Characteristics of suicidal behavior in a Turkish sample

Transcultural differences in suicide attempts among children and adolescents with and without migration background, a multicentre study: in Vienna, Berlin, Istanbul

While suicide can occur throughout the lifespan, worldwide suicide is the second leading cause of death among young people aged between 15 and 29 years. The aim of this multicentre study, conducted in Austria, Germany and Turkey, is to investigate the transcultural differences of suicide attempts among children and adolescents with and without migration background. The present study is a retrospective analyses of the records of 247 young people, who were admitted after a suicide attempt to Emergency Outpatient Clinics of Departments of Child and Adolescent Psychiatry of the collaborating Universities including Medical University of Vienna, Charité University Medicine Berlin and Cerrahpaşa School of Medicine and Bakirkoy Training and Research Hospital for Mental Health in Istanbul over a 3-year period. The results of the present study show significant transcultural differences between minors with and without migration background in regard to triggering reasons, method of suicide attempts and psychiatric diagnosis. The trigger event "intra-familial conflicts" and the use of "low-risk methods" for their suicide attempt were more frequent among patients with migration background. Moreover among native parents living in Vienna and Berlin divorce of parents were more frequent compared to parents living in Istanbul and migrants in Vienna. These results can be partly explained by cultural differences between migrants and host society. Also disadvantages in socio-economic situations of migrants and their poorer access to the healthcare system can mostly lead to acute and delayed treatments. Larger longitudinal studies are needed to understand better the impact of migration on the suicidal behaviour of young people.

Socio-demographic and psychiatric profile of patients hospitalized due to self-poisoning with suicidal intention

OBJECTIVE

To identify the psychiatric profile of patients hospitalized due to self-intoxication associated with suicide-related behavior (SRB).

METHODS

In this retrospective single-center study, records of consecutive patients treated for suicidal poisoning in our Clinical Toxicology unit between 1st January 2012 and 31st December 2016, who received at least one psychiatric exploration during their inpatient stay, were analyzed with regard to epidemiological data, ingested substances, psychiatric and somatic comorbidities, suicidal circumstances and follow-up therapy.

RESULTS

Out of 1289 hospitalized patients, 1090 patients with complete data were analyzed. Mean age was 40.5 ± 17.2 years, 66.7% were female. 32.0% of patients had previously engaged in SRB, in 76.3% intention was suicidal. 64.7% of patients had a pre-existing psychiatric disorder (PD). Patients with a pre-existing PD more often displayed prior SRB than those without PD (40.7% vs 15.3%; p < 0.001; Fisher's exact test), used long-term/on demand medication (70.2% vs 38.9%; p < 0.001), distanced themselves from the current suicide attempt (65.9% vs 50.8%; p < 0.001) and had no detectable trigger (38.7% vs 18.1%; p < 0.001). Partnership conflict was the most commonly named trigger, and it was documented more often in patients without than in those with PD (41.6% vs 25.6%). After psychiatric reevaluation, most patients were diagnosed with mood disorders (29.7%) and stress disorders (17.0%); 32.8% of patients had a combination of two or more PDs.

CONCLUSION

Hospitalization due to self-poisoning is associated with pre-existing PD, prior SRB and access to psychiatric medication. Detection of these risk factors could allow timely introduction of effective preventive measures tailored to particularly vulnerable subgroups and appropriate relief. However, lack of a detectable trigger in many cases may hamper the identification of those at risk.

Attempted suicide and suicide of young Turkish women in Europe and Turkey: A systematic literature review of characteristics and precipitating factors

BACKGROUND

The increased risk of suicidal behaviour among Turkish women living in Europe and Turkey is a serious public health problem. This study compares and synthesises the empirical evidence of demographic, social, psychological and interpersonal characteristics and precipitating factors in the suicides and attempted suicides of Turkish women in Europe and Turkey.

METHODS

We systematically searched eight databases (PsycINFO, PubMed, Med Line, Web of Science, Smart Cat, Safety Lit, BASE and Ulakbim), using search terms in English, Turkish, German and Dutch, as well as the reference lists of the retrieved papers. We extracted data on countries/regions, population characteristics, sample characteristics, recruitment, method of data collection, type of suicidal behaviour (suicide or attempted suicide) and precipitating factors and characteristics. The results were qualitatively synthesised.

RESULTS

We retrieved nine studies on attempted suicide in Europe (from Germany, Switzerland and the Netherlands), 17 studies on attempted suicide in Turkey and 10 studies on suicide in Turkey (36 in total). Overall, we found similar precipitating factors and characteristics of attempted suicide and suicide in Turkey and Europe, including socio-demographic factors (young age and not being enrolled in the labour market), poverty and, to some extent, mental illness. Moreover, conflicts with family or spouses and violence against women, including so-called honour violence, were particularly common for women living in or originating from traditional areas in Turkey.

CONCLUSION

The framework of intersectionality is relevant to understanding our results, because structural inequalities in gender roles, gender role expectations as well as power imbalances among socio-economic classes collectively impact the suicidal behaviour of Turkish women. Moreover, the importance of violence against women points to the cultural continuity of the patriarchal and oppressive structures of Europe and Turkey. Suicide prevention efforts should address cultural attitudes underlying violence against women and girls through community education programmes, cultural and gender-sensitive care provision and jurisdiction.

Transcultural Differences in Risk Factors and in Triggering Reasons of Suicidal and Self-Harming Behaviour in Young People with and without a Migration Background

Minors with and without migration background can have different risk factors and triggering reasons for self-harming and suicidal behaviour. We retrospectively analysed the data of 192 children and adolescents to investigate the transcultural differences in self-harming, as well as suicidal behaviour in Austrian, Turkish, and Bosnian/Croatian/Serbian (BCS)-speaking patients, who were treated in an emergency out-patient clinic in Vienna. Our results showed transcultural differences in both behaviours. In all groups, females had higher rates of suicide attempts and self-harming behaviour than males. While Turkish-speaking patients received treatment more often, after attempted suicide, Austrians and BCS-speaking patients needed treatment more often for acute stress disorder. Suicide attempts and self-harming behaviours were triggered most frequently by intrafamilial problems, but more frequently in migrant patients. Turkish-speaking patients were at a more than 2 times (OR = 2.21, 95%CI: 1.408–3.477) higher risk for suicide attempts, and were triggered almost 3 times (OR = 2.94, 95%CI: 1.632–5.304) more often by interfamilial conflicts. The suicide attempts of BCS-speaking minors were more often caused by relationship and separation crises (OR = 2.56, 95%CI: 1.148–5.705). These transcultural differences in suicidal and self-harming behaviour of minors, demand an increase of transcultural competence to provide optimal treatment of migrant children.

Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Psychiatric disorders are reported to be present in 80% to 90% of suicide deaths in high-income countries (HIC), but this association is less clear in low- and middle-income countries (LMIC). There has been no previous systematic review of this issue in LMIC. The current study aims to estimate the prevalence of psychiatric morbidity in individuals with suicidal behaviour in LMIC.

METHODS AND FINDINGS

PubMed, PsycINFO, and EMBASE searches were conducted to identify quantitative research papers (any language) between 1990 and 2018 from LMIC that reported on the prevalence of psychiatric morbidity in suicidal behaviour. We used meta-analytic techniques to generate pooled estimates for any psychiatric disorder and specific diagnosis based on International classification of disease (ICD-10) criteria. A total of 112 studies (154 papers) from 26 LMIC (India: 25%, China: 15%, and other LMIC: 60%) were identified, including 18 non-English articles. They included 30,030 individuals with nonfatal suicidal behaviour and 4,996 individuals who had died by suicide. Of the 15 studies (5 LMIC) that scored highly on our quality assessment, prevalence estimates for psychiatric disorders ranged between 30% and 80% in suicide deaths and between 3% and 86% in those who engaged in nonfatal suicidal behaviour. There was substantial heterogeneity between study estimates. Fifty-eight percent (95% CI 46%-71%) of those who died by suicide and 45% (95% CI 30%-61%) of those who engaged in nonfatal suicidal behaviour had a psychiatric disorder. The most prevalent disorder in both fatal and nonfatal suicidal behaviour was mood disorder (25% and 21%, respectively). Schizophrenia and related disorders were identified in 8% (4%-12%) of those who died by suicide and 7% (3%-11%) of those who engaged in nonfatal suicidal behaviour. In nonfatal suicidal behaviour, anxiety disorders, and substance misuse were identified in 19% (1%-36%) and 11% (7%-16%) of individuals, respectively. This systematic review was limited by the low number of high-quality studies and restricting our searches to databases that mainly indexed English language journals.

CONCLUSIONS

Our findings suggest a possible lower prevalence of psychiatric disorders in suicidal behaviour in LMIC. We found very few high-quality studies and high levels of heterogeneity in pooled estimates of psychiatric disorder, which could reflect differing study methods or real differences. There is a clear need for more robust evidence in order for LMIC to strike the right balance between community-based and mental health focussed interventions.

Religion and Suicide: New Findings

Suicide rates and risk and protective factors vary across religions. There has been a significant increase in research in the area of religion and suicide since the article, "Religion and Suicide," reviewed these issues in 2009. This current article provides an updated review of the research since the original article was published. PsycINFO, MEDLINE, SocINDEX, and CINAHL databases were searched for articles on religion and suicide published between 2008 and 2017. Epidemiological data on suicidality and risk and protective factors across religions are explored. Updated general practice guidelines are provided, and areas for future research are identified.

Comparing characteristics of suicide attempters with suicidal ideation and those without suicidal ideation treated in the emergency departments of general hospitals in China

Suicide attempts are more frequent than suicides, and suicidal ideation has been identified as an important precursor of both attempted and completed suicide. In this study, we compare the characteristics of suicide attempters with suicidal ideation and suicide attempters without suicidal ideation who were treated in the emergency departments of general hospitals in China. We identified 166 people as having suicidal ideation and 73 people who did not have suicidal ideation. The suicide attempters with suicidal ideation were more likely to be more depressed, older, have a lower score on life quality, female, divorced and unemployed, report having religious beliefs, have a suicide attempt history and a psychiatric diagnosis, and intend to reduce pain as motives. However, the suicide attempters without suicidal ideation were more likely to have a more self-rescue ideation and were more impulsive, and to threaten or intend revenge on others as motives. Multivariate logistic regression analysis identified the following independent predictors of suicidal ideation in the suicide attempters: a higher score on Hamilton Depression Rating Scale, religious beliefs, non-impulsive suicide attempts, and a psychiatric diagnosis. The results indicate the importance of developing different interventions for the two groups to prevent future suicide in China.

Psychometric Characteristics of the Wish to Be Dead Scale (WDS) in Iranian Psychiatric Outpatients

The Wish to be Dead Scale (WDS) was administered to a convenience sample of 200 Iranian psychiatric outpatients. Using a Principal Component Analysis, two factors were identified, labeled Lack of purpose in life (F1), and Lack of interest in living (F2). The WDS had good reliability and significant positive correlations with scores on the Beck Suicide Ideation Scale and with other measures of mental ill-health. This study provides evidence of the usefulness of the WDS for assessing psychiatric patients.

Psychometric Properties of the Persian Version of the Short Beck Depression Inventory with Iranian Psychiatric Outpatients

The short form of the Beck Depression Inventory (BDI-13) is useful for the screening and assessment of depression in clinical and research settings. The aim of the present study was to investigate the psychometric properties of the Persian (Farsi) version of BDI-13 in an Iranian clinical sample. The sample consisted of 52 Iranian psychiatric outpatients who received services at psychiatric and psychological clinics at the School of Behavioral Sciences & Mental Health-Tehran Institute of Psychiatry, Iran University of Medical Sciences (IUMS) in Tehran, Iran. The study examined the reliability, construct validity, and factor structure of the instrument. The instrument indicated good reliability with Cronbach's alpha of .85 and strong construct validity based on moderate to strong positive correlations with other measures of mental health issues. Using a Principal Component Analysis and Varimax Rotation with Kaiser Normalization, three factors were identified and labeled Affective (F1), Somatic/Vegetative (F2), and Cognitive/Loss of Functioning (F3). The current factor structure suggests that depression is a multidimensional construct in an Iranian clinical sample. This study provides further evidence that the Persian version of the BDI-13 is a psychometrically sound instrument that can be used for clinical and research purposes in Iran.

Indicadores de risco para tentativa de suicídio por envenenamento: um estudo caso-controle

RESUMO Objetivo Considerando o envenenamento como o método mais utilizado para a tentativa de suicídio e a escassez de evidências nacionais sobre o tema, investigamos alguns possíveis indicadores de risco nesse tipo de tentativa. Métodos Estudo do tipo caso-controle em uma emergência geral de um hospital público, na cidade do Recife com 220 indivíduos, distribuídos em dois grupos de 110 pacientes cada, que estavam em tratamento, sendo o grupo casos os sobreviventes de tentativa de suicídio por envenenamento e os controles, sem história de intoxicação/envenenamento nem tentativa de suicídio, pareados por gênero e idade. Resultados O gênero feminino predominou na amostra (70,9%), com idade média de 29 anos; 73% declararam etnia branca ou morena; menos da metade vivia em convívio marital; a maioria tinha religião; ambos tinham poucos anos de estudo. Houve diferença significativa (p = 0,003) para dependência financeira entre os grupos, com chance 2,25 vezes maior para tentar suicídio entre os casos. Ter sofrido fatos traumáticos e abuso sexual na infância revelou diferença significativa. Conclusões Foram considerados indicadores de risco no grupo caso: estar em dependência financeira de terceiros, ter sofrido abuso sexual na infância, ideação suicida, histórico de transtorno mental na família, possuir algum transtorno mental e, principalmente, comorbidade(s) psiquiátrica(s). No modelo de regressão, foi possível estimar uma chance de tentativa de suicídio por envenenamento de até 94,0% na presença conjunta de quatro fatores. A pesquisa representa uma das primeiras iniciativas para ampliação das discussões sobre os fatores de risco para tentativa de suicídio em âmbito nacional.

Impact of religious feast days on youth suicide attempts in Istanbul, Turkey

BACKGROUND

Suicidal behaviour is related to psychosocial and biological factors. Although suicide is strictly forbidden by the Islamic faith, there are non-confirmed observations of increased suicidality on religious feast days. The objective of the present study was to find out if suicide attempts of youths living in Istanbul increase on religious feast days compared to ordinary and non-religious holidays.

METHODS

We retrospectively analyzed all suicide attempts (N = 2,232) of young people up to 25 years of age seeking support at various hospitals in Istanbul in 2010. The main hypothesis was that the number of suicide attempts would increase during religious feast days.

RESULTS

The number of suicide attempts was higher on religious feast days and non-religious holidays except for New Year's Day and International Labour Day than the daily average number of the actual months. Like on ordinary days, more female than male youth (84.9% vs. 15.1%) attempted suicide on feast days.

CONCLUSION

We speculate that changes of the daily rhythm and increased family interaction on feast days and non-religious holidays could lead to unexpected confrontations and disputes instead of the expected positive family climate. This "Broken-Promise Effect" and changes of the daily rhythm could contribute to the observed increased suicidal behaviour.

The impact of migration and culture on suicide attempts of children and adolescents living in Istanbul

BACKGROUND

Suicidal attempts are steadily increasing in societies with rapid urbanisation and dramatic social changes in places like Istanbul. Stress related to internal migration may increase suicidal behaviour.

AIM

We investigated the impact of internal migration and culture on suicide attempts among youth in Istanbul.

METHODS

We retrospectively analysed the records of 210 children and adolescents, aged 6-18 years, who presented at the Emergency Outpatient Clinic of the Department of Pediatrics at Cerrahpaşa Medical School in Istanbul because of suicide attempts between January 2008 and December 2010.

RESULTS

The majority of patients (78.95%, N = 165) had a background of internal migration, mostly (65%, N = 136) originating from regions with large cultural differences compared with that of Istanbul. Noticeably, more migrants than non-migrants (18.8% vs. 6.8%) and more patients originating from regions with large cultural differences chose high-risk methods for suicide attempts (20.7% vs. 8.1%).

CONCLUSION

Internal migration can be considered a serious risk factor for suicidal behaviour. Furthermore, the degree of cultural differences between the area of origin and the new environment can be of vital importance. Healthcare measures should, therefore, focus on internal migration as a risk factor for youth suicidal behaviour and provide assistance for appropriate resettlement and integration in countries with increased mobility.

Risk factors of suicide attempts by poisoning: review

Introduction: Suicide, a complex and universal human phenomenon, is a major public health problem. This study reviewed the literature about the major risk factors associated with suicide attempts by poisoning. Methods: An integrative review of the literature was performed in databases (LILACS, PubMed and MEDLINE) to search for studies published between 2003 and 2013, using the following keywords: suicide, attempted; poisoning; risk factors. Inclusion criteria were: original study with abstract, sample of adults, and attempted suicide by poisoning in at least 50% of the study population. Results: Two hundred and nineteen studies were retrieved and read by two independent examiners, and 22 were included in the study. The main risk factors for suicide attempts by poisoning were female sex, age 15-40 years, single status, little education, unemployment, drug or alcohol abuse or addiction, psychiatric disorder and psychiatric treatment using antidepressants. Conclusion: Further prospective studies should be conducted to confirm these risk factors or identify others, and their findings should contribute to planning measures to prevent suicide attempts.

Psychiatric disorders in patients presenting to hospital following self-harm: a systematic review

BACKGROUND

Psychiatric disorders occur in approximately 90% of individuals dying by suicide. The prevalence of psychiatric disorders in people who engage in non-fatal self-harm has received less attention.

METHOD

Systematic review using electronic databases (Embase, PsychINFO and Medline) for English language publications of studies in which psychiatric disorders have been assessed using research or clinical diagnostic schedules in self-harm patients of all ages presenting to general hospitals, followed by meta-analyses using random effects methods.

RESULTS

A total of 50 studies from 24 countries were identified. Psychiatric (Axis I) disorders were identified in 83.9% (95% CI 74.7-91.3%) of adults and 81.2% (95% CI 60.9-95.5%) of adolescents and young persons. The most frequent disorders were depression, anxiety and alcohol misuse, and additionally attention deficit hyperactivity disorder (ADHD) and conduct disorder in younger patients. Personality (Axis II) disorders were found in 27.5% (95% CI 17.6-38.7%) of adult patients. Psychiatric disorders were somewhat more common in patients in Western (89.6%, 95% CI 83.0-94.7%) than non-Western countries (70.6%, 95% CI 50.1-87.6%).

LIMITATIONS

Heterogeneity between study results was generally high. There were differences between studies in identification of study participants and diagnostic procedures.

CONCLUSIONS

Most self-harm patients have psychiatric disorders, as found in people dying by suicide. Depression and anxiety disorders are particularly common, together with ADHD and conduct disorder in adolescents. Psychosocial assessment and aftercare of self-harm patients should include careful screening for such disorders and appropriate therapeutic interventions. Longitudinal studies of the progress of these disorders are required.

Suicidal ideation among patients with gender identity disorder

In this study, we tried to clarify the prevalence of suicidal ideation and self-mutilation including suicide attempts among patients with gender identity disorder (GID) and the relationship of those behaviors to demographic characteristics. A total of 500 consecutive Japanese GID patients without any other psychiatric comorbidity were evaluated at the outpatient GID Clinic of Okayama University Hospital. The lifetime rate of suicidal ideation was 72.0% of the total sample. There were no significant differences in the prevalence of suicidal ideation among groups divided by sex, age, age at onset or education. The lifetime prevalence of self-mutilation including suicide attempts was 31.8% of the total sample. Low level of education was significantly related to self-mutilation among both male-to-female and female-to-male GID patients. Younger age at onset was a significant factor affecting self-mutilation only among MTF GID patients. A lack of strategies to cope with severe distress among persons with lower education might induce a high frequency of self-mutilation including suicidal attempt. GID patients with a low level education might be at high risk of self-mutilation and should be watched with special attention to self-mutilation.

Psychiatric disorders and clinical correlates of suicidal patients admitted to a psychiatric hospital in Tokyo

BACKGROUND

Patients admitted to a psychiatric hospital with suicidal behavior (SB) are considered to be especially at high risk of suicide. However, the number of studies that have addressed this patient population remains insufficient compared to that of studies on suicidal patients in emergency or medical settings. The purpose of this study is to seek features of a sample of newly admitted suicidal psychiatric patients in a metropolitan area of Japan.

METHOD

155 suicidal patients consecutively admitted to a large psychiatric center during a 20-month period, admission styles of whom were mostly involuntary, were assessed using Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID-I CV and SCID-II) and SB-related psychiatric measures. Associations of the psychiatric diagnoses and SB-related characteristics with gender and age were examined.

RESULTS

The common DSM-IV axis I diagnoses were affective disorders 62%, anxiety disorders 56% and substance-related disorders 38%. 56% of the subjects were diagnosed as having borderline PD, and 87% of them, at least one type of personality disorder (PD). SB methods used prior to admission were self-cutting 41%, overdosing 32%, self-strangulation 15%, jumping from a height 12% and attempting traffic death 10%, the first two of which were frequent among young females. The median (range) of the total number of SBs in the lifetime history was 7 (1-141). Severity of depressive symptomatology, suicidal intent and other symptoms, proportions of the subjects who reported SB-preceding life events and life problems, and childhood and adolescent abuse were comparable to those of the previous studies conducted in medical or emergency service settings. Gender and age-relevant life-problems and life events were identified.

CONCLUSIONS

Features of the studied sample were the high prevalence of affective disorders, anxiety disorders and borderline PD, a variety of SB methods used prior to admission and frequent SB repetition in the lifetime history. Gender and age appeared to have an influence on SB method selection and SB-preceding processes. The findings have important implications for assessment and treatment of psychiatric suicidal patients.