Suicide attempts and suicidal ideation: links with psychiatric comorbidity in eating disorder subjects Gabriella Milos, M.D.*, Anja Spindler, Ph.D., Urs Hepp, M.D., Ulrich Schnyder, M.D. Psychiatric Department, University Hospital, Zurich, Switzerland Received 21 May 2003; accepted 21 October 2003 Abstract Additional psychiatric disorders in eating disorders patients may contribute to the risk of suicide and suicide attempts. The aim of this study was to examine associations between Axes I and II comorbidity and suicidality in a large sample of women currently suffering from an eating disorder (ED). In a sample of 288 women (87 anorexia nervosa, 158 bulimia nervosa, 43 eating disorders not otherwise specified) psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview for DSM-IV. Histories of attempted suicide were explored in a structured interview. Suicidal ideation was determined by means of the SCL-90. Past suicide attempts were reported by 26%. Subjects with a purging type ED more frequently had a history of attempted suicide than subjects with a nonpurging type ED. A history of suicide attempts was associated with higher levels of Axes I and II comorbidity, in particular with affective disorders and Cluster B personality disorders. Current suicidal ideation was generally linked with higher levels of all types of Axes I and II comorbidity. Eating disorders are serious psychiatric disorders associated with high levels of comorbidity and suicidality. Incorporating a comprehensive psychiatric evaluation into the clinical assessment of ED patients is important for the assessment of suicidality and for the provision of adequate treatments. © 2004 Elsevier Inc. All rights reserved. Keywords: Eating disorders; Comorbidity; Suicidality; Attempted suicide; Suicide ideation 1. Introduction Suicide attempts and suicidal ideation are risk factors for suicide [1,2] and are thus indicators of suicidality, i.e., a person’s propensity to commit suicide or suicide attempts. The WHO/EURO multicenter study [3] defines suicide at- tempt as “an act with nonfatal outcome, in which an indi- vidual deliberately initiates a nonhabitual behavior that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expressed physical consequences.” The term sui- cidal ideation refers to the occurrence of any thoughts about self-destructive behavior, whether or not death is intended. Such thoughts may range from vague ideas about the pos- sibility of ending one’s life at some point in the future to very concrete plans of committing suicide [4]. Suicide attempt and completed suicide share common features, and the relative risk for suicide in a population of suicide attempters is about 40 times higher than expected in the general population and remains elevated even in the long term [5,6]. Almost all mental disorders are associated with increased suicide attempt and suicide risk [5,7–9]. In women with eating disorders (ED) the prevalence of suicide attempts is markedly increased compared with noneating disordered women from community samples [10,11]. The clinical significance of suicide in eating disorders is indi- cated by studies showing that in patients with anorexia nervosa, suicide is an important contributor to high mortal- ity [12–14]. Eating disorders have a suicide risk comparable with that of other severe mental disorders [5], for example major depression [15]. Bulik et al. found no significant difference in the reported history of suicide attempts be- tween anorexia nervosa, bulimia nervosa, and major depres- sion. On the other hand, Favaro and Santonastaso [11] reported significant differences between ED diagnostic groups. Psychiatric comorbidity of Axes I and II is often high in subjects with eating disorders [16,17]. The presence of additional psychiatric disorders may contribute, together * Corresponding author. Tel.: +411-255-52-80; fax: + 411-255-45-30. E-mail address: gabriella.milos@psy.usz.ch (G. Milos). General Hospital Psychiatry 26 (2004) 129 –135 0163-8343/04/$ – see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2003.10.005