INTRODUCTION

The word “suicide” comes from the Latin word suicidium, derived from the root sui caedere, which means to kill oneself (1). A suicide attempt is defined as destructive behavior aimed at ending one’s own life (2). According to Edwin Schneidman (3), suicide is seen as a way out from feelings of desperation, frustrated needs, unbearable stress, and helplessness. There is a wide spectrum between suicidal thoughts and a suicide attempt. Some people think about suicide, but never carry it out, some plan suicide, and some attempt suicide impulsively.

Suicidal behavior is a serious health problem and among the top causes of psychiatric emergencies. Longitudinal follow-up studies indicate that 10 to 15 percent of those who attempt suicide complete the act of suicide (4). Suicide attempts are seen 10 to 40 times more often than completed suicides (5). Paracıkoğlu et al. (6) found the suicide recurrence rate in a 29-month average follow-up period to be 19.2 percent. The multi-centered ECA study by Petronis et al. (7) covering 18,000 people concluded that 18 suicide attempts on average were made before one completed suicide. A study of society at large on completed suicides determined that suicide was completed on the first attempt at a rate of 56 to 75 percent (8). For this reason, the absence of a suicide attempt in a person’s history does not remove the risk.

The most important predictor for suicide is the presence of psychiatric disorder. More than 90 percent of cases who attempted suicide have a psychiatric disorder. Suicide risk is present in patients with diagnoses of major depression, bipolar disorder, alcohol abuse, schizophrenia, “borderline” personality disorder, antisocial personality disorder, dysthymia, or anxiety disorder (9). In recent years, research has focused on the treatment method for patients who have attempted suicide that seek admittance to psychiatry departments (10-14). Hall et al. (14) showed that 83 percent of people who attempted suicide had consulted a health employee within the one-month period preceding their suicide attempt. Many patients seek admittance to a general hospital for physical complaints related to their suicide attempt. Thereafter, the psychiatric treatment of these patients is arranged for the first time. Psychiatric consultation was observed to have positive effects on the progress of patients having attempted suicide (15,16). The risk of completed suicide is highest in the year following a previous attempt, particularly in the first three months after the attempt (17). Suicide attempters are heterogeneous cases in diagnostic terms given their psychosocial factors and high rate of psychiatric comorbidity (12,13). The aim of this study is to compare the Hospital Anxiety and Depression (HAD) scale scores of inpatients referred for psychiatric consultation in a general hospital who had attempted suicide with the scores of those who had not attempted suicide. The HAD items for which a significant difference is detected in clinical terms may be important predictors of suicide risk, in addition to psychiatric examination.

METHOD

The study included 50 patients, who had attempted suicide and were inpatients in a general hospital for this reason between January 2005 and January 2007, and a control group of 50 age and gender matched patients who were inpatients due to their general medical condition. The data covers all patients over 14 years of age who had attempted suicide and patients who were inpatients due to their general 50 medical condition, all were referred for a psychiatric consultation. Prior to psychiatric evaluation, all suicide attempters were treated at Şişli Etfal Training and Research Hospital’s Internal Disease or Intensive Care units. Patients were given an informed consent form with which they agreed to participate in the study. All consultation results, patient information and socio-demographic data were recorded. Chronic disease, dementia and mental retardation were set as criteria for exclusion from the study. Patients who were in a state of delirium during consultation were enrolled in the study after their general medical condition stabilized and their state of delirium subsided. This study was approved by the hospital’s ethics committee.

Scales

This study used a socio-demographic form, the Hospital Anxiety and Depression (HAD) Scale, and the Mini-International Neuropsychiatric Interview Method (MINI), used widely to make diagnosis and structured by the clinician (18). The MINI was adapted to the Turkish by Engeler (19). Age, marital status, education, occupation, past psychiatric history, family history, psychiatric diagnosis, and alcohol/substance use were evaluated using the socio-demographic form. The patients were first evaluated in terms of alcohol/substance dependence. Since none of the patients met the alcohol/substance dependence criteria, they were then asked whether they smoked, used alcohol, or used any substance.

The HAD scale scans anxiety and depression symptoms, is a self-rating scale and is used frequently in the hospital environment (20). The cutoff point for the HAD depression and anxiety subscales is ≥8. The HAD Turkish translation was validated by Aydemir et al (21).

Statistical Analysis

The SPSS 11.5 program was used for the analyses. Independent t-test and Chi-square were used for comparisons between the group who had attempted suicide and the group who had not attempted suicide. Values of p<0.05 were considered clinically significant.

RESULTS

Both groups were compared in terms of age, gender, education, marital status, economic status, alcohol/substance use, past psychiatric history, and family history. The mean age of the group who had attempted suicide was 24.2±9.0, and that of the control group was 25.4±6.5. Both groups were similar in terms of age, gender, occupational status, and education. In line with the literature, 76 percent of patients who had attempted suicide were female and 24 percent were male. Past psychiatric history (p=0.002), inpatient psychiatric treatment rates (p=0.04), family history (p=0.023), and alcohol/substance use (p=0.004) were significantly higher among those who had attempted suicide, compared to the control group. Demographic data is provided in Table 1.

In 19 (38%) of 50 patients who had attempted suicide, history of past suicide attempt was observed. In those who had attempted suicide, the HAD depression (p=0.002) and anxiety (p=0.005) subscale scores were significantly higher than in the control group. The mean anxiety score was 10.9±4.1 and the mean depression score was 10.0±3.9. Comparing mean total scores, the score of those who had attempted suicide (20.9±6.4) was significantly higher than the score of patients who had not attempted suicide (15.7±8.5) (p=0.001). The tension (item 1), anhedonia (item 2), fear (item 3), loss of humor (item 4), restlessness (item 11), and lack of enjoyment (item 12) scores were significantly higher in those who had attempted suicide than in those who had not. A comparison of HAD scale scores is provided in Table 2.

In this study, 38 percent of patients were diagnosed with bipolar disorder, and all of these bipolar patients had attempted suicide. Adjustment disorder was significantly higher in the group that had not attempted suicide. Axis I diagnoses are provided in Table 3.

DISCUSSION

In this study, 76 percent of patients who had attempted suicide were female and 24 percent were male, in line with literature. Weissman et al. (22) reported that suicide attempts are two to three times more frequent among females than males.

To date, studies have shown that past suicide attempt is the strongest predictor of both subsequent attempt and completed suicide (23). One study revealed that there are past suicide attempts in 18 to 50 percent of completed suicides (24). In this study as well, 38 percent of patients have attempted suicide in the past. Hall et al. reported that 33 percent of patients who had attempted suicide had also previously attempted suicide (14). Greer and Soukes stated that psychiatric consultation and the evaluation of risk factors have a positive effect on the progress of patients who had attempted suicide (15,16). Studies conducted in the U.S.A. emphasize that patients who attempted suicide had consulted to general practitioner in the one-month period before their attempt (25). Thus the HAD scale can be used as a second tool by clinicians and general practitioner in particular to predict suicide after psychiatric evaluation.

In this study, the HAD depression (p=0.002) and anxiety (p=0.005) subscale scores of those who had attempted suicide were found to be significantly higher than the scores of those who had not attempted suicide. Analysis of the data revealed that tension, anhedonia, fear, see the funny side of things, restlessness, and look forward with enjoyment to things items on the scale may be predictors of suicide attempt. Hall et al. (14) reported that anxiety, depressive mood, alcohol/substance abuse, feelings of desperation, and anhedonia may be predictors of suicide attempt. Anhedonia, anxiety, and alcohol abuse are short-term predictors of suicide attempt, while mood fluctuations and feelings of desperation were seen as long-term predictors (26). Comorbid psychiatric diagnosis was found to be the strongest predictor for suicide risk (27). Many patients who had attempted suicide were reported to exhibit depressive symptoms, and 60 percent were reported to have been diagnosed with a mood disorder (28). The data in this study showed that anhedonia, loss of interest, and depressive mood were significantly different between the two groups. The six-month follow-up study by Sertöz et al. (29) showed that diagnosis of major depression according to DSM-IV increased the recurrence risk of suicide attempt twelve-fold.

Although suicide is not questioned directly in the HAD scale, the anhedonia, loss of humor, and lack of enjoyment items may be predictors of a potential suicide attempt. This results may be important for determining suicide risk in patients who do not want to share their suicidal thoughts.

In this study, the anxiety scores of patients who had attempted suicide were significantly higher than those of the control group. The tension, fear, and restlessness items were found to be significantly different. The study conducted by Fawcett et al. (26) with adults indicated that psychical anxiety is pronounced in patients with suicide risk. Likewise, Weissmen et al. (22) reported that anxiety may predict suicidal behavior. Anxiety, irritability, tension, agitation, fear, and restlessness are among the risk factors for suicide. Restlessness and agitation may be precursors of danger (30). A paper on the prevention of suicidal behavior reported that restlessness may be a factor for suicide risk (31). According to Thomas and Kramer (32), intense restlessness may become so insurmountable that suicide is considered. In contrast to these findings, Placidi et al. (33) found that patients who had not attempted suicide scored significantly higher on the anxiety items of the Hamilton Depression Scale related to fear of disease and death.

The data in this study indicate that suicidal behavior is correlated with bipolar disorder. Balazs et al. (34) found that patients who had attempted suicide had a high rate of bipolar disorder. Irritability and psychomotor agitation were stated as strong predictors of a suicide attempt. From 25 to 50 percent of bipolar patients had attempted suicide at least once in their lives (35). In particular, patients with a mixed episode history were evaluated as being at a greater risk for suicide due to dysphoric mood and high energy levels (36,37).

Our findings indicate that alcohol and substance abuse may be related to suicidal behavior, even in a society with no prevalence of alcohol and substance abuse. Some studies report that substance abuse increases instinctive suicidal behavior (13). Alcohol/substance addiction was reported to raise the suicide risk five-fold (14). Cornelius et al. (38) reported that suicide risk is higher in major depression patients with comorbid alcohol dependence, compared to patients with depression but no alcohol dependence. Additionally, some authors stated that greater prevalence of suicide may be related to increase in substance abuse (39,40).

In this study, we found that in addition to depression, anxiety, and alcohol/substance use, the factors of past psychiatric history, history of past psychiatric hospitalization, and family history are associated with greater risk of suicide. One study reported that 98 percent of those who had attempted suicide had a psychiatric diagnosis and that this was the strongest determining factor for suicide risk (41). Although the presence of suicide history in the family indicates genetic predisposition, it also suggests that this may be a learned behavior (25). In support of previous studies, this study showed that those who had attempted suicide more often had history of inpatient treatment. Those with a level of psychiatric disease necessitating hospitalization were shown to have higher risk of suicide (42,43).

One of the limitations of this study is that cases were limited to hospitalized patients and the data reflects this limited group. Another limitation is that the patients’ initial requests for consultation were not evaluated.

CONCLUSION

This study showed that depressive symptoms and anxiety, alcohol/substance abuse, and bipolar disorder are risk factors for suicide attempt, even in a society where alcohol/substance abuse and dependence are rare. Attempting suicide poses a risk for further suicide attempt, while recurring attempts increase both the risk of suicide attempt in the future and the risk of completed suicide (44).

The suicide rate was observed to have increased 60 percent in males and 41 percent in females over the last 10 years (45). Predicting suicide and determining the risk of suicide must therefore be the clinician’s main goal.

The clinician must take into account the patient’s past psychiatric history, family history, alcohol/substance abuse, anhedonia, lack of enjoyment, loss of sense of humor, and fear, stress, and restlessness symptoms. The study’s findings showed that the HAD scale may be a helpful tool, along with psychiatric evaluation, in the determination of suicide risk.

REFERENCES

1. Sadock BJ, Sadock VA (editors). Suicide. In: Kaplan and Sadock’s Synopsis of Psychiatry. Philadelphia: Lippincott Williams and Wilkins, 2003, 913-922.

2. Beck AT, Kovacks M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol 1979; 47:343-352.

3. Schneidman ES. The suicidal Mind. New York: Oxford University Press, 1996.

4. Cullberg J, Wasserman D, Stefansson CG. Who commits suicide after a suicide attempt? Acta Psychiatr Scand 1988; 77:598-603.

5. Haukka J, Suominen K, Partonen T, Lönnqvist J. Determinants and outcomes of serious attempted suicide: a nationwide study in Finland, 1996-2003. Am J Epidemiol 2008; 167:1155-1163.

6. Paracıkoğlu V, Sayıl I, Özgüven HD. Ankara’da intihar girişimleri üzerine bir izleme çalışması: Dünya Sağlık Örgütü-Avrupa çok merkezli intihar davranışı izlem çalışması sonuçları. Kriz Dergisi 2004; 12:1-17.

7. Petronis KR, Samuels JF, Moseicki EK, Anthony JC. An epidemiologic investigation of potential risk factors for suicide attempts. Soc Psychiatry Psychiatr Epidemiol 1990; 25:193-199.

8. Isometsä ET, Lönnqvist JK. Suicide attempts preceding completed suicide. Br J Psychiatry 1998;173:531-535.

9. Rich CL, Runeson BS. Similarities in diagnostic comorbidity between suicide among young people in Sweeden and the United States. Acta Psychiatr Scand 1992; 86:335-339.

10. Hawton K, Bancroft J, Catalan J, Kingston B, Stedeford A, Welch N. Domiciliary and outpatient treatment of self-poisoning patients by medical and non-medical staff. Psychol Med 1981; 11:169-177.

11. Runeson B, Wasserman D, Träksman-Bendz L, Agren H, Asberg M. Management of suicide attempters in psychiatric care in Sweeden- Evaluation of a questionaire. Nord J Psychiatry 1994; 48:117-120.

12. Runeson B, Wasserman D. Management of suicide attempters: what are the routines and the costs? Acta Psychiatr Scand 1994; 90:220-228.

13. Schnyder U, Valach L. Suicide attempters in psychiatric emergency room population. Gen Hosp Psychiatry 1997; 19:119-129.

14. Hall RC, Platt DE, Hall RC. Suicide risk assesment: A review of risk factors for suicide in 100 patients who made severe suicide attempts. Psychosomatics 1999; 40:18-27.

15. Greer S, Bagley C. Effect of psychiatric intervention in attempted suicide: a controlled study. Br Med J 1971; 1:310-312.

16. Suokas J, Lönnqvist J. Outcome of attempted suicide and psychiatric consultation: risk factors and suicide mortality during a five-year follow-up. Acta Psychiatr Scand 1991; 84:545-549.

17. Dahlgren KG. Attempted suicide: 35 years afterwards. Suicide Life Threat Behav 1977; 7:75-79.

18. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 (Suppl.20):22-33.

19. Engeler A. M.I.N.I. Araçları Türkçe Uyarlama 5.0.0., GSK, İstanbul, 2004.

20. Zigmund AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67:361-370.

21. Aydemir Ö, Güvenir T, Küey L. Validity and realibility of Turkish version of Hospital Anxiety and Depression Scale. Turkish Journal of Psychiatry 1997; 8:280-287.

22. Weissmann MM, Bland RC, Canino GJ, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubio-Stipec M, Wells JE, Wickramaratne PJ, Wittchen HU, Yeh EK. Prevalence of suicide ideation and suicide attempts in nine countries. Psychol Med 1999; 29:9-17.

23. Rudd MD, Jonier T, Rajab MH. Relationship among suicide ideators, attempters, and multiple attempters in a young-adult sample. J Abnorm Psychol 1996; 105:541-550.

24. Gould M, Shaffer D, Fisher P, Kleinman M, Morishima A. The clinical prediction of adolescent suicide: In Marris R, Berman A, Maltsberger J, Yufit R (editors). Assessment and prediction of suicide. New York: Guilford Press, 1992, 130-143.

25. Vannoy SD, Unützer J. Detection of suicide risk in patients with depression. WPA Bulletin on Depression 2005; 10:4-6.

26. Fawcett J, Scheftner WA, Fogg L, Clark DC, Young MA, Hedeker D, Gibbons R. Time related predictors of suicide in major affective disorder. Am J Psychiatry 1990; 147:1189-1194.

27. Stevenson JM. Suicide: In Talbot JA, Hales RE, Yudofsky SC (editors). The American psychiatric press textbook of psychiatry. Washington DC: American Psychiatric Press, 1988, 1021-1035.

28. Wasserman D (editor). Affective disorders and suicide. In: Suicide: an unnecessary death. London: Martin Dunitz Ltd., 2001, 39-47.

29. Sertöz Ö, Noyan MA, Sertöz N, Elbi H. İntihar girişimleri öngörülebilir mi? Bir üniversite hastanesi acil servisine intihar girişimiyle başvuran hastaların altı aylık izlem sonuçları. Anadolu Psikiyatri Dergisi 2010; 11:1-8.

30. Simon GE. The antidepressant quandary-considering suicide risk when treating adolescent depression. N Engl J Med 2006; 355:2722-2723.

31. Sainsbury P. Depression, suicide, and suicide prevention: In Roy A (editor). Suicide. London: Williams & Wilkins, 1986, 73-88.

32. Kramer TA. Talking points about antidepressants and suicide. MedGenMed 2004; 6; 30.

33. Placidi GVP, Oquendo MA, Malone KM, Brodsky B, Ellis SP, Mann JJ. Anxiety in major depression: relationship to suicide attempts. Am J Psychiatry 2000;157:1614-1618.

34. Balazs J, Benazzi F, Rihmer Z, Rihmer A, Akiskal KK, Akiskal HS. The close link between suicide attempts and mixed (bipolar)depression: iplications for suicide prevention. J Affect Disord 2006; 91:133-138.

35. Jamison KR. Suicide and bipolar disorder. J Clin Psychiatry 2000; 61 (Suppl.9):47-51

36. Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990.

37. Winokur G, Tsuang M. The Iowa 500: suicide in mania, depression, and schizophrenia. Am J Psychiatry 1975; 132:650-651.

38. Cornelius JR, Salloum IM, Mezzich J, Cornelius MD, Fabrega H Jr, Ehler JG, Ulrich RF, Thase ME, Mann JJ. Disproportionate suicidality in patients with comorbid major depression and alcoholism. Am J Psychiatry 1995; 152:358-364.

39. Rich CL, Fowler RC, Young D. Substance abuse and suicide of San Diego study. Ann Clin Psychiatry 1989; 1:79-85.

40. Fombonne E. Suicidal behaviours in vulnerable adolescents. Time trends and their correlates. Br J Psychiatry 1998; 173:154-159.

41. Kerr-Correa F, Tucci AM. Preventing suicide risk in depressed patients. WPA Bulletin on Depression 2005; 30:7-10.

42. Harris EC, Barraclough B. Suicide as an outcome for mental disorders : a meta-analysis. Br J Psychiatry 1997; 170:205-228.

43. Qin P, Mortensen PB, Agerbo E, Westergard-Nielsen N, Eriksson T, Mortensen PB. Gender differences in risk factors for suicide in Denmark. Br J Psychiatry 2000; 177:546-550.

44. Pagura J, Cox BJ, Sareen J, Enns MW. Factors associated with multiple versus single episode suicide attempts in the 1990-1992 and 2001-2003 United States National Comorbidity Surveys. J Nerv Ment Dis 2008; 196:806-813.

45. Can SS, Sayıl I. Yineleyici intihar girişimleri. Kriz Dergisi 2004; 12:53-62.