importancia mayor que el de la impulsividad dentro de la relación del TLP con la CS. De cara al futuro, estudios longitudinales permitirían aumentar la evidencia científica de los hallazgos presentados. © 2021 Asociación Colombiana de Psiquiatría. Publicado por Elsevier Espafña, S.L.U. Todos los derechos reservados.

Introduction: The spectrum of suicidal behaviour (SB) is nuclear in the clinic andmanagement of borderline personality disorder (BPD). The pathological personality traits of BPD intervene as risk factors for SB in confluence with other clinical and sociodemographic variables associated with BPD. The objective of this work is to evaluate the specific personality traits of BPD that are related to SB. Methods: A cross-sectional, observational and retrospective study was carried out on a sample of 134 patients diagnosed with BPD according to DSM-5 criteria. The Millon-II, Zuckerman-Kuhlman and Barrat questionnaires were used to assess different personality parameters. Variable comparisons were made using the test and the Student's t-test. The association between variables was analysed using multivariate logistic regression. Results: Statistically significant differences were observed between SB and related factors and the neuroticism-anxiety dimension in the Zuckerman-Kuhlman test. It is also significantly related to the phobic and antisocial subscale of the Millon-II. Impulsivity measured with the Zuckerman-Kuhlman and Barrat tests does not appear to be related to SB. Conclusions: The results presented raise the role of phobic, antisocial and neuroticism traits as possible personality traits of BPD related to SB, suggesting an even greater importance within the relationship between BPD and SB than that of impulsivity. Looking to the future, longitudinal studies would increase the scientific evidence for the specified findings. © 2021 Asociacio´n Colombiana de Psiquiatria. Published by Elsevier España, S.L.U. All rights reserved.

Lurasidone for the treatment of schizophrenia in adult and paediatric populations.

Schizophrenia is a common debilitating disorder characterized by significant impairments in how reality is perceived, combined with behavioural changes. In this review, we describe the lurasidone development programme for adult and paediatric patients. Both the pharmacokinetic and pharmacodynamic characteristics of lurasidone are revisited. In addition, pivotal clinical studies conducted on both adults and children are summarized. Several clinical cases, which demonstrate the role of lurasidone in real-world practice, are also presented. Current clinical guidelines recommend lurasidone as the first-line treatment in the acute and long-term management of schizophrenia in both adult and paediatric populations.

The Suicide Prevention and Intervention Study (SURVIVE): Study protocol for a multisite cohort study with nested randomized-controlled trials.

INTRODUCTION: Suicide is one of the leading causes of avoidable death. Gathering national data on suicidal behaviour incidence is crucial to develop evidence-based public policies. The study has two primary objectives: (1) to determine the incidence of suicide attempts in Spain and related risk factors, and (2) to analyze the efficacy of secondary prevention programmes to prevent suicide re-attempting in comparison to treatment as usual (TAU). MATERIALS AND METHODS: Multisite, coordinated, cohort study with three nested randomized controlled trials. A cohort of 2000 individuals (age >=12) with suicidal behaviour will be recruited at ten sites distributed across Spain. Assessments will be conducted within 10 days of the suicide attempt (V0-baseline visit) and after 12 months (V4-last visit) and will include clinician reported and participant reported outcomes (PROs). Between V0 and V4, PROs will be collected remotely every three months (V1, V2 and V3). Optatively, cohort participants will participate in three nested randomized-controlled-trials (RCTs) evaluating different secondary prevention interventions: Participants aged 18 years and older will be randomly allocated to: Telephone-based Management+TAU vs. TAU or iFightDepression-Survive+TAU vs. TAU. Participants aged between 12 and 18 years will be allocated to a specific intervention for youths: Self Awareness of Mental Health+TAU vs. TAU. RESULTS: This study will provide interesting data to estimate suicide attempt incidence in Spain. and will provide evidence on three. CONCLUSIONS: Evidence on three potentially efficacious interventions for individuals at high risk of suicide will be obtained, and this could improve the treatment given to these individuals. TRIAL REGISTRATION: NCT04343703.

Predictive value of the feeling of emptiness in suicidal behaviour of emotionally unstable disorders.

PURPOSE: This study investigates the feeling of emptiness in patients with borderline personality disorder (BPD) and patients with eating disorder (ED) and its relationship with suicidal behaviour and childhood traumatic events. METHODOLOGY: One hundred three BPD patients and 107 ED patients were assessed with the Feeling of Emptiness Scale (FES) and the Traumatic Experiences Questionnaire (TQ). Suicidal behaviour was assessed with a specific interview for frequency and intensity of suicidal behaviour. RESULTS: Significant differences were found between the different factors of the FES between BPD patients and ED patients. A significant relationship was observed between Factors 1 and 4 of the FES and suicidal behaviour scores in both groups. Traumatic experiences were more strongly related to Factors 1, 2 and 4 in BPD patients. CONCLUSIONS: BPD patients and ED patients show similar scores in the global construct of feeling of emptiness. However, results suggest some qualitatively difference between the nature of feeling of emptiness in BPD and in ED. As expected, suicidal behaviour is most frequently in BPD patients, and is significantly associated with Factors 1 and 4 of the FES in both groups. Therefore, feeling of emptiness could be a predictor of suicidal behaviours in patients with emotional and behavioural instability.

Executive dysfunction in eating disorders: Relationship with clinical features.

Eating disorders (ED) are severe mental disorders that may result in significant functional impairment and disability. Neuropsychological studies have consistently found impaired executive function (EF) among ED patients. EF is particularly involved in fundamental skills of daily living and in behavioral and emotional regulation. In this study, impairment of executive functioning is investigated in patients with eating disorders and the associations with clinical features and clinical subtypes are analyzed. METHOD: 75 female patients (m = 22.01 years, sd = 9.15) with eating disorder (43 restrictive anorexia, 30 binge-eating anorexia and 13 bulimia nervosa) and 37 healthy controls (m = 18.54 years, sd = 4.21) were included in the study. An extensive assessment of executive function domains (verbal fluency, set shifting, attention span, selective attention, working memory, inhibitory control and processing speed) was carried out in both groups. Clinical scales for food intake restriction, binge-eating/purging, depression, anxiety and impulsivity were also administered and correlated with scores on executive function tests. RESULTS: Patients with an ED had significantly lower scores than healthy controls in performance of several executive function tests, particularly in set shifting, interference control and processing speed (p < .01, in all three domains). Executive function impairment was related to anxious, depressive and eating disorder symptoms (p < .05), regardless of clinical subtype. CONCLUSIONS: Executive function impairment in eating disorders is associated with greater ED symptomatic severity and might involve a negative treatment outcome. Therefore, cognitive remediation techniques should probably be considered in a number of severe patients with ED.

Clinical predictors and psychosocial risk factors of suicide attempt severity.

BACKGROUND: Suicide attempts are an important predictor of completed suicide and may differ in terms of severity of medical consequences or medical lethality. There is little evidence on serious suicide attempt (SSA) and very few studies have compared SSA with non-SSA. OBJECTIVE: The aim of this multisite, coordinated, cohort study was to analyze the role of clinical variables and the sociodemographic and psychological risk factors of SSA. METHOD: In this multisite, coordinated, cohort study, 684 participants (222 for the mild suicide attempt group, 371 for the moderate suicide attempt group and 91 for the SSA group) were included in the study. Ordinal regression models were performed to analyze the predictor variables of SSA. RESULTS: Early physical abuse (OR=1.231) and impulsivity (OR=1.036) were predictors of SSA, while depressive symptoms were associated with a lower risk of SSA. CONCLUSION: Environmental and psychological factors as physical abuse and impulsivity are related with severe suicide severity. These findings will help to develop strategies to prevent suicide and may be considered for the treatment and management of suicide.