The suicide rate in Korea has been the highest of those among the Organization for Economic Cooperation and Development countries since 2003, and in 2013, it was 1.53 times higher than that of Japan, the country with the second-highest suicide rate.1 Although the suicide rate in Korea has decreased since 2015, suicide was the fifth leading cause of death, with 26.5 deaths per 100,000 persons, in 2015. Furthermore, more than 13,000 people died by suicide in 2015, and the number of suicide-bereaved individuals — secondary victims of suicide — is estimated to exceed 80,000 annually.23 Suicide or suicide attempts can cause physical injury and psychological trauma, increase medical and social costs, and lead to loss of life and family breakups; therefore, government policies for suicide prevention are required.4

Suicide victims and survivors differ in terms of demographic and clinical factors as well as the factors related to suicide.23 According to the analysis on suicide statistics in 2015, hanging was the most common method of successful suicide, followed by gas inhalation and jumping from heights, whereas drug overdose was most common among suicide survivors, followed by cutting and hanging.3 In addition, suicide survivors can be classified into 2 types — those whose attempts are intentional and those who engage in non-suicidal self-harm.5 As demographic and clinical data, as well as a number of factors related to suicide, differ between the 2 groups, interventions aimed at those whose attempts are intentional must take a different approach from non-suicidal self-harm interventions.5 According to the model suggested by O'Connell et al.,6 suicide is a serial process encompassing ideation, planning, attempts, and completion. Attempted suicide is the stage immediately preceding death by suicide, and a history of attempted suicide is known to be the highest predictor of further suicide attempts or death by suicide.7 Therefore, we hypothesized that suicide attempters with higher suicidal intent have similar characteristics to those who have died by completing suicide; identifying these characteristics could provide important baseline data for developing interventions for suicide prevention.

In their examination of suicide attempters, several studies have focused on suicidal intent. Sisask et al.8 reported that age is an important factor in determining suicide risk, as the strength of suicidal intent increases with age. Niméus et al.9 reported that the strength of suicidal intent is an important predictor of suicide in elderly suicide attempters. However, while numerous studies have been conducted to examine other suicide-related topics in Korea, few have focused on suicidal intent in suicide attempters. Furthermore, these studies had limitations in that they studied people who had died by suicide,1011 or had a history of attempted suicide, as opposed to current suicide attempters,12 or that they reported only the demographic and suicide-related behavioral characteristics in suicide attempters.131415 Moreover, although the Korean government has provided wide-ranging suicide statistics, in-depth data regarding the characteristics of suicide attempters are lacking; therefore, studies examining suicidal intent in suicide attempters are needed to improve the effectiveness of suicide prevention strategies.

Accordingly, this study aimed to examine the differences in demographic, suicide-related, and clinical variables, including psychological and psychosocial characteristics, based on the strength of suicidal intent in suicide attempters who had been admitted to emergency departments.

This study analyzed the demographic, psychosocial, suicide-related, and clinical characteristics of 328 suicide attempters who were admitted to the emergency departments at one of the 5 university hospitals in Daegu-Gyeongbuk province. Our study used credible data based on various ratings by trained clinicians in the emergency department. The results regarding the characteristics of individuals who had attempted suicide and exhibited strong suicidal intent could serve as a theoretical foundation for the development of effective suicide prevention policies.

With regard to age, individuals who exhibited higher suicidal intent were older, on average, which is consistent with the findings of previous studies in which older people' scores on suicidal intent scales were higher than those observed in younger people.924 Similar to the existing reports, the results of the present study showed that the proportion of suicide attempters among adolescents and the elderly were high.1425 Furthermore, while the proportion of subjects who were younger than 17 years tended to increase as the strength of suicidal intent decreased, the proportion of subjects who were older than 66 years tended to increase as the strength of suicidal intent increased.

There were group differences in the main reasons for attempting suicide and the methods used in suicide attempts. Depression was reported as the reason for attempting suicide by most subjects in the high-intent group, while relationship problems were reported as the main reason for attempting suicide by subjects in the low-intent group. These results support those of previous studies in which depression was the highest risk factor for death by suicide.7262728 Some studies have reported that family relationship problems, including problems with spouses, parents, and children, were the main reason for attempted suicide.2930 However, these results could have been affected by suicidal intent. Our study suggests that relationship problems and external stress are considered the main reasons for attempted suicide, while depression is a key predictor of the severity of injury in attempted suicide. It is known that suicide methods used by people with stronger suicidal intent are more lethal relative to those used by people with weaker suicidal intent. However, in this study, there were no significant differences in suicidal methods between the 3 groups. This could be explained by the fact those with very high suicidal intent and those who had used very lethal methods generally did not agree to participate in the study. Meanwhile, there was a report31 that suicide methods are not significantly related to suicidal intent. With respect to the timing of suicide attempts, the proportion of subjects who attempted suicide at night was more than twice the proportion of subjects who attempted suicide during the day in the low-intent group. There is no consensus in the existing literature regarding the most common time of day at which suicide is attempted.3233 Considering the place where suicide attempts were most commonly made — home — the low-intent group in our study tended to attempt suicide at night, when they were more likely to be discovered or helped by caregivers.

The proportions of premeditation and subjects who expressed an intention to attempt suicide again were the highest in the high-intent group. Although the findings of some studies have indicated that suicidal intent scales are not useful for predicting suicide,3435 the findings of this study are consistent with those of studies in which people with high suicidal intent were more likely to attempt suicide repeatedly.9 Increasing numbers of suicide attempts have been revealed as a reliable predictor of future death by suicide.3637 Therefore, our findings imply that the use of active, objective evaluations of suicidal intent, as opposed to mere questioning during interviews of patients at risk of suicide, would be the most effective means of predicting future suicide risk.

With regard to the subjects' presumed diagnoses, the prevalence of depressive disorder was higher than that of other conditions in all 3 groups and increased with the strength of suicidal intent, which is consistent with the findings of previous studies wherein depression was identified as a major cause of suicide and a risk factor for death by suicide.713253134 The finding that approximately 30% of the subjects in the intermediate and high-intent groups were receiving psychiatric treatment when they attempted suicide, and none of the subjects in the low-intent group had received psychiatric treatment, suggests that a history of psychiatric treatment is a major risk factor for attempted suicide. However, rather than simply concluding that a history of psychiatric treatment per se is a risk factor, researchers and clinicians should be mindful of the fact that patients with severe depression, which can translate into high suicide risk, attend mental health clinics frequently, and that people in the early stages of the disorder who have yet to experience an improvement in their symptoms remain at risk of suicide, even if they are treated at a mental health clinic. Furthermore, it should be noted that a considerable proportion (70%) of subjects who exhibited moderate or strong suicidal intent had not attended a mental health clinic. Therefore, mental health services should be promoted more actively, and institutional measures should be implemented to facilitate access to these services as a means of suicide prevention. Furthermore, the prevalence of adjustment disorder, which was the second-most prevalent diagnosis, tended to increase as the strength of suicidal intent decreased, and adjustment disorder was the presumed diagnosis for most subjects in the low-intent group. Therefore, clinicians should carefully assess the people who have recently been exposed to stressors. Adjustment disorder generally develops within 3 months of the occurrence of a stressor, and the prognosis for patients with adjustment disorder is good with appropriate early psychiatric treatment, suggesting that this could prevent suicide attempts.

We performed a logistic regression and identified depressed mood being among the reasons for attempting suicide, premeditation, sustained suicidal ideation, and HDRS scores of 18 or higher as key predictors of high suicidal intent. Therefore, meticulous attention to and observation of individuals with high suicidal intent, who were found to be at high risk of suicide in the current study, and patients with depression and suicidal intent are essential for the prevention of suicide. Furthermore, in-depth interviews should be conducted with individuals who attempt suicide, to ascertain whether their attempts were premeditated and whether they continue to experience suicidal ideation. Sisask et al.8 and Niméus et al.9 reported that the strength of suicidal intent increases with age. In this study, the regression analysis showed that higher age is not a significant risk factor. Further consideration is needed in future studies by increasing the number of subjects.

This study has some limitations. First, it did not include suicide attempters who had died following emergency medical treatment or declined to provide consent to participate. Therefore, it is possible that a considerable number of the subjects' suicide attempts involved methods with lower levels of lethality and resulted in less severe injury relative to those of people who had died by suicide. Therefore, the findings might not be generalizable to all suicide attempters admitted to emergency departments. Second, although we provided periodic training for the evaluators and tested their knowledge, the evaluations were performed by different residents from several universities, which could have affected interrater reliability. Third, our sample size was rather small, and our retrospective data could be insufficient to confirm the variables of suicidal intent.

Despite these limitations, the study is meaningful in that it included interviews with suicide attempters admitted to emergency departments and conducted in-depth assessment according to the degree of one's intent, unlike previous studies wherein medical records were reviewed retrospectively. Suicidal thoughts, plans, and attempts are, in fact, different. It is hard to say that all the people who visit the emergency room because of a suicide attempt have high suicidal intent. In other words, many of those who visited emergency rooms were there because of non-suicidal self-harm. Such people are less likely to commit imminent suicide than high-intent attempters, which calls for different therapeutic interventions.5 Sometimes hospitalization is not necessary for them. Since previous suicide attempts are the most powerful risk factor for suicide, it is important to select a group of people who are in emergency rooms because they clearly intend to commit suicide and examine their characteristics. Kawanishi et al.38 performed a multicenter, randomized controlled trial to determine whether assertive case management is feasible in real-world clinical settings for suicidal patients with psychiatric disorders admitted to the emergency department. Although it was not effective in reducing the incidence of repetition of suicide attempts in the long term, the results of their ad-hoc analyses suggested that it was effective for up to 6 months. In Japan, since this study, the emergency-based suicide management program has been expanded with medical insurance support, which actually helped reduce the suicide rate.

This study aimed to identify the risk factors for high suicidal intent by comparing demographic and clinical characteristics between suicide attempters admitted to emergency departments. They were divided into low, intermediate, and high-intent groups according to the degree of suicidal intent. The high-intent group was older and displayed greater depressive symptoms. Also, the proportion of subjects who reported premeditated suicide attempts and continued to experience suicidal ideation was higher in the high-intent group, relative to those observed in the other 2 groups. In multivariate analysis, depressed mood, premeditation, and HDRS scores of 18 or higher were identified as risk factors for high suicidal intent. Therefore, measures that adequately reflect these risk factors would be useful in the prevention of suicide attempts in individuals with strong suicidal intent, which could ultimately reduce the suicide mortality rate.