Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies
Open accessAbstract
Background: A history of self-injurious thoughts and behaviors (SITBs) is consistently cited as one of the strongest predictors of future suicidal behavior. However, stark discrepancies in the literature raise questions about the true magnitude of these associations. The objective of this study is to examine the magnitude and clinical utility of the associations between SITBs and subsequent suicide ideation, attempts, and death. Method: We searched PubMed, PsycInfo, and Google Scholar for papers published through December 2014. Inclusion required that studies include at least one longitudinal analysis predicting suicide ideation, attempts, or death using any SITB variable. We identified 2179 longitudinal studies; 172 met inclusion criteria. Results: The most common outcome was suicide attempt (47.80%), followed by death (40.50%) and ideation (11.60%). Median follow-up was 52 months (mean = 82.52, s.d. = 102.29). Overall prediction was weak, with weighted mean odds ratios (ORs) of 2.07 [95% confidence interval (CI) 1.76–2.43] for ideation, 2.14 (95% CI 2.00–2.30) for attempts, and 1.54 (95% CI 1.39–1.71) for death. Adjusting for publication bias further reduced estimates. Diagnostic accuracy analyses indicated acceptable specificity (86–87%) and poor sensitivity (10–26%), with areas under the curve marginally above chance (0.60–0.62). Most risk factors generated OR estimates of <2.0 and no risk factor exceeded 4.5. Effects were consistent regardless of sample severity, sample age groups, or follow-up length. Conclusions: Prior SITBs confer risk for later suicidal thoughts and behaviors. However, they only provide a marginal improvement in diagnostic accuracy above chance. Addressing gaps in study design, assessment, and underlying mechanisms may prove useful in improving prediction and prevention of suicidal thoughts and behaviors.
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No single risk factor, whether previous suicidal ideation or behaviour, mental health disorder, or other psychological traits, is a strong predictor of suicidal behaviour.
“As previously mentioned, no single risk factor, whether previous suicidal ideation or behaviour, mental health disorder, or other psychological traits, is a strong predictor of suicidal behaviour 203,204 .”
From Suicide and suicide risk (2019) · cites this paper as [204]
The Discussion (page unavailable) concludes that prior self-injurious thoughts and behaviors are weak predictors in absolute terms, and the Results report poor accuracy for predicting suicide death. The meta-analysis examines those prior thoughts and behaviors, not whether mental health disorders or other psychological traits are individually weak predictors; the claim extends beyond its findings. (LLM, conf=0.88)
Experimental — accuracy not yet measuredEngaging in NSSI increases the risk of subsequent suicidal ideation, suicide attempts, and death by suicide.
“A growing body of evidence demonstrates that engaging in NSSI increases the risk of subsequent suicidal ideation, suicide attempts, and death by suicide [5, 7, 27, 63].”
From Does treatment method matter? A meta-analysis of the past 20 years of research on therapeutic interventions for self-harm and suicidal ideation in adolescents (2020) · cites this paper as [63]
The Results (Risk factor category analyses; page not provided) report that prior NSSI was associated with significantly increased odds of a later suicide attempt (weighted mean OR 4.27). The same passage says there were insufficient cases to test NSSI’s association with later suicidal ideation or death by suicide, so this source does not establish those two parts of the claim. (LLM, conf=0.91)
Experimental — accuracy not yet measuredTypical behavioral manifestations of emotion dysregulation, such as self-harm, suicidal ideation, eating disorder behaviors, or substance abuse, are associated with increased morbidity and mortality.
“Additionally, typical behavioral manifestations of emotion dysregulation, such as self-harm, suicidal ideation, eating disorder behaviors, or substance (ab)use, are associated with increased morbidity and mortality (4–7).”
From Radical Acceptance of Reality: Putting DBT®-A Skill Groups Online During the COVID-19 Pandemic: A Qualitative Study (2022) · cites this paper as [6]
The Results (Risk factor category analyses; page unavailable) link prior suicidal ideation and self-injurious thoughts and behaviors to increased odds of later suicide attempts and death. The paper does not establish eating-disorder behaviors or substance use as manifestations of emotion dysregulation associated with increased morbidity and mortality, so it supports only part of the sentence. (LLM, conf=0.88)
Experimental — accuracy not yet measuredA prior suicide attempt confers a significantly higher odds of experiencing a future suicide attempt compared to ideation.
“As a prior suicide attempt confers a significantly higher odds of experiencing a future suicide attempt compared to ideation [5]”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [5]
The Results (Risk factor category analyses; page unavailable) report that a prior suicide attempt was associated with higher odds of a future attempt (weighted mean OR 3.61) than of future ideation (OR 1.58). Both associations were statistically significant, but the passage does not establish that the difference between those two odds ratios was itself statistically significant. (LLM, conf=0.81)
Experimental — accuracy not yet measuredPrior suicidal ideation and behaviors are relatively weak predictors of future suicidal behavior; in most studies only a minority of those who attempt suicide are likely to do so again.
“Even the effects of prior suicidal ideation and behaviors are relatively weak in predicting future suicidal behavior (Ribeiro et al. 2016), reflecting that in most studies, only a minority of those who attempt suicide are likely do so again.”
From Adolescent Suicide as a Failure of Acute Stress-Response Systems. (2019) · cites this paper as Ribeiro et al. 2016
Adolescents who engage in NSSI or make suicide attempts are significantly more likely to engage in future suicidal behavior, especially within the first few months after an attempt.
“Adolescents who engage in NSSI or make suicide attempts are significantly more likely to engage in future suicidal behavior (Ribeiro et al. 2016), especially within the first few months following an attempt (Goldston et al. 2001)”
From Adolescent Suicide as a Failure of Acute Stress-Response Systems. (2019) · cites this paper as Ribeiro et al. 2016
Suicidal ideation does not lead to suicidal behaviour in the vast majority of those affected.
“While suicidal ideation does not lead to suicidal behaviour in the vast majority of those affected (3)”
From Ambivalence model of suicidality [ABS-model]: an orientation model for the treatment of suicidal individuals (2024) · cites this paper as [3]
Pooled findings indicate that the odds of a future suicide attempt are 1.88 times higher among individuals with suicidal ideation than those without.
“Although pooled findings indicate that the odds of a future suicide attempt are only 1.88 times higher among individuals with suicidal ideation than those without [5]”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [5]
Suicidal ideation is estimated to double the risk of suicide.
“Suicidal ideation is estimated to double the risk of suicide (Ribeiro 2016).”
From Prevention of self-harm and suicide in young people up to the age of 25 in education settings (2024) · cites this paper as Ribeiro 2016
Self-harm and suicidal ideation are known to increase the risk of suicide.
“Instead, we measured self-harm and suicidal ideation, both known to increase the risk of suicide (Hawton 2015a; Ribeiro 2016).”
From Prevention of self-harm and suicide in young people up to the age of 25 in education settings (2024) · cites this paper as Ribeiro 2016
NSSI is a risk factor for suicide attempts in the general population.
“Non-suicidal self-injury (NSSI) is a risk factor for suicide attempts in the general population [9].”
From Risk markers for suicidality in autistic adults (2018) · cites this paper as [9]
NSSI in the general population is considered a possible risk marker for later suicide attempts.
“By contrast NSSI in the general population is considered a possible risk marker for later suicide attempts [9].”
From Risk markers for suicidality in autistic adults (2018) · cites this paper as [9]
Meta-analyses of longitudinal studies have highlighted suicidal ideation, previous self-harm, and psychiatric disorders as replicated risk factors.
“Meta-analyses of longitudinal studies have highlighted suicidal ideation, previous self-harm, and psychiatric disorders as replicated risk factors,68, 69, 70, 71, 72”
From Risk factors for self-harm in prison: a systematic review and meta-analysis (2020) · cites this paper as [69]
Previous self-harm is among the strongest predictors of future self-harm and suicide.
“Given that previous self-harm is among the strongest predictors of future self-harm68, 69, 70 and suicide,9, 10”
From Risk factors for self-harm in prison: a systematic review and meta-analysis (2020) · cites this paper as [69]
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References 55 · Cited by 1,346
- Authors
- Ribeiro, J. D., Franklin, J. C., Fox, K. R., Bentley, K. H., Kleiman, E. M., Chang, B. P., & Nock, M. K.
- Affiliations
- Florida State University (US)
- Harvard University (US)
- Boston University (US)
- Columbia University (US)
- Corresponding author
- Ribeiro, J. D.
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2015-09-15
- Volume
- 46
- Issue
- 2
- Pages
- 225-236
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- PMC
- PMC4774896
- OpenAlex
- W1893670457
- Cited by
- 1,346
- References
- 55
- Citations by year
- 2026: 168 · 2025: 158 · 2024: 172 · 2023: 156 · 2022: 141 · 2021: 154 · 2020: 143 · 2019: 95 · 2018: 84 · 2017: 55 · 2016: 18 · 2014: 1
- FWCI
- 7.51
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Psychological Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- Funders
- U.S. Department of Defense (W81XWH, W81XWH1020181)
- University of Cambridge
- National Institute of Mental Health (T32 MH 18921, T32MH018921)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Sociology and Political Science › Homicide, Infanticide, and Child Abuse
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Keywords
- self-injurious thoughts and behaviors, suicidal ideation, suicide attempts, suicide mortality, suicide risk prediction, diagnostic accuracy, publication bias, suicide prevention
- MeSH terms
- Humans, Longitudinal Studies, Mortality, Risk Factors, Suicide, Suicide, Attempted, Self-Injurious Behavior, Suicidal Ideation
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