Gender-specific suicide risk factors: a case-control study of individuals with major depressive disorder

Available information on risk for suicide completion in females is limited and often extrapolated from studies conducted in males. However, the validity of extending to females risk factors identified among male suicide cases is unclear. In this study, we aimed to investigate clinical and behavioral risk factors for suicide among female depressed patients and compare them to similar factors among male depressed patients.

We identified 201 suicide completers (160 male and 41 female) who died during an episode of major depressive disorder (MDD). Cases were compared to 127 living patients with MDD (88 male and 39 female). All subjects were characterized for Axis I and II diagnoses using the Structured Clinical Interview for DSM-IV Axis I Disorders and Structured Clinical Interview for DSM-IV Axis II Personality Disorders according to the DSM-IV, as well as behavioral and temperament dimensions using proxy-based interviews. The primary outcome was measures of impulsive and impulsive-aggressive behaviors.

Compared to controls, male, but not female suicide cases had higher levels of impulsive aggression (P < .05). Nonimpulsive aggression differentiated both female (P < .05) and male (P < .01) suicide cases from controls. However, nonimpulsive aggression and impulsive aggression were correlated constructs in males (r = 0.297; P < .001), yet uncorrelated among females (r = 0.121; P = .390). Established risk factors for suicide, such as alcohol and substance dependence, cluster B disorders, and elevated hostility and aggression, were replicated in the pooled-sex analyses, and, though not statistically significant in discriminating between suicide cases and controls by gender, maintained strong group differences.

Males and females share many risk factors for suicide in MDD, yet alcohol dependence is much more specific though less sensitive among depressed females. Nonimpulsive aggression is part of a diathesis for suicide in females, which is distinct from the well-characterized impulsive aggression that is consistently reported in a portion of male suicide cases.