Journal of Affective Disorders 328 (2023) 87–94

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Prevalence and correlates of suicide planning and attempt among

individuals with suicidal ideation: Results from a nationwide
cross-sectional survey
Yen Sin Koh a, *, Shazana Shahwan a, Anitha Jeyagurunathan a, Edimansyah Abdin a,
Janhavi Ajit Vaingankar a, Wai Leng Chow b, Siow Ann Chong a, Mythily Subramaniam a, c
a
Research Division, Institute of Mental Health, Singapore, Singapore
b
Ministry of Health, Singapore, Singapore
c
Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Suicidality spans from having suicidal ideation to planning and making an attempt. However, not all
Suicide behavior individuals with suicidal thoughts will proceed to plan or attempt suicide. Our study investigated (i) the prev­
Suicide planning alence of suicide planning and attempt among those with suicidal ideation and (ii) their associations with
Suicide attempt
sociodemographic characteristics, mental disorders, adverse childhood events and prior suicidal behaviour.
Suicide ideation
Method: This cross-sectional analysis utilised data from Singapore Mental Health Study 2016. Only respondents
Suicidality
Adverse childhood event with suicidal ideation were included. A total of 411 and 365 individuals were examined to establish the prev­
alence of suicide planning and attempt respectively. Multivariable logistic regressions were performed to
determine associations.
Results: The prevalence of suicide planning and attempt were 17.7 % and 10.6 % respectively, with >80.0 %
occurring within a year of suicidal ideation. Suicide planning was more likely among those who had mood
disorders. Suicide attempt was more likely for those were currently married, had lower educational qualifica­
tions, history of anxiety disorders, history of emotional neglect and parental separation.
Limitations: Recall bias may be present because the age of onset for various mental disorders and suicidal be­
haviours were self-reported. As suicide was criminalised when the study was conducted, the prevalence of sui­
cidal behaviours may have been underestimated.
Conclusion: Individuals at risk of suicide planning and attempt should be identified early since most of them
progressed within a year. Findings suggest the importance of including prior suicide behaviour and history of
dysfunctional family and emotional abuse in suicide risk assessment and intervention.

1. Introduction
Suicide is a form of self-directed violence with the intention to die
(Crosby et al., 2011). According to the World Health Organization
(WHO), 703,000 people worldwide die by suicide each year (World
Health Organization (WHO), 2021). In 2019, it accounted for 1.3 % of
all fatalities and was the fourth leading cause of death among in­
dividuals aged 15 to 29 years (World Health Organization (WHO),
2021). For Singapore, the number of suicide deaths increased from 429
in 2016 to 452 in 2020 (Ministry of Health Singapore, 2021). As suicide
has negative implications such as financial losses (Shepard et al., 2016)
as well as grief to families and friends (Crosby et al., 2011), WHO has
identified it as a public health concern and aims to reduce the number of
suicides by one-third by 2030 (World Health Organization (WHO),
2021).
A known precursor to suicide is suicidality, which includes suicidal

Abbreviations: ACEs, adverse childhood experiences; AUD, Alcohol use disorders; ACE-IQ, Adverse Childhood Experiences — International Questionnaire; CAPI,
Computer-Assisted Personal Interview; GAD, generalised anxiety disorder; MDD, major depressive disorder; OCD, obsessive-compulsive disorder; PTSD, Post-trau­
matic stress disorder; SMHS 2016, Singapore Mental Health Study 2016; WHO, World Health Organization; WHO-CIDI 3.0, World Health Organization Composite
International Diagnostic Interview version 3.0.
* Corresponding author at: 10 Buangkok View, Buangkok Green, Medical Park, 539747 Singapore, Singapore.
E-mail address: Yen_Sin_KOH@imh.com.sg (Y.S. Koh).

https://doi.org/10.1016/j.jad.2023.02.033
Received 28 May 2022; Received in revised form 8 February 2023; Accepted 9 February 2023
Available online 13 February 2023
0165-0327/© 2023 Elsevier B.V. All rights reserved.
Y.S. Koh et al.
ideation, planning and attempt (Nock et al., 2008). While prior studies
have examined suicidality as an outcome, emerging literature has shown
that analysing suicidal ideation, planning and attempt separately may be
more informative for two reasons. Firstly, not all individuals with sui­
cidal ideation will eventually plan and attempt suicide. In a study that
examined the prevalence of suicidal behaviour across 17 countries, 33.6
% of people with suicidal ideation developed a suicide plan, whereas
29.0 % attempted suicide (Nock et al., 2008).
Secondly, studies have suggested that suicidal ideation and the
transition from suicidal ideation to action (planning and attempt) have
distinctive features. For instance, Batterham et al. revealed that several
mental disorders (e.g., major depressive disorder (MDD), generalized
anxiety disorder (GAD), alcohol use disorders (AUD)) were significantly
associated with suicidal ideation (Batterham et al., 2018). However,
among individuals with suicidal ideation, major depressive disorder and
alcohol use disorders were not associated with suicide attempt (Batter­
ham et al., 2018). Only obsessive-compulsive disorder (OCD), general­
ized anxiety disorder and post-traumatic stress disorder (PTSD) were
significantly correlated with suicide attempt (Batterham et al., 2018).
These findings led to the development of the ideation-to-action frame­
work, which posits that the process of developing suicidal ideation is
different from the transition from ideation to action (David Klonsky
et al., 2017).
Studies investigating the transition from suicidal ideation to action
have examined several characteristics, which include sociodemographic
characteristics, pre-existing mental disorders before suicidal ideation
and prior suicidal behaviour (Martin et al., 2016; Sunderland et al.,
2021; Ten Have et al., 2013). However, limited studies have adopted a
life-course perspective in investigating how past events, such as adverse
childhood experiences, may motivate the progression from suicidal
ideation to action (de Araújo and Lara, 2016). This perspective has been
used in several studies in understanding the motivation for suicide
(Chew and McCleary, 1994; Gunnell and Lewis, 2005). For instance,
Gunnell et al. (Gunnell and Lewis, 2005) has identified several events in
early life that may lead to suicide, including sexual abuse in childhood
and a history of self-harm in the family. Williams and Pollock (2000) has
also postulated that these adverse childhood experiences may impair
episodic memory. As a result, it can affect problem-solving and lead to
suicidality when experiencing a crisis.
Although common characteristics are present in populations across
different countries, specific differing associations have also been
observed. In an Australian-based nationwide study, variables that were
associated with the transition from ideation to attempt included gender,
age of first ideation, age at interview and drug use disorder (Sunderland
et al., 2021). Nonetheless, a similar study from Netherlands failed to find
any significant association between sociodemographic variables and the
progression from ideation to attempt (Ten Have et al., 2013). Only prior
suicidal behaviour, such as the age of first ideation, recurring suicidal
ideation and previous suicide plans, were significantly related to the
shift from ideation to attempt (Ten Have et al., 2013). These differences
suggest that it would be more relevant for the planning of any national
suicide prevention programme by examining the putative risk factors for
suicide ideation to action in the general population of that country
rather than extrapolating from studies done elsewhere (Sunderland
et al., 2021; Ten Have et al., 2013).
Moreover, not all mental illnesses were associated with suicide
planning and attempt. The aforementioned Australian-based nationwide
study found that MDD and OCD were positively associated with suicide
planning (Sunderland et al., 2021). However, GAD was not associated
with suicide planning (Sunderland et al., 2021). Furthermore, MDD,
GAD, OCD and AUD were not significantly correlated with suicide
attempt (Sunderland et al., 2021). The study by Ten Have et al. (2013)
also showed that among all the common mental disorders, only attention
deficit/hyperactivity disorder was positively associated with suicide
plan for individuals with suicidal ideation. These findings imply that
having any mental disorder does not increase the chance of suicide
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Journal of Affective Disorders 328 (2023) 87–94
planning and attempt. Identifying the specific mental conditions with a
higher chance for suicide planning and attempt can be helpful for timely
intervention.
Singapore is a Southeast Asian country, with a population of 5.69
million, consisting of 75.9 % Chinese, 15.0 % Malay, 7.5 % Indian and
1.6 % other races (Prime Minister’s Office. Singapore, 2020). In study
among the adult population, the lifetime prevalence of suicidal ideation
was found to be 7.8 %, whereas planning and attempting suicides were
both 1.6 % (Kudva et al., 2021). Between 2000 and 2004, the top three
suicide methods were jumping (72.4 %), hanging (16.6 %) and
poisoning (5.9 %) (Chia et al., 2011). While several studies have
examined the epidemiology of suicide in Singapore, few have investi­
gated the transition from suicidal ideation to action. This topic is salient
in Singapore because research has shown that among those who died by
suicide, most of them consulted a primary healthcare provider within
three months before their death (Ng et al., 2017). Understanding the
prevalence and the characteristics of those who will act on suicidal
thoughts can identify these high-risk individuals for timely intervention;
and the findings would aid policymakers in developing effective pro­
grammes to prevent suicide.
In this study, we examined (i) the prevalence of suicide planning and
attempt among individuals with suicidal ideation and (ii) the association
between the transition from suicidal ideation to planning and attempt
with sociodemographic characteristics, pre-existing mental disorders,
adverse childhood events and prior suicidal behaviour.
2. Method
This cross-sectional study utilised data from the Singapore Mental
Health Study 2016 (SMHS 2016), a nationwide survey conducted to
determine the prevalence of mental disorders. The methodology has
been described in detail in a previous publication (Subramaniam et al.,
2019). Respondents of Singapore citizens and permanent residents aged
18 and above and living in Singapore were eligible for the study. Those
who were unable to answer the questionnaire due to physical or
cognitive conditions, had language barriers, resided outside of
Singapore and stayed in hospitals or institutions were excluded from the
study.
The participants chosen for the study received an invitation letter
outlining its purpose and methodology. Trained interviewers scheduled
a convenient time for the participants and conducted a face-to-face
interview in one of three languages: English, Chinese, or Malay. The
interviews were administered using Computer-Assisted Personal Inter­
view (CAPI). All respondents provided written informed consent. For
respondents below 21 years old, consent was also taken from a parent or
legal representative. All participants were recruited between August
2016 and March 2018. The study was approved by the National
Healthcare Groups’ Domain Specific Review Board (Ref: 2015/1035).
The sample was drawn from the national population registry data­
base using disproportionate stratified sampling, with 16 strata specified
by ethnicity and age groups (Subramaniam et al., 2019). Individuals
aged 65 and above, of Malay and Indian ethnicity, were oversampled to
ensure reliable estimates for subgroup analysis (Subramaniam et al.,
2019). The sample size was calculated using the estimated prevalence of
various mental disorders from the Singapore Mental Health Study 2010,
with a power of 0.8 and a type I error of 0.05 (Subramaniam et al.,
2019). The margin of error was 0.3–0.8 % for the overall prevalence and
0.7–1.8 % for subgroups specified by age groups and ethnicity (Sub­
ramaniam et al., 2019). The target sample size was calculated to be
6000.
For the analysis, only respondents with suicidal ideation (n = 425)
were included. The sample was divided into two groups to analyse
suicide planning (n = 411) and attempt (n = 365) due to missing data. A
total of 358 respondents overlapped between the two groups. The flow
chart for the analysis is shown in Fig. 1.
Y.S. Koh et al.
Fig. 1. Study flow chart.
Abbreviation: AOO – age of onset.
2.1. Measures
2.1.1. Mental disorders
The SMHS 2016 assessed several mental disorders, which include
major depressive disorder (MDD), bipolar disorder, generalised anxiety
disorder (GAD), obsessive-compulsive disorder (OCD), alcohol abuse,
alcohol dependence and suicidality (Subramaniam et al., 2019). These
mental disorders were assessed using the World Health Organization
Composite International Diagnostic Interview version 3.0 (WHO-CIDI
3.0), which is based on the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition criteria (American Psychiatric Association,
1994). The questionnaire has been widely used in previous studies and
has good reliability and validity (Wittchen, 1994).
Pre-existing mental disorders were coded as positive if the age of first
experiencing the mental disorder was earlier or the same as the age of
onset for suicidal ideation. As the prevalence for the respective mental
disorders were small, mental disorders were classified into mood dis­
orders (MDD and bipolar disorders), anxiety disorders (GAD and OCD)
and alcohol use disorders (Alcohol abuse and alcohol dependence).
Suicidality was assessed using the suicide section from WHO-CIDI
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Journal of Affective Disorders 328 (2023) 87–94
3.0. Respondents were asked whether they ‘seriously thought about
committing suicide’ (suicidal ideation). Those who answered “Yes” to
this question, were then asked whether they ‘made a plan for commit­
ting suicide’ (suicide planning) and ‘attempted suicide’ (suicide
attempt). If respondents answered ‘Yes’ to any of the questions, they
were asked how old they were at the time of the event. The time from
suicidal ideation to planning or attempt was calculated by subtracting
the age of onset for suicidal ideation from the age of onset for first sui­
cide planning or attempt. Individuals were excluded from the group
intended for analysing suicide planning if their age of onset for first
suicide planning was earlier than suicide ideation (Fig. 1). A similar
exclusion criterion was also applied to the group intended for studying
suicide attempt (Fig. 1). Respondents were considered to have prior
suicide planning in the sample intended for studying suicide attempt if
the age of onset for suicide planning was the same or later than suicidal
ideation.
2.1.2. Adverse childhood experiences
Adverse childhood experiences (ACEs) were assessed using the
Adverse Childhood Experiences – International Questionnaire (ACE-IQ),
Y.S. Koh et al. Journal of Affective Disorders 328 (2023) 87–94

which was utilised worldwide (World Health Organization WHO, 2018). Table 1
The SMHS 2016 examined the following ACEs: emotional neglect, Summary statistics for sociodemographic, mental disorders, adverse childhood
physical neglect, household dysfunction (living with household mem­ experiences and prior suicidal planning.
bers who were abusing substances, living with household members who Planning among those Attempt among those
were mentally ill or suicidal, having a battered mother/female guardian with suicidal ideation with suicidal ideation
and living with household members who were imprisoned), physical (n = 411) (n = 365)

abuse, emotional abuse, sexual abuse, and bullying (Subramaniam et al., Weighted % Weighted %
2020). We only asked one question about sexual abuse: “Did someone (unweighted n) (unweighted n)
touch or fondle you in a sexual way when you did not want them to?”. Median age of suicidal ideation 21 (15–35) 21 (15–35)
The explicit questions were omitted because we were unsure if they (IQR)┼
would distress the respondents especially given Singapore’s conserva­ Median age of suicidal planning 21 (15–40)
(IQR)
tive culture (Subramaniam et al., 2020). The responses for the ques­ Median age of suicidal attempt 18 (15–28)
tionnaires were either binary (Yes/No) or frequency-based. They were (IQR)
used to create dichotomised variables (Yes/No) for the various ACEs. Age group
18–34 years 47.4 % (202) 48.9 % (184)
35–49 years 30.8 % (98) 30.4 % (89)
2.1.3. Sociodemographic data
50–64 years 16.1 % (73) 15.5 % (60)
The analysis included the following sociodemographic information 65+ years 5.7 % (38) 5.2 % (32)
collected from the SMHS 2016: age groups (18–34, 35–49, 50–64 and Gender
65+), gender (male, female), ethnicity (Chinese, Malay, Indian and Male 43.0 % (169) 44.0 % (154)
Others), marital status (currently married, never married, separated/ Female 57.0 % (242) 56.0 % (211)
Ethnicity
divorced, widowed), employment status (employed, economically Chinese 76.8 % (130) 78.1 % (122)
inactive, unemployed), and education (secondary education and below, Malay 11.2 % (110) 10.8 % (99)
Pre-University/Junior College/Vocational Institute/Institute of Tech­ Indian 8.8 % (131) 7.8 % (106)
nical Education/Diploma, University). Others 3.3 % (40) 3.4 % (38)
Marital status
Currently married 36.8 % (168) 36.4 % (145)
2.2. Statistical analysis Never married 49.5 % (184) 50.8 % (169)
Separated/divorced 11.3 % (46) 10.2 % (39)
The analysis was weighted to account for the complex sampling Widowed 2.5 % (13) 2.7 % (12)
Employment status
design, non-response bias, and post-stratification by age and ethnic
Employed 73.9 % (291) 73.5 % (260)
groups. The outcomes were suicide planning and attempt, which were Economically inactive 17.5 % (83) 17.6 % (72)
dichotomised as Yes or No. The independent variables included socio­ Unemployed 8.6 % (37) 8.9 % (33)
demographic factors, pre-existing mental disorders (mood disorders, Education
anxiety disorders and alcohol use disorders) and number of ACEs (0 Secondary education and 31.3 % (157) 30.6 % (133)
below
ACE, 1 ACE, 2 ACEs and 3 or more ACEs). For suicide attempt, prior
Pre-university/junior 39.3 % (157) 39.0 % (143)
suicide planning was also included as a correlate of interest. college/vocational institute/
As the continuous variables were not normally distributed, they were institute of technical
expressed as medians and interquartile range (IQR). Categorical vari­ education/diploma^
ables, including prevalence, were summarized with weighted percent­ University 29.4 % (97) 30.4 % (89)
Mood disorders 17.1 % (73) 16.8 % (63)
ages and unweighted frequencies. The cumulative lifetime hazard rate of Anxiety disorders 10.2 % (44) 10.3 % (39)
suicide planning and attempt were determined using the life table Alcohol use disorders 7.3 % (29) 6.9 % (25)
method. Multivariable logistic regressions were performed to investi­ Prior suicide planning# 14.6 % (61)
gate the associations between the outcomes and independent variables. Number of ACEs╪
0 ACE 13.1 % (45) 12.8 % (39)
As the number of ACEs was significantly associated with suicide attempt,
1 ACE 30.1 % (92) 30.2 % (82)
a logistic regression adjusted for sociodemographic factors, mental dis­ 2 ACEs 20.5 % (63) 20.0 % (55)
orders and prior suicide planning was also generated to investigate the 3 or more ACEs 36.4 % (129) 37.0 % (115)
type of ACEs that were associated with suicide attempt. The regression Emotional neglect╪ 65.8 % (210) 65.4 % (185)
results were reported in odds ratio (OR) and 95 % confidence interval Physical neglect╪ 12.0 % (42) 11.9 % (36)
Living with household members 13.7 % (46) 14.5 % (42)
(95 % CI). Due to the complex sampling design, the standard errors were who were substance abusers╪
calculated using the Taylor Series’ linearization method. Living with household members 14.4 % (49) 15.9 % (45)
We analysed the data using STATA M/P Version 17.0 with two-sided who were mentally ill or
tests at a 5 % significance level. Missing data were removed in a listwise suicidal╪
Parental separation, divorce or 32.8 % (124) 33.5 % (107)
manner.
death of a parent╪
Battered mother/female 20.6 % (79) 20.0 % (69)
3. Results guardian╪
Living with household members 10.4 % (37) 9.9 % (31)
The total sample size for SMHS 2016 was 6126, with a response rate who were imprisoned╪
Physical abuse╪ 17.8 % (62) 17.5 % (53)
of 69.0 %. The prevalence of suicide planning was 17.7 % (n = 84), with Emotional abuse╪ 29.6 % (97) 30.3 % (86)
80.4 % of these cases occurring within a year of suicidal ideation. The Sexual abuse╪ 12.7 % (36) 12.1 % (29)
prevalence of suicide attempt was 10.6 % (n = 47), with 83.9 % of cases Bullying╪ 4.9 % (21) 4.8 % (17)
occurring within a year of suicidal ideation. ┼
Missing data: planning among those with suicidal ideation (n = 11), attempt
Table 1 summarises the descriptive statistics for sociodemographic among those with suicidal ideation (n = 13).
factors, mental disorders and adverse childhood experiences for both ^
These education levels are post-secondary educational qualifications. In­
groups. The median age of onset (IQR) of suicide planning and suicide dividuals who meet the academic criteria can proceed to tertiary education.
attempt were 21 (15–35 years) and 18 (15–28 years) respectively. In ╪
Missing data: planning among those with suicidal ideation (n = 82), attempt
both groups, the highest proportion of respondents were aged 18–34 among those with suicidal ideation (n = 74).
#
(Suicide planning: 47.4 %, Suicide attempt: 48.9 %), female (Suicide Missing data: attempt among those with suicidal ideation (n = 7).

90
Y.S. Koh et al.
planning: 57.0 %, Suicide attempt: 56.0 %), of Chinese ethnicity (Sui­
cide planning: 76.8 %, Suicide attempt: 78.1 %), never married (Suicide
planning: 49.5 %, Suicide attempt: 50.8 %), employed (Suicide plan­
ning: 73.9 %, Suicide attempt: 73.5 %) and had Pre-University/Junior
College/Vocational Institute/Institute of Technical Education/Diploma
educational qualification (Suicide planning: 39.3 %, Suicide attempt:
39.0 %). Mood disorders had the highest prevalence among all mental
disorders in both groups (Suicide planning: 17.1 %, Suicide attempt:
16.8 %).
For ACEs, the percentage of respondents was the highest for three or
more ACES (Suicide planning: 36.4 %, Suicide attempt: 37.0 %). The top
three adverse childhood experiences were emotional neglect (Suicide
planning: 65.8 %, Suicide attempt: 65.4 %), parental separation, divorce
or death of a parent (Suicide planning: 32.8 %, Suicide attempt: 33.5 %)
and emotional abuse (Suicide planning: 29.6 %, Suicide attempt: 30.3
%). In the group intended for analysis of suicide attempt, 14.6 % indi­
cated that they had previously made a suicide plan.
Figs. 2 and 3 show the hazard rate for suicide planning and suicide
attempt respectively. Respondents with suicidal ideation had the highest
risk of planning suicide in their mid-40s and attempting suicide in their
20s.
Table 2 presents the multivariable logistic regressions for suicide
planning and attempt. For suicide planning, those with mood disorders
had higher odds of suicide planning (OR: 2.60, 95 % CI: 1.08–6.22). For
suicide attempt, respondents who were never married were less likely to
attempt suicide (OR: 0.12, 95 % CI: 0.02–0.64) than those who were
currently married. Respondents with university educational qualifica­
tions were less likely to attempt suicide (OR: 0.15, 95 % CI: 0.03–0.67)
than those with secondary educational qualifications and below. Those
with anxiety disorders (OR: 10.25, 95 % CI: 2.24–46.92) and those with
prior suicide planning (OR: 38.14, 95 % CI: 8.93–162.79) had higher
odds of attempting suicide. Numbers of ACEs were also significantly
associated with suicide attempt, with those having two ACEs being more
likely to attempt suicide than those with no ACEs (OR: 35.01, 95 % CI:
1.11–1102.13).
Table 3 examines the association between the types of ACEs and
suicide attempt among respondents with suicidal ideation. Emotional
neglect (OR: 9.19, 95 % CI: 1.33–63.46) and parental separation,
divorce or death of a parent (OR: 28.22, 95 % CI: 5.29–150.45) were
positively associated with suicide attempt.
4. Discussion
Our results show that among those with suicidal ideation, 17.7 % had
made plans for suicide, and 10.6 % attempted suicide. Furthermore,
Fig. 2. Hazard rate of suicide planning based on age of onset.
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Journal of Affective Disorders 328 (2023) 87–94
Fig. 3. Hazard rate of suicide attempt based on age of onset.
>80 % of those who acted on their suicidal thoughts did so within a year.
Suicide planning was more likely for individuals who had pre-existing
mood disorders. Suicide attempt was more likely for those who were
currently married, had a lower educational qualification, had a history
of anxiety disorders, emotional neglect and parental separation, divorce
or death of a parent before the age of 18 years.
Compared to other countries (Nock et al., 2008; Ten Have et al.,
2013), our results showed that the prevalence of those who will plan or
attempt suicide is lower. However, the proportion of cases among those
who will progress from suicidal thoughts to either planning or attempt
within a year is slightly higher. In a Netherlands-based study, the
prevalence of transitioning from suicidal ideation to attempt was 26.8
%, with 76.5 % of these cases occurring within a year (Ten Have et al.,
2013). In another cross-national study that utilised data from 17 coun­
tries, 33.6 % of individuals with suicidal ideation planned for suicide
and 29.0 % attempted suicide, with 60 % of them occurring within a
year. (Nock et al., 2008). Since most cases in our study progressed within
a year, understanding these individuals’ characteristics will aid health­
care professionals in identifying them as early as possible.
Our findings showed that among respondents with suicidal ideation,
those who were never married and had higher educational qualification
were less likely to attempt suicide. For most sociodemographic corre­
lates, the findings from various studies have been contrasting (Sunder­
land et al., 2021; Ten Have et al., 2013). Nonetheless, several studies
have identified lower education level as a significant correlate for sui­
cide attempt. In a nationwide survey conducted in South Korea, re­
spondents with middle school and below elementary school educational
qualifications were more likely to attempt suicide than those with col­
lege educational qualifications (Choi et al., 2017). In the cross-national
study, respondents with higher educational qualifications had lower
odds of attempting suicide (Nock et al., 2008) which is consistent with
our findings.
In our study, mood disorders were significantly associated with
planning suicide. Anxiety disorders were also significantly correlated
with attempting suicide. Our finding on suicide planning was similar to a
study done in Nigeria, which showed that mood disorders had 16.2
times higher odds of planning suicide (Gureje et al., 2007). However, the
same study failed to show any association between mental disorders and
suicide attempt (Gureje et al., 2007). Other studies have also suggested
that suicide planning and attempt were associated with specific mood
and anxiety disorders, such as major depressive episodes and OCD
(Sunderland et al., 2021). Due to the low prevalence of the respective
mental disorders, we were unable to investigate mental disorders as a
correlate of suicide plan and attempt at a more granular level.
Our results revealed that individuals who had a history of emotional
Y.S. Koh et al. Journal of Affective Disorders 328 (2023) 87–94

Table 2 Table 3
Logistic regression for suicide plan and attempt. Logistic regression to examine association between types of ACEs and suicide
Planning among those Attempt among those with
attempt.
with suicidal ideation suicidal ideation (n = 273) Attempt among those with
(n = 325) suicidal ideation (n = 273)┼
OR (95 % CI) p- OR (95 % CI) p-Value OR (95 % CI) p-Value
Value
Emotional neglect 9.19 (1.33–63.46) 0.025
Age of onset for suicidal 0.97 0.309 0.93 0.057 Physical neglect 1.34 (0.21–8.51) 0.753
ideation (0.93–1.02) (0.87–1.00) Living with household members who were 0.37 (0.04–3.02) 0.349
Age group substance abusers
18–34 (reference) Living with household members who were 0.20 (0.02–2.37) 0.203
35–49 2.60 0.091 0.53 0.419 mentally ill or suicidal
(0.86–7.90) (0.11–2.51) Parental separation, divorce or death of a parent 28.22 <0.001
50–64 2.01 0.433 0.47 0.429 (5.29–150.45)
(0.35–11.50) (0.07–3.10) Battered mother/female guardian 0.22 (0.02–2.12) 0.191
65+ 3.29 0.373 0.04 0.060 Living with household members who were 1.63 (0.21–12.61) 0.639
(0.24–45.49) (0.00–1.16) imprisoned
Gender Physical abuse 0.39 (0.05–3.04) 0.364
Male (reference) Emotional abuse 4.35 (0.52–36.18) 0.173
Female 1.10 0.836 0.42 0.325 Sexual abuse 0.98 (0.06–16.77) 0.986
(0.44–2.73) (0.07–2.40) Bullying 6.38 (0.55–73.62) 0.137
Ethnicity
Chinese (reference)
┼
Adjusted for age of onset for suicidal ideation, age group, gender, ethnicity,
Malay 1.05 0.918 0.91 0.915 marital status, employment status, education, mood disorders, anxiety disor­
(0.40–2.76) (0.17–4.78) ders, alcohol usage disorders, prior suicide planning.
Indian 1.61 0.235 3.46 0.082
(0.73–3.56) (0.85–14.03)
Others 1.18 0.799 0.77 0.766
adverse childhood events as a correlate to the transition from suicidal
(0.33–4.16) (0.13–4.47) ideation to planning and attempt. Nonetheless, our findings corrobo­
Marital status rated with a web-based study conducted in Brazil, which showed that a
Currently married history of emotional abuse was significantly associated with serious
(reference)
suicide attempt (de Araújo and Lara, 2016). We postulate that in­
Never married 2.06 0.168 0.12 0.014
(0.74–5.75) (0.02–0.64) dividuals raised in dysfunctional families, such as those who faced
Separated 2.50 0.248 2.07 0.568 parental separation, may be deficient in skills such as problem-solving
(0.53–11.88) (0.17–25.36) (Saffer et al., 2015). Hence, they are less likely to find appropriate so­
Widowed 0.52 0.612 –┼ –
lutions to their problems and are more likely to engage in harmful be­
(0.04–6.53)
Employment status
haviours such as suicide planning and attempt (Saffer et al., 2015).
Employed (reference) Individuals experiencing emotional abuse may be more prone to suicide
Economically inactive 0.90 0.838 3.64 0.134 attempt because they may have low self-esteem and perceive themselves
(0.32–2.50) (0.67–19.81) as burdensome (de Araújo and Lara, 2016).
Unemployed 0.53 0.378 0.60 0.591
Previous suicidal behaviour was shown in numerous studies to be
(0.13–2.17) (0.09–3.97)
Education directly associated with the transition from suicidal thoughts to plan­
Secondary education ning and attempt. We showed that individuals with prior suicide plan­
and below (reference) ning were more likely to attempt suicide. A study on adolescents and
Pre-university/junior 0.54 0.247 0.80 0.824 young adults in Germany also found that the odds of attempting suicide
college/vocational (0.19–1.54) (0.11–6.02)
institute/institute of
were 1.08 times higher for every suicide plan episode (Voss et al., 2019).
technical education/ Furthermore, Stack’s study showed that having a suicide plan increased
diploma the odds of attempting suicide by 2.69 times (Stack, 2014). Similar to
University 0.49 0.211 0.15 0.013 individuals with dysfunctional families, people who planned for suicide
(0.16–1.50) (0.03–0.67)
may execute their plan as a way of coping with their issues (Ten Have
Mood disorders 2.60 0.032 2.16 0.512
(1.08–6.22) (0.21–21.71) et al., 2013).
Anxiety disorders 0.56 0.494 10.25 0.003 Recognizing high-risk individuals promptly is critical in preventing
(0.10–3.01) (2.24–46.92) suicide planning and attempt. Singapore has a multi-pronged approach
Alcohol use disorders 2.43 0.265 0.07 0.224 to suicide prevention and intervention, which includes identifying high-
(0.51–11.64) (0.00–5.36)
Prior suicide planning 38.14 <0.001
risk individuals early, encouraging them to seek help and providing
(8.93–162.79) support such as befriending services (Ministry of Health Singapore,
Number of ACEs 2020). Other than healthcare professionals, other stakeholders in the
0 ACE community are also equipped with skills through educational pro­
1 ACE 1.01 0.992 20.94 0.108
grammes. For instance, teachers are trained to recognize high-risk in­
(0.21–4.78) (0.51–856.25)
2 ACEs 2.45 0.228 35.01 0.043 dividuals and direct them to mental health professionals (Ministry of
(0.57–10.55) (1.11–1102.13) Health Singapore, 2020). However, as suicide is an uncommon cause of
3 or more ACEs 2.79 0.130 21.46 0.112 death in Singapore (Department of Statistics Singapore, 2012), targeting
(0.74–10.52) (0.49–941.69) interventions on at-risk individuals instead of the entire community may
┼
Insufficient sample size to estimate the odds ratio. be more resource-efficient. Further studies can examine whether this
approach is effective and cost-efficient in preventing suicide.
neglect and parental separation, divorce or death of a parent had higher This study has several limitations. Firstly, recall bias is present as the
odds of suicide attempt. Although several studies had investigated the respondents may have problems recalling the exact age of onset for the
associations between adverse childhood events and suicidality (Saffer various mental disorders and suicide behaviours Secondly, suicidal
et al., 2015; Taliaferro and Muehlenkamp, 2014), few had examined behaviour was criminalised when the survey was conducted. Hence, this

92
Y.S. Koh et al.
may have led to under-reporting, and the prevalence of suicidal
behaviour may be underestimated. However, this limitation was miti­
gated by assuring the respondents that their responses would be anon­
ymous. Thirdly, the suicide section from WHO-CIDI 3.0 asked about
suicide planning and attempt only if the respondents had suicidal
ideation. We might have missed the following groups of respondents: (i)
those with a very short interval between ideation and attempt and (ii)
those with less frequent or severe ideation. These groups of individuals
might have answered no to the question on suicidal ideation, but might
have planned or attempted suicide subsequently. Lastly, as suicidality is
relatively uncommon, the sample sizes available for analysis were
relatively small. As a result, some associations had overestimated odds
ratios and imprecise confidence intervals, such as the association be­
tween suicide attempt and prior suicide planning. Therefore, we could
not deduce the actual effect size of these associations. This limitation
was also observed in some related studies (Gureje et al., 2007; Posada-
Villa et al., 2009; Ten Have et al., 2013).
Despite these limitations, one of the study’s strengths is that the
findings are generalizable to Singapore because the study was conducted
at a population level. Suicidality was assessed using the WHO-CIDI 3.0,
which has high validity and reliability. As WHO-CIDI 3.0 is also used in
other countries, our findings can be compared with the results from
other countries.
5. Conclusion
Our findings imply that early identification of high-risk individuals is
pertinent in preventing the transition. Since prior suicide planning was
positively associated with suicide attempt, it suggests that suicide at­
tempts can be prevented with timely and appropriate intervention. Our
findings also suggest that efforts to identify and support individuals who
have experienced ACEs can be effective in preventing suicide later in
life. Moreover, high-risk individuals can be identified by assessing pre-
existing mental disorders, background of dysfunctional family, history
of emotional abuse and prior suicidal behaviour.
CRediT authorship contribution statement
YSK and MS conceptualised the manuscript. YSK performed the
analysis and drafted the manuscript. SS, AJ, EA, JV, WLC, SAC and MS
were involved in the planning and conducting of the study. All authors
had reviewed and provided intellectual input to the manuscript. All
authors read and approved the final manuscript.
Roles of funding sources
The study was funded by the Ministry of Health Singapore and
Temasek Foundation.
Conflict of interest
None.
Acknowledgements
None.
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