# Risk factors of transition from suicidal ideation to suicide attempt: A one-year longitudinal study among hospital-based in- and outpatients

B. Nobile, E. Gourguechon-Buot, E. Olié, Ph H Courtet

► To cite this version:

B. Nobile, E. Gourguechon-Buot, E. Olié, Ph H Courtet. Risk factors of transition from suicidal ideation to suicide attempt: A one-year longitudinal study among hospital-based in- and outpatients. Journal of Affective Disorders, 2025, 390, pp.119854. 10.1016/j.jad.2025.119854. hal-05173913

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Submitted on 21 Jul 2025

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Research paper

# Risk factors of transition from suicidal ideation to suicide attempt: A one-year longitudinal study among hospital-based in- and outpatients

B. Nobile<sup>a,b,*</sup>, E. Gourguechon-Buot<sup>a,b</sup>, E. Olié<sup>a,b</sup>, Ph. Courtet<sup>a,b</sup>

<figure><img src="image_2.png" /></figure>

## ARTICLE INFO

**Keywords:**

Suicidal ideation

Suicide attempt

Psychological pain

Anxiety disorders

## ABSTRACT

Identifying risk factors for transitioning from suicidal ideation to suicide attempts is crucial for improving suicide prevention strategies. Many existing risk factors fail to differentiate between those who attempt suicide and those who only experience suicidal thoughts. This study aimed to prospectively examine risk factors for suicide attempt over a one-year follow-up period in patients with mood disorders and current suicidal ideation, stratified by their history of lifetime suicide attempt.

A cohort of 679 hospital-based patients with mood disorders and current suicidal ideation was assessed. Sociodemographic and clinical data, including depression severity, psychological pain, and suicidal ideation, were collected. Multivariate analyses and Cox proportional hazard models identified risk factors for suicide attempts.

Among patients with a history of suicide attempt (n = 440), 20.2 % attempted suicide during follow-up. Significant risk factors included comorbid anxiety disorders (OR = 2.11; 95 % CI = [1.24, 3.70]) and higher levels of maximum suicidal ideation (OR = 1.19; 95 % CI = [1.04, 1.40]). Among those without a prior attempt (n = 239), 9.6 % attempted suicide, with younger age (OR = 0.93; 95 % CI = [0.87, 0.97]) and an interaction between psychological pain and suicidal ideation (OR = 2.08; 95 % CI = [1.31, 3.58]) as key predictors.

High suicidal ideation levels were a common risk factor, regardless of attempt history. Suicidal ideation and associated risk factors, particularly anxiety and psychological pain, should be addressed through evidence-based and person-centered pharmacological, psychotherapeutic, and psychosocial strategies to help prevent suicidal behavior.

## 1. Introduction

Suicidal behavior (i.e., suicide death and suicide attempt) is a major public health concern, and identifying risk factors is essential to determine which patients are most at risk and to provide them with appropriate care. A suicide attempt is now recognized as the strongest predictor of future death by suicide (Nobile et al., 2024; Franklin et al., 2017). Thus, identifying risk factors for suicide attempts can be considered a critical first step in suicide prevention. Unfortunately, many of the current risk factors that predict suicide attempt also predict suicidal ideation and therefore fail to distinguish between individuals who ideate and those who attempt (Klonsky et al., 2018; Klonsky et al., 2016; Porras-Segovia et al., 2023). This distinction is problematic because suicidal ideation is highly prevalent in mood disorders, with up to 75 % of patients experiencing suicidal ideation at some point (Nobile

et al., 2021a). However, not all individuals with suicidal ideation will attempt suicide. In fact, only 3 % to 37 % of individuals with suicidal ideation progress to a suicide attempt, depending on the population being studied (e.g., general population, psychiatric patients) (Haregu et al., 2023). The high prevalence of suicidal ideation, combined with the relatively lower prevalence of suicide attempts, can lead to overconsumption of care by patients who are not at immediate risk of attempting suicide, as well as insufficient care for those who are. Therefore, it is of utmost importance to identify specific risk factors that predict the transition from suicidal ideation to suicide attempt. This need is supported by Franklin et al. (Franklin et al., 2017), whose meta-analysis showed that most known risk factors weakly predict suicidal behavior, underscoring the importance of identifying predictors of the transition from ideation to action.

Three major theories of suicide incorporate the “ideation-to-action

<footnote><sup>a</sup> Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, France</footnote>

<footnote><sup>b</sup> IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France</footnote>

<footnote>* Corresponding author at: IGF, Hôpital La Colombière, 39, avenue Charles Flahault, BP 34493, 34093 Montpellier cedex 5, France.
E-mail address: benedicte.nobile@gmail.com (B. Nobile).</footnote>
framework,” which proposes that the development of suicidal ideation and the transition to suicidal behavior are distinct processes. These include the interpersonal theory of suicide (Van Orden et al., 2010), the three-step theory of suicide (Klonsky et al., 2018) and the integrated motivational-volitional model (Wetherall et al., 2018). The first two theories suggest that the transition from ideation to action is mediated by the capacity to attempt suicide, while the third theory emphasizes factors such as impulsivity or access to lethal means as critical in this transition (Porras-Segovia et al., 2023). For example, in a recent study of >3000 young adults aged 18–34, researchers found that motivational factors (e.g., burdensomeness, lack of social support) distinguished healthy controls from individuals with lifetime suicidal ideation or attempts, while volitional factors (e.g., impulsivity, fearlessness about death) differentiated ideators from attempters (Wetherall et al., 2018).

Other studies have sought to examine the ideation-to-action framework and identify factors associated with the transition from suicidal ideation to suicide attempt (Richardson et al., 2023; Marie et al., 2020; Sunderland et al., 2023; May et al., 2012; Naifeh et al., 2019). However, most of these studies used cross-sectional designs and assessed individuals with a lifetime history of suicidal ideation or suicide attempt, while relatively fewer studies have prospectively evaluated risk factors for suicide attempt specifically among individuals with recent current suicidal ideation. The main factors associated with the transition from suicidal ideation to suicidal behavior identified in these studies include the severity of suicidal ideation at baseline, history of suicide attempt, past psychiatric hospitalization, and less improvement in suicidal ideation and depression over the short term (e.g., 6 weeks of follow-up) (Porras-Segovia et al., 2023; Naifeh et al., 2019; Chan et al., 2014). Nevertheless, most of these studies have limitations, including variability in follow-up durations (e.g., 30 days, 6 weeks, 1 year, and 10 years), small sample sizes, and a focus on specific populations (e.g., veterans).

Given these limitations, further prospective studies are necessary to identify risk factors associated with the transition from ideation to attempt. It has been observed that suicidal acts occur most frequently within the two years following the onset of suicidal ideation (Sunderland et al., 2023), with over 60% of these transitions occurring within the first year (Nock et al., 2008). This underscores the importance of conducting studies on large cohorts of patients with recent current suicidal ideation and assessing risk factors for suicide attempt within the first year following the onset of ideation. To better understand the mechanisms underlying the transition from ideation to action, it is essential to consider the heterogeneity within populations presenting with suicidal ideation. Additionally, given that a history of suicide attempt is one of the most significant risk factor for future attempt, even among individuals with current suicidal ideation (Franklin et al., 2017; Porras-Segovia et al., 2023), it is critical to assess risk factors for suicide attempt among ideators without any history of suicide attempts separately from ideators with a history of at least one suicide attempt. Indeed, according to ideation-to-action theories, particularly the Interpersonal Theory of Suicide and the Three-Step Theory, the transition from suicidal thoughts to action is partly facilitated by the acquisition of the capability for suicide, often developed through previous suicide attempt. Therefore, individuals with and without a history of suicide attempts represent distinct clinical populations, and separate analyses allow a more accurate identification of specific risk factors. Furthermore, considering that only a minority of individuals with suicidal ideation will eventually attempt suicide (Haregu et al., 2023), it is particularly relevant to analyze separately “pure” ideators who have never transitioned to action.

The present study was based on a large cohort of hospital-based patients diagnosed with mood disorders, from which we selected the subgroup presenting with recent current suicidal ideation for analysis. Only patients with current suicidal ideation at the time of hospital consultation or hospitalization were considered eligible for the present analyses. Accordingly, the aim of our study was to identify risk factors

associated with transitioning from suicidal ideation to suicide attempt over a one-year follow-up period in a large sample of hospital-based patients with current suicidal ideation and mood disorders according to the history of lifetime suicide attempt or not. To explore potential risk factors for this transition, patients were compared on a set of clinical variables previously associated with suicidal risk in the literature, including childhood trauma (Koola et al., 2018), anhedonia (Auerbach et al., 2022), anxiety disorders (Bentley et al., 2016), psychological pain (Alacreu-Crespo et al., 2020), and others, to determine whether these factors were specifically related to the transition from suicidal ideation to suicide attempt or not. Furthermore, based on the Three-Step Theory of Suicide, which posits that psychological pain exacerbates suicidal desire, we hypothesized that psychological pain might interact with suicidal ideation to heighten the risk of transitioning to a suicide attempt. We expected this interaction to be particularly relevant among individuals without a history of suicide attempts, as they may have not yet acquired the capability for suicidal behavior, and thus the emotional intensity of suicidal ideation combined with psychological pain could play a more central role in facilitating the transition to action.

## 2. Methods

### 2.1. Participants' recruitment

This observational, longitudinal, naturalistic study involved a cohort of 1523 adult outpatients and inpatients admitted for consultation or hospitalization at the Department of Emergency Psychiatry & Acute Care of Montpellier Academic Hospital, France, with a primary diagnosis of a mood disorder (i.e., major depressive episode or bipolar disorder) according to DSM-5 criteria.

Inclusion criteria for the overall cohort were: being older than 18 years of age, having been hospitalized or seen in consultation at our Department at the University Hospital of Montpellier (France), having a primary diagnosis of a mood disorder (i.e., major depressive episode or bipolar disorder) according to DSM-5 criteria, and the ability to speak and understand French.

Among the 1523 patients of the total sample, only patients with current suicidal ideation (N = 803 (52.7 %)) were included in this study (see flowchart, Fig. 1).

This study was performed according to the French regulatory guidelines and current codes of Good Clinical Practice. Each patient was informed about the study aims and procedures and signed a written informed consent. The study protocol was approved by a local independent ethics committee (IRB-MTP_2012_07_202100867).

### 2.2. Clinical assessment

This naturalistic study did not interfere with the clinical management of the included patients. For hospitalized patients, the clinical assessment was carried out a few days after hospitalization. For both outpatients and inpatients, the clinical assessment was based on interviews conducted by trained psychiatrists or trained psychologists, as well as self-administered questionnaires. All tools used to assess patients were validated for both daily clinical practice and clinical research.

Based on patients' reports, clinicians recorded the following:

- Sociodemographic data (i.e., age, sex, education level, professional activity, marital status, and having children),

- History of lifetime suicide attempt (SA),

- Number of lifetime SA,

- History of violent SA (i.e., defined as an attempt involving: the use of firearms; the use of sharp weapons; hanging; jumping from a height; jumping in front of a train/subway; drowning; self-immolation),

- History of serious SA (i.e., causes a significant physical injury requiring intensive, substantial medical treatment),

- Age at first SA,
<figure><img src="image_3.png" /><figcaption>Fig. 1. Flowchart of patients' selection.</figcaption></figure>

- Current psychotropic treatments (e.g., antipsychotics, antidepressants, and anxiolytics) at admission or consultation.

Psychopathology and depression were evaluated in all patients as follows:

- Psychopathology using the MINI-5 (i.e., DSM-5 criteria) (Sheehan et al., 1998).

- Depression was assessed using the self-rated 13-item short version of the original Beck Depression Inventory (BDI-I). The BDI-I displays high reliability (Cronbach's alpha: 0.86) and has been validated for use in patients with mental disorders (Beck et al., 1988). This scale explores a range of depressive symptoms experienced over the past week, including sadness, pessimism, anhedonia, self-dislike, guilt, irritability, indecisiveness, and suicidal thoughts. Each item is rated on a 4-point scale (0–3), with higher total scores indicating greater depression severity (Beck et al., 1988). In addition to the total score, the anhedonia item was also analyzed separately, given its known association with suicidal risk. Using single items from depression scales to assess specific symptoms such as anhedonia is a common and validated approach in clinical research (Luca et al., 2024).

Other assessments were:

- History of childhood trauma using the Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 1997). The CTQ explores five dimensions of childhood trauma: physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse. The cutoff scores for the different subscales are: ≥10 for physical abuse; ≥8 for sexual abuse; ≥13 for emotional abuse; ≥15 for emotional neglect; ≥10 for physical neglect. The CTQ has good reliability (Cronbach's alpha: 0.91 for the total score and Cronbach's alpha: 0.85 for

emotional abuse; 0.83 for physical abuse; 0.92 for sexual abuse; 0.85 for emotional neglect, and 0.61 for physical neglect) and is widely used in clinical research (Bernstein et al., 1997; Scher et al., 2001; Bernstein et al., 2003).

- Level of psychological pain, physical pain, and suicidal ideation (SI) were assessed using visual analog scales (PPP-VAS), each ranging from 0 (“no pain/ideation”) to 10 (“worst imaginable pain/ideation”) (Richard-Devantoy et al., 2020). For each construct, participants rated their current level, their usual level over the past 15 days, and the maximum intensity experienced during the same period. This approach offers a detailed measure of the **intensity** of suicidal ideation, which may be more informative for identifying short-term suicide risk than categorical or binary assessments. The PPP-VAS has shown good reliability among psychiatric patients (Cronbach's alpha: 0.92) (Alacreu-Crespo et al., 2024).

- Regarding follow-up, as this was a naturalistic cohort (treatment as usual according to the clinician's judgment), patients returned for routine follow-up visits. Therefore, the occurrence of suicide attempts (SA) (i.e., actual, aborted, and interrupted) was recorded by psychiatrists during the routine follow-up visits and was also extracted from the patients' hospital records. Using two sources reduced the risk of oversight and/or mistakes (e.g., using only medical records may miss non-hospitalized SA). Patients who did not return for follow-up visits and had no record of SA during the one-year follow-up period were considered lost to follow-up (N = 114, 14.2 % of patients with SI at inclusion) and were not included in the analyses. In addition, patients with interrupted or aborted SA during the one-year follow-up were also excluded from the analyses (N = 10, 1.2 % of patients with SI at inclusion) (See flowchart, Fig. 1). Interrupted SA was defined as cases in which patients attempted to end their lives but were prevented by external factors (e.g., intervention by others). Aborted SA referred to instances where
individuals chose to stop themselves due to internal factors. No significant differences in age, gender, SI, history of lifetime suicide attempt and baseline depression severity at inclusion were observed between patients included in or excluded from the analysis (i.e., loss to follow-up or interrupted/aborted SA, Suppl. Mat. Table 1). To our knowledge, there were no deaths by suicide in this cohort. While this may seem unexpected, it is consistent with the low incidence of suicide observed even in high-risk populations, particularly in settings offering specialized care.

Regarding follow-up, as this was a naturalistic cohort (treatment as usual according to the clinician's judgment), patients returned for routine follow-up visits. Therefore, the occurrence of suicide attempts (SA) (i.e., actual, aborted, and interrupted) was recorded by psychiatrists during the routine follow-up visits and was also extracted from the patients' hospital records. Using two sources reduced the risk of oversight and/or mistakes (e.g., using only medical records may miss non-hospitalized SA). Patients who did not return for follow-up visits and had no record of SA during the one-year follow-up period were considered lost to follow-up (N = 114, 14.2% of patients with SI at inclusion) and were not included in the analyses. In addition, patients with interrupted or aborted SA during the one-year follow-up were also excluded from the analyses (N = 10, 1.2% of patients with SI at inclusion) (See flowchart, Fig. 1). Interrupted SA was defined as cases in which patients attempted to end their lives but were prevented by external factors (e.g., intervention by others). Aborted SA referred to instances where individuals chose to stop themselves due to internal factors. No significant differences in age, gender, SI, history of lifetime suicide attempt and baseline depression severity at inclusion were observed between patients included in or excluded from the analysis (i.e., loss to follow-up or interrupted/aborted SA, Suppl. Mat. Table 1). To our knowledge, there were no deaths by suicide in this cohort. While this may seem unexpected, it is consistent with the low incidence of suicide observed even in high-risk populations, particularly in settings offering specialized care.

## 2.3. Definition of suicidal ideation and suicide attempt

Presence of SI at inclusion was defined as having a score equal or superior to one to the suicidal item of the BDI (Joiner et al., 2025). The ratings range from 0 to 3: (0) I don't have any thoughts of killing myself; (1) I think that death will liberate me; (2) I have precise plan to kill myself; (3) I would kill myself if I had the chance. A single suicide item from a depression rating scale, either clinician- or self-rated, is a valid approach to assess SI, compared with the Beck Scale for Suicidal Ideation, and has been used in previous clinical studies (Desseilles et al., 2012; Green et al., 2015) (Nobile et al., 2018; Bernert et al., 2017). Among the 1523 patients of the total samples, 803 (52.7%) patients had a score superior or equal to one to the suicidal item of the BDI (See flowchart, Fig. 1).

Both the BDI suicidal item and the VAS were retained in the analyses, as they capture complementary aspects of suicidal ideation: the BDI item reflects its presence and qualitative nature, while the VAS provides a quantitative measure of its intensity.

SA was defined as a self-aggressive act done with the intention to die (not only self-mutilation) (Mann et al., 1999) and that required a treatment or at least a medical evaluation.

## 2.4. Statistical analysis

Comparisons between patients who attempted suicide during follow-up and those who did not were conducted separately for patients with and without a history of suicide attempts. Univariate comparisons were performed to identify variables associated with the outcome, using the Wilcoxon rank-sum test for continuous variables and either Pearson's chi-squared test or Fisher's exact test for categorical variables.

The probability of a suicide attempt occurring during the one-year follow-up was assessed using logistic regression models, adjusted for gender, age, depression severity (BDI score), psychological pain (VAS), suicidal ideation (VAS), the presence of an anxiety disorder, and the number of previous suicide attempts. In addition, given previous evidence highlighting psychological pain and suicidal ideation as key predictors of suicidal behavior, and based on theoretical models such as the Three-Step Theory of Suicide, we specifically tested an interaction term between maximum psychological pain and maximum suicidal ideation. Patients with missing data for any of the adjustment variables were excluded from the analyses.

For patients with a history of suicide attempt, a multivariate Cox regression analysis was also conducted to examine the potential association between the variables of interest and the time elapsed between inclusion and the first suicide attempt, allowing for consideration of the temporal dimension of risk. This complementary approach provides additional insight beyond logistic regression and helps assess the robustness of the findings over time.

## 3. Results

The final sample consisted of 679 patients, 67% of whom were women, with a mean age of 41 years (SD = 14). The mean BDI score was 21 (SD = 7), representing moderate depression, and 65% of patients had a history of lifetime SA. Patients were stratified based on the presence or absence of a lifetime SA.

Risk factors of transitioning from ideation to suicide attempt in patient with a history of lifetime suicide attempt (Tables 1, 2 and 3).

In the final sample, 440 patients (64.8%) had a history of lifetime suicide attempt (SA) and current suicidal ideation (SI) at inclusion. During the one-year follow-up period, 89 patients (20.2%) attempted suicide. There were no significant differences in sociodemographic variables between the groups, except that patients who attempted suicide during follow-up were significantly younger. Patients with a SA during follow-up tended to have a history of more than one lifetime SA and significantly less often had a history of severe SA.

There were also no significant differences between the groups in terms of psychiatric comorbidities, such as eating disorders, although there was a trend suggesting an association between the presence of anxiety disorders and a higher risk of suicide attempt during follow-up (p = 0.06).

No significant differences were found between the groups in total BDI scores, including scores on anhedonia and suicidal ideation items. Similarly, there were no differences in levels of physical or psychological pain (current, maximum, or usual within the past 15 days). However, patients who attempted suicide during follow-up reported significantly higher levels of maximum SI during the last 15 days, assessed using the PPP-VAS, compared to those who did not (maximum SI: 8.8 vs. 8.02, p = 0.04).

Regarding childhood trauma, no significant differences were observed between the groups. Additionally, there were no significant differences regarding psychotropic treatment at inclusion.

Multivariate analysis and Cox proportional hazards models showed that patients who attempted suicide during follow-up were significantly more likely to have an associated anxiety disorder (OR = 2.11; 95% CI = [1.24, 3.70], multivariate analysis, Model 4; and OR = 1.86; 95% CI = [1.13, 3.07], Cox model, Model 3). The only other clinical variable significantly associated with the risk of SA during the one-year follow-up was a higher level of maximum SI during the last 15 days, assessed using the PPP-VAS (OR = 1.19; 95% CI = [1.04, 1.40], multivariate analysis, Model 4; and OR = 1.16; 95% CI = [1.01, 1.33], Cox model, Model 3).

Risk factors of transitioning from ideation to suicide attempt in patient without a history of lifetime suicide attempt (Tables 1 and 4).

In the cohort, 239 patients (35.2%) had no history of lifetime SA and presented with current SI at inclusion. Among these patients, 23 (9.6%) attempted suicide during the one-year follow-up period. Patients who
<caption>**Table 1**</caption>

Risk factors associated with transitioning from suicidal ideation to suicide attempt in patients with a history of lifetime suicide attempt and patients with no history of lifetime suicide attempt (Univariate analysis).

<table><thead><tr><th rowspan="2">Variables</th><th colspan="4">Patients with SA history</th><th colspan="4">Patients with no SA history</th></tr><tr><th>No SA during follow-up N = 351<sup>1</sup></th><th>SA during follow-up N = 89<sup>1</sup></th><th>p-value<sup>2</sup></th><th>No SA during follow-up N = 216<sup>1</sup></th><th>SA during follow-up N = 23<sup>1</sup></th><th>p-value<sup>2</sup></th></tr></thead><tbody><tr><td>Age</td><td>41 (14)</td><td>37 (12)</td><td>0.028</td><td>42 (14)</td><td>32 (12)</td><td>&lt;0.001</td></tr><tr><td>Gender</td><td></td><td></td><td>0.8</td><td></td><td></td><td>0.3</td></tr><tr><td>Female</td><td>248 (71 %)</td><td>64 (72 %)</td><td></td><td>126 (58 %)</td><td>16 (70 %)</td><td></td></tr><tr><td>Male</td><td>103 (29 %)</td><td>25 (28 %)</td><td></td><td>90 (42 %)</td><td>7 (30 %)</td><td></td></tr><tr><td>Single</td><td></td><td></td><td>0.5</td><td></td><td></td><td>0.077</td></tr><tr><td>No</td><td>131 (38 %)</td><td>30 (34 %)</td><td></td><td>100 (47 %)</td><td>6 (27 %)</td><td></td></tr><tr><td>Yes</td><td>216 (62 %)</td><td>59 (66 %)</td><td></td><td>113 (53 %)</td><td>16 (73 %)</td><td></td></tr><tr><td>Children</td><td></td><td></td><td>0.2</td><td></td><td></td><td>0.2</td></tr><tr><td>No</td><td>160 (46 %)</td><td>47 (53 %)</td><td></td><td>101 (47 %)</td><td>14 (61 %)</td><td></td></tr><tr><td>Yes</td><td>191 (54 %)</td><td>42 (47 %)</td><td></td><td>115 (53 %)</td><td>9 (39 %)</td><td></td></tr><tr><td>Living alone</td><td></td><td></td><td>0.8</td><td></td><td></td><td>0.2</td></tr><tr><td>No</td><td>186 (60 %)</td><td>46 (58 %)</td><td></td><td>129 (68 %)</td><td>9 (53 %)</td><td></td></tr><tr><td>Yes</td><td>125 (40 %)</td><td>33 (42 %)</td><td></td><td>60 (32 %)</td><td>8 (47 %)</td><td></td></tr><tr><td>Study level (Senior secondary school or more)</td><td></td><td></td><td>&gt;0.9</td><td></td><td></td><td>&gt;0.9</td></tr><tr><td>No</td><td>90 (31 %)</td><td>22 (31 %)</td><td></td><td>33 (19 %)</td><td>3 (20 %)</td><td></td></tr><tr><td>Yes</td><td>199 (69 %)</td><td>48 (69 %)</td><td></td><td>139 (81 %)</td><td>12 (80 %)</td><td></td></tr><tr><td>Professional activity</td><td></td><td></td><td>0.8</td><td></td><td></td><td>0.025</td></tr><tr><td>No activity</td><td>148 (48 %)</td><td>39 (49 %)</td><td></td><td>106 (58 %)</td><td>5 (29 %)</td><td></td></tr><tr><td>Working or studying</td><td>160 (52 %)</td><td>40 (51 %)</td><td></td><td>78 (42 %)</td><td>12 (71 %)</td><td></td></tr><tr><td>Current MDE</td><td></td><td></td><td>0.3</td><td></td><td></td><td>0.7</td></tr><tr><td>No</td><td>19 (5.4 %)</td><td>2 (2.3 %)</td><td></td><td>21 (9.8 %)</td><td>1 (4.3 %)</td><td></td></tr><tr><td>Yes</td><td>331 (95 %)</td><td>86 (98 %)</td><td></td><td>194 (90 %)</td><td>22 (96 %)</td><td></td></tr><tr><td>Bipolar disorder</td><td></td><td></td><td>0.4</td><td></td><td></td><td>0.005</td></tr><tr><td>No</td><td>229 (65 %)</td><td>62 (70 %)</td><td></td><td>133 (62 %)</td><td>21 (91 %)</td><td></td></tr><tr><td>Yes</td><td>121 (35 %)</td><td>26 (30 %)</td><td></td><td>83 (38 %)</td><td>2 (8.7 %)</td><td></td></tr><tr><td>Current Agoraphobia</td><td></td><td></td><td>0.6</td><td></td><td></td><td>0.14</td></tr><tr><td>No</td><td>265 (78 %)</td><td>66 (75 %)</td><td></td><td>158 (74 %)</td><td>13 (59 %)</td><td></td></tr><tr><td>Yes</td><td>75 (22 %)</td><td>22 (25 %)</td><td></td><td>56 (26 %)</td><td>9 (41 %)</td><td></td></tr><tr><td>Current Panic Disorder</td><td></td><td></td><td>0.6</td><td></td><td></td><td>0.6</td></tr><tr><td>No</td><td>268 (79 %)</td><td>67 (76 %)</td><td></td><td>169 (79 %)</td><td>16 (73 %)</td><td></td></tr><tr><td>Yes</td><td>72 (21 %)</td><td>21 (24 %)</td><td></td><td>45 (21 %)</td><td>6 (27 %)</td><td></td></tr><tr><td>Current Social Phobia</td><td></td><td></td><td>0.017</td><td></td><td></td><td>0.6</td></tr><tr><td>No</td><td>285 (83 %)</td><td>63 (72 %)</td><td></td><td>156 (73 %)</td><td>15 (68 %)</td><td></td></tr><tr><td>Yes</td><td>59 (17 %)</td><td>25 (28 %)</td><td></td><td>58 (27 %)</td><td>7 (32 %)</td><td></td></tr><tr><td>Current OCD</td><td></td><td></td><td>&gt;0.9</td><td></td><td></td><td>&gt;0.9</td></tr><tr><td>No</td><td>310 (91 %)</td><td>80 (91 %)</td><td></td><td>182 (86 %)</td><td>19 (86 %)</td><td></td></tr><tr><td>Yes</td><td>32 (9.4 %)</td><td>8 (9.1 %)</td><td></td><td>29 (14 %)</td><td>3 (14 %)</td><td></td></tr><tr><td>Anxiety disorders</td><td></td><td></td><td>0.062</td><td></td><td></td><td>&gt;0.9</td></tr><tr><td>No</td><td>162 (46 %)</td><td>31 (35 %)</td><td></td><td>74 (34 %)</td><td>8 (35 %)</td><td></td></tr><tr><td>Yes</td><td>188 (54 %)</td><td>57 (65 %)</td><td></td><td>142 (66 %)</td><td>15 (65 %)</td><td></td></tr><tr><td>Current PTSD</td><td></td><td></td><td>0.2</td><td></td><td></td><td>0.4</td></tr><tr><td>No</td><td>313 (92 %)</td><td>77 (88 %)</td><td></td><td>193 (91 %)</td><td>19 (86 %)</td><td></td></tr><tr><td>Yes</td><td>28 (8.2 %)</td><td>11 (13 %)</td><td></td><td>18 (8.5 %)</td><td>3 (14 %)</td><td></td></tr><tr><td>Current alcohol dependence</td><td></td><td></td><td>0.15</td><td></td><td></td><td>0.13</td></tr><tr><td>No</td><td>306 (89 %)</td><td>73 (83 %)</td><td></td><td>196 (92 %)</td><td>18 (82 %)</td><td></td></tr><tr><td>Yes</td><td>39 (11 %)</td><td>15 (17 %)</td><td></td><td>18 (8.4 %)</td><td>4 (18 %)</td><td></td></tr><tr><td>Current substance dependence</td><td></td><td></td><td>0.2</td><td></td><td></td><td>&gt;0.9</td></tr><tr><td>No</td><td>319 (93 %)</td><td>78 (89 %)</td><td></td><td>191 (90 %)</td><td>20 (91 %)</td><td></td></tr><tr><td>Yes</td><td>24 (7.0 %)</td><td>10 (11 %)</td><td></td><td>21 (9.9 %)</td><td>2 (9.1 %)</td><td></td></tr><tr><td>Current Anorexia</td><td></td><td></td><td>0.4</td><td></td><td></td><td>0.6</td></tr><tr><td>No</td><td>332 (97 %)</td><td>82 (94 %)</td><td></td><td>206 (97 %)</td><td>21 (95 %)</td><td></td></tr><tr><td>Yes</td><td>12 (3.5 %)</td><td>5 (5.7 %)</td><td></td><td>7 (3.3 %)</td><td>1 (4.5 %)</td><td></td></tr><tr><td>Current Bulimia</td><td></td><td></td><td>0.5</td><td></td><td></td><td>0.7</td></tr><tr><td>No</td><td>314 (91 %)</td><td>81 (93 %)</td><td></td><td>199 (93 %)</td><td>20 (91 %)</td><td></td></tr><tr><td>Yes</td><td>31 (9.0 %)</td><td>6 (6.9 %)</td><td></td><td>15 (7.0 %)</td><td>2 (9.1 %)</td><td></td></tr><tr><td>Psychological pain VAS (current)</td><td>6.51 (2.51)</td><td>6.61 (2.42)</td><td>0.7</td><td>6.26 (2.56)</td><td>6.67 (2.56)</td><td>0.5</td></tr><tr><td>Psychological pain VAS (15 last days average)</td><td>7.55 (1.84)</td><td>7.47 (1.78)</td><td>0.6</td><td>7.23 (1.97)</td><td>7.57 (2.31)</td><td>0.3</td></tr><tr><td>Psychological pain VAS (15 last days maximum)</td><td>9.00 (1.44)</td><td>9.06 (1.29)</td><td>0.7</td><td>8.80 (1.36)</td><td>9.00 (2.05)</td><td>0.093</td></tr><tr><td>Physical pain VAS (current)</td><td>3.52 (3.02)</td><td>3.10 (3.15)</td><td>0.2</td><td>3.04 (2.92)</td><td>2.76 (2.81)</td><td>0.7</td></tr><tr><td>Physical pain VAS (15 last days average)</td><td>3.97 (3.04)</td><td>3.62 (2.95)</td><td>0.3</td><td>3.83 (2.94)</td><td>3.33 (3.09)</td><td>0.4</td></tr><tr><td>Physical pain VAS (15 last days maximum)</td><td>5.1 (3.3)</td><td>4.9 (3.4)</td><td>0.4</td><td>5.0 (3.3)</td><td>5.0 (3.4)</td><td>&gt;0.9</td></tr><tr><td>SI VAS (current)</td><td>3.8 (3.4)</td><td>4.5 (3.3)</td><td>0.11</td><td>3.05 (3.07)</td><td>3.71 (3.42)</td><td>0.3</td></tr><tr><td>SI VAS (15 last days average)</td><td>6.2 (2.9)</td><td>6.8 (2.1)</td><td>0.2</td><td>4.79 (2.99)</td><td>6.19 (2.98)</td><td>0.034</td></tr><tr><td>SI VAS (15 last days maximum)</td><td>8.02 (2.63)</td><td>8.80 (1.56)</td><td>0.036</td><td>6.4 (3.3)</td><td>8.2 (3.0)</td><td>0.004</td></tr><tr><td>BDI total score</td><td>21 (7)</td><td>21 (7)</td><td>0.7</td><td>21 (6)</td><td>23 (7)</td><td>0.085</td></tr><tr><td>CTQ total score</td><td>55 (20)</td><td>54 (18)</td><td>0.8</td><td>50 (17)</td><td>56 (19)</td><td>0.2</td></tr><tr><td>CTQ physical abuse (≥10)<sup>3</sup></td><td></td><td></td><td>0.9</td><td></td><td></td><td>0.079</td></tr><tr><td>No</td><td>232 (70 %)</td><td>57 (71 %)</td><td></td><td>161 (77 %)</td><td>14 (61 %)</td><td></td></tr></tbody></table>

(continued on next page)
<table><caption>**Table 1 (continued)**</caption><thead><tr><th rowspan="2">Variables</th><th colspan="3">Patients with SA history</th><th colspan="3">Patients with no SA history</th></tr><tr><th>No SA during follow-up N = 351<sup>1</sup></th><th>SA during follow-up N = 89<sup>1</sup></th><th>p-value<sup>2</sup></th><th>No SA during follow-up N = 216<sup>1</sup></th><th>SA during follow-up N = 23<sup>1</sup></th><th>p-value<sup>2</sup></th></tr></thead><tbody><tr><td>Yes</td><td>98 (30 %)</td><td>23 (29 %)</td><td></td><td>47 (23 %)</td><td>9 (39 %)</td><td></td></tr><tr><td>CTQ sexual abuse (≥8)<sup>3</sup></td><td></td><td></td><td>0.6</td><td></td><td></td><td>0.5</td></tr><tr><td>No</td><td>231 (71 %)</td><td>55 (68 %)</td><td></td><td>160 (77 %)</td><td>16 (70 %)</td><td></td></tr><tr><td>Yes</td><td>95 (29 %)</td><td>26 (32 %)</td><td></td><td>49 (23 %)</td><td>7 (30 %)</td><td></td></tr><tr><td>CTQ emotional abuse (≥13)<sup>3</sup></td><td></td><td></td><td>&gt;0.9</td><td></td><td></td><td>0.4</td></tr><tr><td>No</td><td>151 (46 %)</td><td>39 (46 %)</td><td></td><td>103 (50 %)</td><td>9 (41 %)</td><td></td></tr><tr><td>Yes</td><td>174 (54 %)</td><td>45 (54 %)</td><td></td><td>101 (50 %)</td><td>13 (59 %)</td><td></td></tr><tr><td>CTQ physical neglect (≥10)<sup>3</sup></td><td></td><td></td><td>0.7</td><td></td><td></td><td>0.2</td></tr><tr><td>No</td><td>193 (60 %)</td><td>50 (62 %)</td><td></td><td>144 (71 %)</td><td>13 (57 %)</td><td></td></tr><tr><td>Yes</td><td>130 (40 %)</td><td>31 (38 %)</td><td></td><td>60 (29 %)</td><td>10 (43 %)</td><td></td></tr><tr><td>CTQ emotional neglect (≥15)<sup>3</sup></td><td></td><td></td><td>0.7</td><td></td><td></td><td>0.5</td></tr><tr><td>No</td><td>155 (48 %)</td><td>37 (45 %)</td><td></td><td>103 (51 %)</td><td>13 (59 %)</td><td></td></tr><tr><td>Yes</td><td>169 (52 %)</td><td>45 (55 %)</td><td></td><td>100 (49 %)</td><td>9 (41 %)</td><td></td></tr><tr><td>Anxiolytics (N05B) and Hypnotics/ Sedatives (N05C)</td><td></td><td></td><td>0.8</td><td></td><td></td><td>0.6</td></tr><tr><td>No</td><td>67 (19 %)</td><td>18 (20 %)</td><td></td><td>54 (25 %)</td><td>7 (30 %)</td><td></td></tr><tr><td>Yes</td><td>280 (81 %)</td><td>71 (80 %)</td><td></td><td>162 (75 %)</td><td>16 (70 %)</td><td></td></tr><tr><td>Anxiolytics (N05B)</td><td></td><td></td><td>0.8</td><td></td><td></td><td>0.7</td></tr><tr><td>No</td><td>79 (23 %)</td><td>19 (21 %)</td><td></td><td>57 (26 %)</td><td>7 (30 %)</td><td></td></tr><tr><td>Yes</td><td>268 (77 %)</td><td>70 (79 %)</td><td></td><td>159 (74 %)</td><td>16 (70 %)</td><td></td></tr><tr><td>Antidepressants (N06A)</td><td></td><td></td><td>0.8</td><td></td><td></td><td>0.091</td></tr><tr><td>No</td><td>162 (47 %)</td><td>43 (48 %)</td><td></td><td>96 (44 %)</td><td>6 (26 %)</td><td></td></tr><tr><td>Yes</td><td>185 (53 %)</td><td>46 (52 %)</td><td></td><td>120 (56 %)</td><td>17 (74 %)</td><td></td></tr><tr><td>Antiepileptics (N03A)</td><td></td><td></td><td>&gt;0.9</td><td></td><td></td><td>0.4</td></tr><tr><td>No</td><td>292 (84 %)</td><td>75 (84 %)</td><td></td><td>178 (82 %)</td><td>21 (91 %)</td><td></td></tr><tr><td>Yes</td><td>55 (16 %)</td><td>14 (16 %)</td><td></td><td>38 (18 %)</td><td>2 (8.7 %)</td><td></td></tr><tr><td>Antipsychotics (N05A)</td><td></td><td></td><td>0.5</td><td></td><td></td><td>0.8</td></tr><tr><td>No</td><td>138 (40 %)</td><td>39 (44 %)</td><td></td><td>97 (45 %)</td><td>11 (48 %)</td><td></td></tr><tr><td>Yes</td><td>209 (60 %)</td><td>50 (56 %)</td><td></td><td>119 (55 %)</td><td>12 (52 %)</td><td></td></tr><tr><td>Lithium (N05AN)</td><td></td><td></td><td>0.9</td><td></td><td></td><td>0.4</td></tr><tr><td>No</td><td>325 (94 %)</td><td>83 (93 %)</td><td></td><td>201 (93 %)</td><td>23 (100 %)</td><td></td></tr><tr><td>Yes</td><td>22 (6.3 %)</td><td>6 (6.7 %)</td><td></td><td>15 (6.9 %)</td><td>0 (0 %)</td><td></td></tr></tbody></table>

attempted suicide during follow-up were significantly younger and more likely to be employed compared to those who did not attempt suicide.

Patients who attempted suicide were significantly less likely to have a diagnosis of bipolar disorder than those who did not. However, there were no significant differences between the groups in terms of psychiatric comorbidities, such as anxiety disorders, eating disorders, or alcohol/substance use disorders.

There were no significant differences between the groups in total BDI scores, including scores on anhedonia and suicidal ideation items. Additionally, there were no differences between the groups in levels of physical or psychological pain (current, maximum, or usual within the past 15 days). However, patients who attempted suicide during follow-up reported significantly higher levels of maximum and average SI within the last 15 days, as measured by the PPP-VAS, compared to those who did not attempt suicide (maximum SI: 8.2 vs. 6.4, *p* = 0.004; average SI: 6.19 vs. 4.81, *p* = 0.04).

Regarding childhood trauma, no significant differences were found between the groups, although there was a trend toward a higher prevalence of physical abuse among patients who attempted suicide during follow-up. Finally, there were no significant differences between the groups regarding psychotropic treatment at inclusion.

Multivariate analysis revealed that patients who attempted suicide during the follow-up period were significantly younger (OR = 0.93; 95% CI = [0.87, 0.97], Model 5). Additionally, there was a significant interaction between maximum psychological pain and maximum SI (OR = 2.08; 95% CI = [1.31, 3.58], Model 5). Younger patients, as well as those experiencing high levels of maximum psychological pain and SI, were at a higher risk of attempting suicide during the follow-up period.

## 3.1. Comparison of anxiety-related risk across subgroups

To formally assess whether the association between anxiety disorders and suicide attempt differed according to suicide attempt history, we conducted a logistic regression including an interaction term between anxiety disorders and lifetime suicide attempt history (see Table 5). The interaction term was not statistically significant (OR = 1.62, 95% CI = 0.53–4.68, *p* = 0.40), suggesting that the strength of the association between anxiety disorders and suicide attempt did not significantly differ between the two subgroups.

# 4. Discussion

## 4.1. Main results

To our knowledge, this is the first study to longitudinally assess risk factors for the transition from suicidal ideation to suicide attempt in a large cohort of hospital-based patients with mood disorders (i.e., major depressive episode or bipolar disorder), stratifying patients based on the presence or absence of a history of lifetime suicide attempt. During the one-year follow-up, 20.2% of patients with a history of suicide attempt and 9.6% of those without a prior attempt made a suicide attempt. These rates are consistent with those reported in previous prospective studies of individuals with current suicidal ideation or a history of suicide attempt (Nobile et al., 2024; Forkmann et al., 2020). The main risk factors associated with suicide attempt among ideators with a history of suicide attempt were having a comorbid anxiety disorder and a higher level of maximum suicidal ideation. Among patients with no history of lifetime suicide attempt, the main risk factors for suicide attempt were a higher level of maximum suicidal ideation, particularly when

<footnote n="1">¹ Values are expressed as mean (standard deviation) or n (%).</footnote>

<footnote n="2">² p-values were calculated using the Wilcoxon rank-sum test for continuous variables and Pearson's chi-squared test or Fisher's exact test for categorical variables.</footnote>

<footnote n="3">³ CTQ subscales were dichotomized based on established cutoffs.</footnote>
<caption>**Table 2**</caption>

Risk factors associated with transitioning from suicidal ideation to suicide attempt in patients with a history of lifetime suicide attempt (Multivariate analysis).

<table><thead><tr><th rowspan="2">Characteristic</th><th colspan="3">Model 1</th><th colspan="3">Model 2</th><th colspan="3">Model 3</th><th colspan="3">Model 4</th><th colspan="3">Model 5</th></tr><tr><th>OR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th></tr></thead><tbody><tr><td>Age</td><td>0.98</td><td>0.96, 1.00</td><td><strong>0.039</strong></td><td>0.98</td><td>0.96, 1.00</td><td><strong>0.048</strong></td><td>0.98</td><td>0.97, 1.00</td><td>0.12</td><td>0.98</td><td>0.97, 1.00</td><td>0.11</td><td>0.98</td><td>0.96, 1.00</td><td>0.11</td></tr><tr><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>Male</td><td>1.10</td><td>0.63, 1.88</td><td>0.7</td><td>1.10</td><td>0.63, 1.88</td><td>0.7</td><td>1.04</td><td>0.59, 1.80</td><td>0.9</td><td>1.04</td><td>0.59, 1.78</td><td>&gt;0.9</td><td>1.02</td><td>0.58, 1.76</td><td>&gt;0.9</td></tr><tr><td>Beck Depression Inventory total score</td><td>0.98</td><td>0.94, 1.01</td><td>0.2</td><td>0.97</td><td>0.94, 1.01</td><td>0.2</td><td>0.97</td><td>0.94, 1.01</td><td>0.2</td><td>0.98</td><td>0.94, 1.01</td><td>0.2</td><td>0.98</td><td>0.94, 1.02</td><td>0.2</td></tr><tr><td>Anxiety disorders</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>Yes</td><td>1.98</td><td>1.17, 3.44</td><td><strong>0.013</strong></td><td>1.99</td><td>1.17, 3.48</td><td><strong>0.012</strong></td><td>2.12</td><td>1.24, 3.71</td><td><strong>0.007</strong></td><td>2.11</td><td>1.24, 3.70</td><td><strong>0.007</strong></td><td>2.08</td><td>1.22, 3.65</td><td><strong>0.008</strong></td></tr><tr><td>Number of lifetime SA</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>One</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>&gt;1</td><td>1.61</td><td>0.95, 2.80</td><td>0.083</td><td>1.60</td><td>0.94, 2.79</td><td>0.086</td><td>1.57</td><td>0.92, 2.73</td><td>0.11</td><td>1.57</td><td>0.92, 2.74</td><td>0.10</td><td>1.60</td><td>0.94, 2.80</td><td>0.091</td></tr><tr><td>Psychological pain VAS (15 last days maximum)</td><td></td><td></td><td></td><td>1.06</td><td>0.88, 1.29</td><td>0.6</td><td></td><td></td><td></td><td>0.94</td><td>0.76, 1.18</td><td>0.6</td><td>1.20</td><td>0.73, 2.76</td><td>0.6</td></tr><tr><td>SI VAS (15 last days maximum)</td><td></td><td></td><td></td><td></td><td></td><td></td><td>1.17</td><td>1.03, 1.35</td><td><strong>0.020</strong></td><td>1.19</td><td>1.04, 1.40</td><td><strong>0.022</strong></td><td>1.60</td><td>0.89, 4.02</td><td>0.2</td></tr><tr><td>Psychological pain * SI</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>0.97</td><td>0.87, 1.03</td><td>0.4</td></tr></tbody></table>

Age was treated as a continuous variable. Anxiety disorders were coded as present/absent based on MINI-5 diagnosis.

Psychological pain and Suicidal Ideation (SI) were measured with Visual Analog Scales (maximum during the last 15 days, 0–10 scale).

<caption>**Table 3**</caption>

Risk factors associated with transitioning from suicidal ideation to suicide attempt in patients with a history of lifetime suicide attempt (Cox Models).

<table><thead><tr><th rowspan="2">Characteristic</th><th colspan="3">Model 1</th><th colspan="3">Model 2</th><th colspan="3">Model 3</th><th colspan="3">Model 4</th></tr><tr><th>HR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th><th>HR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th><th>HR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th><th>HR<sup>1</sup></th><th>95 % CI<sup>1</sup></th><th>p-value</th></tr></thead><tbody><tr><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>Male</td><td>1.14</td><td>0.69, 1.90</td><td>0.6</td><td>1.11</td><td>0.67, 1.85</td><td>0.7</td><td>1.06</td><td>0.63, 1.77</td><td>0.8</td><td>1.04</td><td>0.62, 1.74</td><td>0.9</td></tr><tr><td>Age</td><td>0.98</td><td>0.96, 1.00</td><td><strong>0.027</strong></td><td>0.98</td><td>0.96, 1.00</td><td><strong>0.020</strong></td><td>0.98</td><td>0.97, 1.00</td><td>0.060</td><td>0.98</td><td>0.97, 1.00</td><td>0.059</td></tr><tr><td>Anxiety disorders</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>Yes</td><td>1.88</td><td>1.12, 3.16</td><td><strong>0.017</strong></td><td>1.97</td><td>1.16, 3.33</td><td><strong>0.012</strong></td><td>2.06</td><td>1.22, 3.50</td><td><strong>0.007</strong></td><td>2.05</td><td>1.21, 3.47</td><td><strong>0.008</strong></td></tr><tr><td>Number of lifetime SA</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>One</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>&gt;1</td><td>1.55</td><td>0.95, 2.54</td><td>0.082</td><td>1.55</td><td>0.94, 2.54</td><td>0.084</td><td>1.50</td><td>0.91, 2.46</td><td>0.11</td><td>1.53</td><td>0.93, 2.51</td><td>0.10</td></tr><tr><td>Beck Depression Inventory total score</td><td></td><td></td><td></td><td>0.98</td><td>0.94, 1.01</td><td>0.2</td><td>0.98</td><td>0.94, 1.01</td><td>0.2</td><td>0.98</td><td>0.94, 1.01</td><td>0.2</td></tr><tr><td>Psychological pain VAS (15 last days maximum)</td><td></td><td></td><td></td><td></td><td></td><td></td><td>0.97</td><td>0.80, 1.18</td><td>0.8</td><td>1.16</td><td>0.65, 2.07</td><td>0.6</td></tr><tr><td>SI VAS (15 last days maximum)</td><td></td><td></td><td></td><td></td><td></td><td></td><td>1.14</td><td>1.0, 1.32</td><td>0.059</td><td>1.42</td><td>0.75, 2.72</td><td>0.3</td></tr><tr><td>Psychological pain * SI</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>0.98</td><td>0.91, 1.05</td><td>0.5</td></tr></tbody></table>

Age was treated as a continuous variable. Anxiety disorders were coded as present/absent based on MINI-5 diagnosis.

Psychological pain and Suicidal Ideation (SI) were measured with Visual Analog Scales (maximum during the last 15 days, 0–10 scale).

<footnote n="1">¹ OR = Odds Ratio, CI = Confidence Interval.</footnote>

<footnote n="1">¹ HR = Hazard Ratio, CI = Confidence Interval.</footnote>
<caption>**Table 4**</caption>

Risk factors associated with transitioning from suicidal ideation to suicide attempt in patients without a history of lifetime suicide attempt (Multivariate analysis).

<table><thead><tr><th rowspan="2">Characteristic</th><th colspan="3">Model 1</th><th colspan="3">Model 2</th><th colspan="3">Model 3</th><th colspan="3">Model 4</th><th colspan="3">Model 5</th></tr><tr><th>OR<sup>1</sup></th><th>95% CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95% CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95% CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95% CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95% CI<sup>1</sup></th><th>p-value</th></tr></thead><tbody><tr><td>Age</td><td>0.93</td><td>0.89,<br>0.97</td><td><strong>0.003</strong></td><td>0.93</td><td>0.89,<br>0.97</td><td><strong>0.003</strong></td><td>0.94</td><td>0.89,<br>0.98</td><td><strong>0.010</strong></td><td>0.94</td><td>0.89,<br>0.98</td><td><strong>0.009</strong></td><td>0.93</td><td>0.87,<br>0.97</td><td><strong>0.006</strong></td></tr><tr><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>Male</td><td>1.26</td><td>0.43,<br>3.54</td><td>0.7</td><td>1.22</td><td>0.41,<br>3.44</td><td>0.7</td><td>1.23</td><td>0.41,<br>3.53</td><td>0.7</td><td>1.15</td><td>0.38,<br>3.34</td><td>0.8</td><td>1.69</td><td>0.53,<br>5.39</td><td>0.4</td></tr><tr><td>Beck Depression Inventory<br>total score</td><td>1.02</td><td>0.95,<br>1.11</td><td>0.5</td><td>1.03</td><td>0.95,<br>1.13</td><td>0.4</td><td>1.01</td><td>0.93,<br>1.10</td><td>0.8</td><td>1.02</td><td>0.94,<br>1.11</td><td>0.6</td><td>1.00</td><td>0.92,<br>1.10</td><td>&gt;0.9</td></tr><tr><td>Psychological pain VAS<br>(15 last days maximum)</td><td></td><td></td><td></td><td>0.89</td><td>0.62,<br>1.37</td><td>0.6</td><td></td><td></td><td></td><td>0.75</td><td>0.49,<br>1.21</td><td>0.2</td><td>1.14</td><td>0.49,<br>3.14</td><td>0.8</td></tr><tr><td>SI VAS (15 last days<br>maximum)</td><td></td><td></td><td></td><td></td><td></td><td></td><td>1.13</td><td>0.93,<br>1.44</td><td>0.2</td><td>1.21</td><td>0.96,<br>1.62</td><td>0.14</td><td>2.04</td><td>0.78,<br>6.90</td><td>0.2</td></tr><tr><td>Psychological pain * SI</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>2.08</td><td>1.31,<br>3.58</td><td><strong>0.004</strong></td></tr></tbody></table>

Age was treated as a continuous variable. Anxiety disorders were coded as present/absent based on MINI-5 diagnosis.

Psychological pain and Suicidal Ideation (SI) were measured with Visual Analog Scales (maximum during the last 15 days, 0–10 scale).

<caption>**Table 5**</caption>

Association between anxiety disorders and lifetime suicide attempt history (Multivariate analysis).

<table><thead><tr><th rowspan="2">Characteristic</th><th colspan="3">Model 1</th><th colspan="3">Model 2</th></tr><tr><th>OR<sup>1</sup></th><th>95% CI<sup>1</sup></th><th>p-value</th><th>OR<sup>1</sup></th><th>95% CI<sup>1</sup></th><th>p-value</th></tr></thead><tbody><tr><td>Age</td><td>0.97</td><td>0.95,<br>0.99</td><td><strong>&lt;0.001</strong></td><td>0.97</td><td>0.95,<br>0.99</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>Male</td><td>1.03</td><td>0.64,<br>1.65</td><td>0.9</td><td>1.03</td><td>0.63,<br>1.64</td><td>&gt;0.9</td></tr><tr><td>Beck Depression Inventory total score</td><td>0.99</td><td>0.96,<br>1.03</td><td>0.6</td><td>0.99</td><td>0.96,<br>1.03</td><td>0.6</td></tr><tr><td>Lifetime SA history</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>Yes</td><td>2.45</td><td>1.49,<br>4.16</td><td><strong>&lt;0.001</strong></td><td>1.74</td><td>0.75,<br>4.57</td><td>0.2</td></tr><tr><td>Anxiety disorders</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>-</td><td>-</td><td></td><td>-</td><td>-</td><td></td></tr><tr><td>Yes</td><td>1.53</td><td>0.97,<br>2.45</td><td>0.074</td><td>1.05</td><td>0.42,<br>2.87</td><td>&gt;0.9</td></tr><tr><td>Lifetime SA History * Anxiety disorders</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes * Yes</td><td></td><td></td><td></td><td>1.62</td><td>0.53,<br>4.68</td><td>0.4</td></tr></tbody></table>

Age was treated as a continuous variable. Anxiety disorders were coded as present/absent based on MINI-5 diagnosis.

Psychological pain and Suicidal Ideation (SI) were measured with Visual Analog Scales (maximum during the last 15 days, 0–10 scale).

interacting with a higher level of maximum psychological pain, and younger age. These results highlight that, aside from the common role of high maximum suicidal ideation, possible distinct risk factors for the transition to suicide attempt emerge depending on whether or not patients have a history of prior suicide attempt, reinforcing the clinical

relevance of analyzing these groups separately. However, although, anxiety disorders were found to be associated with suicide attempt only in patients with a history of prior attempt, the strength of this association did not statistically differ across subgroups. This suggests that subgroup-specific effects may partly reflect differences in statistical power.

## 4.2. Common risk factor regardless of suicide attempt history

The only common risk factor for suicide attempt among hospital-based patients with current baseline suicidal ideation, regardless of whether they had a history of lifetime suicide attempt, was the higher intensity of maximum suicidal ideation. This finding underscores the importance and necessity of targeting suicidal ideation in clinical practice, as well as the usefulness of the PPP-VAS in assessing suicidal ideation. Suicidal ideation is often viewed as a symptom or consequence of a major depressive episode, and as a result, clinicians typically aim to reduce suicidal ideation by treating depression with antidepressants (Courtet et al., 2020; Zimmerman et al., 2013). However, numerous studies have shown that patients with current suicidal ideation are less responsive to antidepressant treatments, and that suicidal depression (i. e., depression with current suicidal ideation) may represent a distinct subtype of depression with its own pathophysiology, clinical characteristics, and unique course (Nobile et al., 2021a; Nobile et al., 2020; Nobile et al., 2021b; Nobile et al., 2022; Batterham et al., 2019; van Ballegooijen et al., 2019; Köhler-Forsberg et al., 2017; Lopez-Castroman et al., 2016). Interestingly, in our study, depression severity was not predictive of suicide attempt among ideators. This is consistent with previous large epidemiological studies that found mood disorders to be predictive of suicidal ideation but not of suicidal acts (Nock et al., 2009). This finding also reinforces the hypothesis that suicidal ideation and depression are associated but can evolve independently, and that depression severity has a different impact on suicide risk compared to the maximum level of suicidal ideation. Based on these findings, along with the results of our study, it appears crucial to prioritize the rapid and effective treatment of suicidal ideation, particularly in patients experiencing high levels of maximum suicidal ideation, as a means of preventing suicide attempts. Although our study did not directly evaluate specific treatments, our findings underline the importance of targeting suicidal ideation to prevent suicide attempts. Although the transition to suicide attempt often occurs over a longer timeframe, acute crises

<footnote n="1">¹ OR = Odds Ratio, CI = Confidence Interval.</footnote>

<footnote n="1">¹ OR = Odds Ratio, CI = Confidence Interval.</footnote>
characterized by intense suicidal ideation may require immediate in-
terventions such as ketamine to reduce short-term risk (Abbar et al.,
2022; Andrade, 2018; Ballard et al., 2014; Grunebaum et al., 2018).
Additionally, specific cognitive behavioral therapies (CBT) (e.g.,
acceptance and commitment therapy, brief CBT targeting suicidal
ideation) have shown efficacy in reducing suicidal ideation and should
be offered to patients with high levels of maximum suicidal ideation
(Ducasse et al., 2018a; Van Ballegooijen et al., 2025; Bryan et al., 2018).
Indeed, for example, brief CBT for Suicide Prevention (BCBT-SP) has
shown efficacy in reducing suicide attempts, particularly in high-risk
patients (Diefenbach et al., 2024). It includes crisis response planning,
emotion regulation, and strategies for managing suicidal thoughts, of-
fering tools that are both rapid and adaptable to acute risk. Similarly, the
Collaborative Assessment and Management of Suicidality (CAMS) is a
flexible, suicide-specific intervention that emphasizes collaboration and
targets core drivers of suicidal ideation—such as psychological pain and
hopelessness—through the use of the Suicide Status Form and individ-
alized stabilization plans (Swift et al., 2021). These interventions and
their components provide evidence-based tools to reduce suicidal
ideation and manage acute distress.

4.3. *Specific risk factor among patients with a history of suicide attempt*

In the group of patients with a history of lifetime suicide attempt, the
second most important risk factor for suicide attempt during the one-
year follow-up was having a comorbid anxiety disorder. This finding is
consistent with previous research demonstrating a strong association
between anxiety and suicide risk (Nobile et al., 2024; Baek et al., 2015;
Batterham et al., 2013; Busby Grant et al., 2023). For example, a recent
study assessing risk factors for suicide re-attempt in a large cohort of
recent suicide attempters over a two-years follow-up period found that
trait anxiety was one of the strongest risk factors for re-attempt (Nobile
et al., 2024). These findings emphasize the importance of specifically
addressing anxiety disorders in patients with a history of suicide
attempt. Nevertheless, a formal statistical test of interaction between
anxiety disorders and suicide attempt history did not reach significance,
suggesting that the strength of this association did not differ signifi-
cantly between the two groups. This finding may reflect a lack of sta-
tistical power in the subgroup without prior attempt, given the lower
number of events, rather than a true absence of effect. Therefore, while
our stratified analyses highlight clinically relevant patterns, they should
be interpreted cautiously and not necessarily as evidence of distinct
mechanisms. However, clinicians should systematically screen for co-
morbid anxiety disorders and, if necessary, provide targeted in-
terventions, including specific pharmacological treatments and
psychotherapies. However, regarding the treatment of anxiety disorders,
clinicians should limit as much as possible the use of benzodiazepines
and pregabalin, given the high suicidal risk associated with these med-
ications (Tournier et al., 2023; Dodds, 2017; Tracy, 2019). Interestingly,
in our study, univariate analysis revealed an association between the
absence of a history of severe suicide attempt and an increased risk of
suicide attempt during follow-up. This suggests that patients with a
history of severe suicide attempt may have a lower risk of re-attempting
suicide. This phenomenon may be related to the trauma of being hos-
pitalized in an intensive care unit, as suggested by other studies (Nohl
et al., 2022; Pajonk et al., 2005). Hospitalization in intensive care units
is often a traumatic experience, and patients with a history of severe
suicide attempt may avoid re-attempt due to a fear of being hospitalized
again in such units.

4.4. *Specific risk factors among patients without a history of suicide attempt*

Among patients with no history of suicide attempt, the other main
risk factors for suicide attempt during the one-year follow-up were
younger age and higher levels of maximum psychological pain, in

addition to higher levels of maximum suicidal ideation. Psychological
pain is well documented as being strongly associated with both suicidal
ideation and the risk of suicide attempt (Alacreu-Crespo et al., 2020;
Conejero et al., 2018; Ducasse et al., 2018b). For instance, a study
conducted in patients with major depressive episode found that higher
levels of psychological pain were associated with a 1.35-fold increased
risk of suicidal events (i.e., suicide attempt or hospitalization for suicidal
ideation) over six months of follow-up, independent of psychotropic
medications, prior suicide attempt, depressive symptoms, or psychiatric
comorbidities (Alacreu-Crespo et al., 2020). Moreover, this finding
supports the Three-Step Theory of Suicide, suggesting that psychological
pain not only contributes to the emergence of suicidal ideation but also
amplifies its intensity, thereby increasing the likelihood of a suicide
attempt, particularly among individuals without prior attempts. In our
study, the significant interaction between maximum suicidal ideation
and maximum psychological pain was found only in patients without a
history of suicide attempt, but not among those with such a history,
reinforcing the Three-Step Theory of Suicide hypothesis that psycho-
logical pain plays a critical role in the transition to action mainly when
the capability for suicide has not yet been acquired. These findings
underscore the necessity of focusing on the management of psycholog-
ical pain in hospital-based patients with current baseline suicidal idea-
tion, particularly among those with high levels of maximum suicidal
ideation. Unfortunately, there is no existing pharmacological treatment
specifically targeting psychological pain, although recent evidences
suggest a positive effect of ketamine on psychological pain (Johnston
et al., 2024). Psychological interventions such as CAMS, which specif-
ically assess and address the drivers of suicidal suffering—including
psychological pain—may also offer promising avenues for non-
pharmacological management in clinical settings (Swift et al., 2021).
Given the strong association between psychological pain and suicide
risk, it is crucial to conduct further research to better characterize psy-
chological pain, understand its pathophysiology, and identify specific
therapeutic targets. In the absence of such treatments, clinicians should
pay close attention to patients exhibiting both high psychological pain
and suicidal ideation and should provide close monitoring to mitigate
the risk of suicide in these patients. In addition, the proportion of pa-
tients progressing to a suicide attempt was higher among those with a
history of lifetime suicide attempts (20.2 %) compared to those without
(9.6 %), supporting both the Interpersonal Theory of Suicide and the
Three-Step Theory of Suicide, which posit that the acquired capability
for suicide significantly increases the risk of suicidal behavior. Together,
these findings provide empirical support for ideation-to-action models
of suicide and highlight the importance of considering both psycholog-
ical pain and acquired capability when assessing the short-term risk of
suicidal behavior.

4.5. *Limits of the current study*

Our study has some limitations. First, due to the small number of
patients with current suicidal ideation and no history of lifetime suicide
attempt, it was not possible to include a wide range of variables in the
multivariate analysis. Additionally, it was not feasible to include the
history of severe suicide attempt in the multivariate analysis for patients
with a history of suicide attempt, as there were too few patients with
such histories to perform meaningful adjustments. Another limitation of
the present study is that the sample was entirely recruited from a single
hospital setting (both inpatients and outpatients), which may restrict the
generalizability of the findings. A significant proportion of individuals
with suicidal ideation do not present to healthcare or hospital services
(Stene-Larsen and Reneflot, 2019). Therefore, our results may primarily
apply to hospital-treated patients with suicidal ideation, rather than to
all individuals experiencing suicidal thoughts in the general population.
In addition, the classification of patients based on their history of suicide
attempt relied on self-reported information collected by clinicians.
Although self-report is widely used in clinical settings, it may be subject
to recall or reporting biases. Nevertheless, previous studies have sug-
gested that such biases are less frequent among individuals with current
mood disorders or suicidal ideation (Klimes-Dougan et al., 2022).
Although the study used a longitudinal design with one-year follow-up,
the naturalistic framework and lack of predefined hypotheses limit the
interpretation of our findings in terms of underlying mechanisms of
action. Therefore, while associations were identified, causal inferences
or mechanistic explanations should be drawn with caution. Moreover,
the naturalistic design of our study also precluded the assessment of
certain variables known to be associated with suicide attempt, such as
impulsivity. While it is acknowledged that some suicide attempts and
deaths may occur impulsively or without prior reported suicidal idea-
tion, the primary aim of this study was to specifically identify risk factors
associated with the transition from reported suicidal ideation to suicide
attempt. Furthermore, variables such as impulsivity are not routinely
assessed in clinical practice, whereas the factors identified in our study
are typically evaluated during standard clinical assessments, thus
enhancing their practical relevance. Then, suicidal ideation was assessed
only at baseline, and no formal distinction was made between passive
and active forms. However, given the one-year follow-up period, passive
ideation at baseline could plausibly evolve into active ideation or result
in a suicide attempt. Moreover, passive suicidal ideation has also been
shown to predict future suicidal behavior (Baca-Garcia et al., 2011). This
limitation, though important, is consistent with many studies in the
ideation-to-action framework relying on baseline assessments. Finally,
suicidal ideation was measured at a single time point, and our design did
not capture its short-term fluctuations, as demonstrated in ecological
momentary assessment studies (Kleiman et al., 2017; Hallensleben et al.,
2019). These studies show that suicidal ideation can vary substantially
within hours, and that its short-term predictors may differ from those
assessed at baseline. While our study does not aim to address short-term
prediction, it provides insights into baseline characteristics associated
with future suicide attempts among individuals presenting with current
suicidal ideation, in line with the ideation-to-action framework. We
acknowledge that this approach has limitations in terms of real-time
prediction, as emphasized by recent critiques (Franklin et al., 2017),
and that further research using intensive longitudinal methods is
needed. Despite these limitations, our study has several strengths. Its
longitudinal design enabled the assessment of suicide risk among cur-
rent ideators over the year following the onset of suicidal ideation,
filling a gap in research on the ideation-to-action framework. Moreover,
unlike many studies that focus on patients with a history of lifetime
suicidal ideation, our study specifically examined patients with current
suicidal ideation. In addition, the consistency of our findings across both
logistic regression and Cox proportional hazards models reinforces the
robustness of our results, as two different statistical approaches yielded
convergent conclusions regarding the main risk factors for suicide
attempt. The large sample size also allowed for separate analyses of
patients with and without a history of lifetime suicide attempt. This
distinction is particularly important because patients with a history of
suicide attempt differ from those without, not only in terms of baseline
characteristics but also in the specific risk factors for transitioning to a
suicide attempt. Therefore, merely adjusting for prior suicide attempts
would have been insufficient to fully capture these differences, and
stratified analyses provided novel and clinically relevant insights into
distinct pathways to suicidal behavior. While our study was not designed
to serve as a predictive model for individual suicide risk, it aligns with
recent recommendations (e.g., such as those outlined in Franklin et al.
(Franklin et al., 2017)) to improve suicide risk assessment by using more
refined methodological approaches. Specifically, our longitudinal and
stratified design enabled the identification of subgroup-specific risk
factors that may otherwise be obscured in unstratified samples.
Although no single risk factor offers strong predictive value on its own,
identifying clinically significant correlates of suicidal behavior remains
essential.

5. Conclusions

In conclusion, our findings highlight the importance of promptly
addressing high-intensity suicidal ideation in all hospital-based patients
with mood disorders, regardless of prior suicide attempts. While
maximum suicidal ideation was a common risk factor, other predictors
seem to differ by subgroup: psychological pain was especially relevant in
patients without prior attempt, whereas anxiety disorders may play a
greater role in those with a history of attempt. These findings support
the need for both general and stratified approaches in suicide preven-
tion, adapted to patients' clinical histories and current symptomatology.
Suicidal ideation and its associated risk factors, particularly anxiety and
psychological pain, should be managed using evidence-based and
person-centered pharmacological, psychotherapeutic, and psychosocial
strategies.

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jad.2025.119854.

CRediT authorship contribution statement

**B. Nobile:** Writing – original draft, Conceptualization. **E. Gourguechon-Buot:** Formal analysis. **E. Olié:** Writing – review & editing, Conceptualization. **Ph. Courtet:** Writing – review & editing, Supervision, Conceptualization.

Declaration of Generative AI and AI-assisted technologies in the
writing process

During the preparation of this work the author(s) used ChatGPTo1 to
improve English of the manuscript. After using this tool/service, the
author(s) reviewed and edited the content as needed and take(s) full
responsibility for the content of the publication.

Funding

This study did not receive funding from any sources. The research did
not receive specific funding but was performed as part of the employ-
ment of the authors: CHU Montpellier, France.

Declaration of competing interest

None of the authors declare conflict of interests related to this
manuscript.

Acknowledgements

None.

Data availability

Due to ethical and legal restrictions, data involving clinical partici-
pants cannot be made publicly available.

References

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