Gender differences in the association of agitation and suicide attempts among psychiatric inpatients Craig J. Bryan, Psy.D., A.B.P.P. a, ⁎, Mario J. Hitschfeld, M.D. b, c , Brian A. Palmer, M.D. b , Kathryn M. Schak, M.D. b , Erika M. Roberge, B.A. a , Timothy W. Lineberry, M.D. b a National Center for Veterans Studies, The University of Utah, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84112, USA b Mayo Clinic, Department of Psychiatry and Psychology, 200 First Street Southwest, Rochester, MN 55905, USA c Sotero Del Rio Hospital, Department of Psychiatry, Av. Concha y Toro 3459, Puente Alto, Santiago 8207257, Chile abstract article info Article history: Received 10 June 2014 Revised 3 September 2014 Accepted 22 September 2014 Keywords: Suicide Agitation Inpatient Gender Psychiatric hospitalization Objective: To determine if the relationship of agitation with suicide ideation and suicide attempts differed between men and women. Method: Self-reported severity of agitation and other suicide risk factors was obtained from 7698 consecutive patients during admission for inpatient psychiatric treatment during a 5-year period. Results: Agitation was highest among men with a history of suicide attempts. Agitation was significantly associ- ated with frequency of suicide ideation and history of suicide attempt, but the gender-by-suicide interaction was only significant as a predictor of suicide attempt history. For men, agitation was associated with significantly in- creased risk for suicide attempt, but for women, agitation was not associated with risk for suicide attempt history. Results were unchanged when analyses were repeated among the subgroup of patients with suicide ideation. Conclusions: Agitation is associated with history of suicide attempt among male but not female psychiatric inpa- tients. Agitation differentiates between those men who have only thought about suicide and those who have made suicide attempts. © 2014 Elsevier Inc. All rights reserved. 1. Introduction Over 32,000 individuals die by suicide in the United States each year, placing suicide among the leading causes of death [1]. Results of meta- analyses [2] and prospective studies indicate that suicide attempts, defined as self-enacted, potentially injurious behaviors with nonfatal outcomes for which there is evidence of intent to die [3], are among the strongest risk factors for death by suicide [4–7]. Suicide attempts appear to confer persistent vulnerability for death by suicide over time, even many years after an individual's initial suicide attempt [8], which aligns with the fluid vulnerability theory (FVT) of suicide [9]. The FVT posits that overall suicide risk entails the interaction of aggravating variables with an individual's predisposing vulnerability for suicide, such that aggravating variables contribute to acute suicidal episodes and lead to suicide attempts only in the presence of sufficient vulnera- bility. According to the FVT, the reason why some acutely distressed individuals make suicide attempts but others do not is that the former group has a greater predisposition to suicide. Predispositions to suicide include demographic and historical variables that are relatively static in nature, such as genetic or biological vulnerabilities, race, gender, psychiatric conditions and previous suicide attempts. Aggravating variables, by contrast, include relatively short- term or acute risk factors such as depression, hopelessness, agitation and suicide ideation. Of the many aggravating risk factors that have been empirically identified, physiological agitation has received consid- erable empirical and clinical attention and is considered by experts to be a particularly important short-term indicator or warning sign for suicide attempts [10]. Clinically, agitation has been described as an acute state of psychological and physiological overarousal often characterized by behavioral restlessness emotional unrest [11]. Consistent with this gen- eral definition, Koukopoulos and Koukopoulos [11] have proposed that agitated mood states include at least two of the following signs and symptoms: motor agitation, psychic agitation or intense inner tension, or crowded thoughts. Although agitation and aggression are associated with each other [12], the two are conceptually distinct; agitation is an internal psychophysiological state, whereas aggression is an external- ized behavior. Studies have found that agitation is observed in over 80% of suicide deaths among psychiatric inpatients [13] and patients ad- mitted to emergency departments immediately following a suicide at- tempt [14]. Agitation further predicts future suicide deaths and suicide attempts among psychiatric outpatients [7,15]. Our understanding of how agitation differentially confers increased risk for suicide attempts across patient subgroups is limited, however, by the absence of studies examining how agitation interacts with predisposing vulnerabilities for suicide attempts. General Hospital Psychiatry 36 (2014) 726–731 ⁎ Corresponding author. National Center for Veterans Studies, The University of Utah, 260 S. Central Campus Dr., Room 205, Salt Lake City, UT 84105, USA. Tel.: +1 801 587 7978. E-mail address: craig.bryan@utah.edu (C.J. Bryan). http://dx.doi.org/10.1016/j.genhosppsych.2014.09.013 0163-8343/© 2014 Elsevier Inc. All rights reserved. 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