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Comparing characteristics of suicide attempters with suicidal ideation and those without suicidal ideation treated in the emergency departments of general hospitals in China
Author’s Accepted Manuscript Comparing characteristics of suicide attempters with suicidal ideation and those without suicidal ideation treated in the emergency departments of general hospitals in China Shengnan Wei, Haiyan Li, Jinglin Hou, Wei Chen, Shanyong Tan, Xu Chen, Xiaoxia Qin www.elsevier.com/locate/psychres
PII: DOI: Reference:
S0165-1781(17)30887-9 https://doi.org/10.1016/j.psychres.2018.02.007 PSY11181
To appear in: Psychiatry Research Received date: 21 May 2017 Revised date: 26 January 2018 Accepted date: 2 February 2018 Cite this article as: Shengnan Wei, Haiyan Li, Jinglin Hou, Wei Chen, Shanyong Tan, Xu Chen and Xiaoxia Qin, Comparing characteristics of suicide attempters with suicidal ideation and those without suicidal ideation treated in the emergency departments of general hospitals in China, Psychiatry Research, https://doi.org/10.1016/j.psychres.2018.02.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Comparing characteristics of suicide attempters with suicidal ideation and those without suicidal ideation treated in the emergency departments of general hospitals in China
Shengnan Weia,b, Haiyan Lic, Jinglin Houc, Wei Chenc, Shanyong Tanc, Xu Chenc, Xiaoxia Qinc,*
a
Brain Function Research Section, First Affiliated Hospital, China Medical University,
Shenyang, Liaoning, PR China b
Department of Radiology, First Affiliated Hospital, China Medical University,
Shenyang, Liaoning, PR China c
Department of Psychiatry, First Affiliated Hospital, China Medical University,
Shenyang, PR China
*
Corresponding author:
Xiaoxia Qin, Department of Psychiatry, The First Affiliated
Hospital, China Medical University, Shenyang, PR China, 155 Nanjing Road North, Shenyang,
Liaoning,
China
110001.
Telephone:
86-24-8328-2184.
E-mail:
[email protected]
Abstract Suicide attempts are more frequent than suicides, and suicidal ideation has been
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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. Keywords: Suicidal ideation; Attempted suicide; General hospital; Emergency department
1. Introduction Suicide is a major public health problem worldwide (Chishti et al., 2003; Sharma et
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al., 2007) and a leading cause of death worldwide, with more than one million deaths by suicide per year. In China, suicide was the fifth leading cause of death and accounted for 3.6% of all deaths, with a rate of 23 per 100,000 (Phillips et al., 2002). The number of past suicide attempts is the single strongest predictor of suicide (Brown et al., 2000; Fawcett et al., 1990; Nordstrom et al., 1995), and suicide attempts are more frequent than suicides, occurring almost 20 times as often. There are approximately 2 million suicide attempts per year in China. Previous studies have concluded that those who commit suicide and those who attempt suicide are overlapping populations (Parra Uribe et al., 2013; Younes et al., 2015). Detailed information on precursors to suicide attempts could be of help in preventing suicide. Suicidal ideation, defined as thoughts of engaging in behavior intended to end one’s life, has been identified as an important precursor of both attempted suicide and suicide (Brown et al., 2000; Crandall et al., 2006; Kuo et al., 2001). Suicidal ideation added incremental validity to the prediction of future suicide attempts beyond the influence of a past suicide attempt (Horwitz et al., 2015). The previous study indicated that the risk of suicidal ideation was 9 times higher among those who attempt suicide than in a control group of those who do not (Pompili et al., 2009). However, suicidal ideation may vary in persistence, content, methods, and intent, among other characteristics. Past research has also shown that numerous factors from multiple risk factor domains associated with suicidal ideation and attempts (Aaltonen et al., 2016). In adolescents, the duration of suicidal thoughts may be particularly important for risk of suicidal behavior (Gipson et al., 2015). Other research reported
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that higher suicidal ideation was related to the desire to die in the month preceding an attempt among suicide attempters (Perquier et al., 2017) and that reasons for living were negatively associated with suicidal intent (Flowers et al., 2014). In addition, some studies have examined relationships between suicidal ideation and psychological disorders. For example, participants who were identified with psychiatric symptoms by a psychiatrist had more severe and intense suicidal ideation and more determined suicidal intention (Lim et al., 2014). Hospitalized patients with major depression with suicidal ideation had received significantly less education (Bi et al., 2012) and were almost 2 times more likely to have been admitted for a suicide attempt (Pompili et al., 2010), and patients with higher impulsivity appeared to be more likely to have suicidal ideations, even when they were less depressed (Wang et al., 2015). The complexity of factors motivates a closer examination of suicidal ideation. While suicidal ideation has been documented as an important risk factor for suicidal behavior, detailed comparisons of suicide attempters with suicidal ideation and those without suicidal ideation are sparse. However, some studies have indicated characteristics that differentiate the two groups. For instance, adolescent suicide attempters were more likely to show suicidal ideation before the attempt if they had any of the following characteristics: male, psychiatric history, history of previous suicide attempts, or clinical toxicity at the time of the visit to the emergency department (Margarit Soler et al., 2016). Self-harm with and without suicidal intent include some overlapping behaviors, but with some distinct characteristics, indicating
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the importance of fully exploring vulnerability factors, motivations, and intentions of adolescents who self-harm (Mars et al., 2014). Decreasing the intensity of suicide ideation in suicide attempters might be important in preventing them from committing suicide (Joo et al., 2016). Therefore, assessing suicidal ideation and past suicide attempts as important risk indicators is likely to improve sensitivity in predicting completed suicide, and suicide attempts with suicidal ideation and without suicidal ideation are notably important sub-categories. However, studies are few that compare characteristics of suicide attempters with suicidal ideation and without suicidal ideation in China. Previous studies reported that suicide attempters were more likely to report ongoing suicidal ideation during psychiatric evaluation in the emergency departments (Pompili et al., 2011). Suicidal ideation was self-disclosed frequently by patients in emergency department waiting rooms and patients who disclosed suicidal ideation did not always receive referrals for mental health services (Kemball et al., 2008). Therefore, emergency departments are increasingly an important setting for introducing suicide prevention measures, and studies have focused on developing effective interventions to initiate during emergency department stays for patients who have attempted suicide (Boudreaux et al., 2013; Hirayasu et al., 2009). The increasing number of emergency department visits for suicide is and will continue to be a significant challenge (Arango et al., 2016). Logically, then, research on suicidal behavior in emergency departments is highly desirable. The present study compared characteristics of suicide attempters exhibited suicidal
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ideation with attempters who did not show suicidal ideation. We specifically targeted individuals who presented for treatment in the emergency departments of general hospitals in China. A better understanding of the similarities and differences in sociodemographic and psychological characteristics of suicide attempters between the two groups may provide a basis for developing suicide prevention plans. Such plans may be specific to China, as an immediate focus, but also may be helpful in other countries, as well. 2. Methods 2.1. Design and settings The individuals enrolled in this study were patients treated for attempted suicide (as reported by the patient or family members) in the emergency departments of 4 tertiary-level general hospitals in Shenyang (a city with a population of 6.9 million residents), Liaoning Province, in northeastern China. The hospitals were randomly selected from 15 tertiary general hospitals located in Shenyang. The 4 hospitals are the First Affiliated Hospital of China Medical University, ShenYang First People’s Hospital, ShenYang Fourth People’s Hospital, and Central Hospital Affiliated with ShenYang Medical College, and all are academic affiliated hospitals. All individuals who came to the emergency departments after having made a suicide attempt were identified and approached by a trained research assistant. Participants who were 15 years of age or older, who were able to understand the study procedures, who had at least one contact person (to enable follow-up), and who provided written informed consent, were enrolled. The study was approved by the Institutional Review Board of
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the China Medical University. 2.2. Materials The 239 individuals and their accompanying family members were independently interviewed by two trained researchers. The comprehensive suicide attempt interview schedule that was used included several components that took a total of two hours to complete, as follows: (1) a detailed structured questionnaire to assess the patients’ sociodemographic characteristics (age, gender, employment status, marital status, residence, annual family income, educational level, and religious beliefs), the characteristics of the attempt (method of self-harm, alcohol use at the time of the episode, reported motive, time suicide had been considered before acting, presence or absence of a suicide note, and help-seeking prior to the attempt), and self-reports of prior attempts and suicidal history among family members or associates; (2) the Beck 19-item Scale for Suicide Ideation (Beck et al., 1979) to evaluate the intensity of patients' attitudes, behaviors, and plans to commit suicide, with each of the items providing three options graded 0–2 according to the intensity of the suicidality, and higher scores indicating stronger suicide ideation; (3) the 24-item Hamilton Depression Rating Scale (HAMD) (Hamilton, 1960; Williams, 1988); and (4) a quality of life rating scale covering the month prior to the attempt, on which respondents assess six characteristics of the attempter (physical health, psychological health, economic circumstances, work, family relationships, and relationships with non-family associates) on a scale of 1 (very poor) to 5 (excellent). In addition, attempters received a psychiatric diagnosis made according to the
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Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), as assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). The Chinese translation of the SCID has been shown to be reliable and valid (Shi et al., 2005). This version of the SCID allowed for the inclusion of “not otherwise specified” (NOS) categories of illness for subjects who had clinically significant symptoms combined with social dysfunction, but did not meet the full criteria of a specific disorder (which is fairly common in China), and for the recording of multiple diagnoses ranked according to clinical importance. The six psychiatric researchers who participated in the study attended a 4-week training course in the use of the SCID; their interrater reliability at the end of training, using 16 taped interviews of different types of patients, was excellent (intra-class correlation coefficient = 0.95). In the study, the presence of suicidal ideation was the outcome variable based on the Beck 19-item Scale for Suicide Ideation; we used the item about suicidal ideation found in the Beck 19-item Scale for Suicide Ideation to stratify our patients. The suicide attempters divided into groups with suicidal ideation and without suicidal ideation. 2.3. Data analysis We compared the sociodemographic and clinical characteristics of suicide attempters with suicidal ideation and without ideation. To examine the mean differences between the two groups in the study variables, for example, age, gender, employment status, marital status, and so on, we used frequency distributions, Student's t tests, chi-square tests, and Fisher's exact tests with the assistance of SPSS
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for Windows Version 11.5 (SPSS, Chicago, IL, USA). The critical level of statistical significance was set at 0.05 and the analysis was two-tailed. A logistic regression model examined factors associated with suicide attempters with suicidal ideation, with suicidal ideation as the dependent variable. Independent variables in the model included age; gender; years of education; religious beliefs; previous episodes of suicide attempts; alcohol use at the time of the episode or up to 12 h prior to the attempt; self-rescue; psychiatric diagnosis; impulsivity; depression; and life quality. First, we entered all eleven variables into unconditional logistic regression analyses (the 11 variables were chosen based on p-values from correlation analysis and our previous studies; Bi et al., 2010; Wei et al., 2013). The significant independent predictors from the analyses were then selected for possible use in a final model. In this analysis process, we selected a concrete option of method (Forward: Conditional), and we also examined confounding variables or any interactions in the model. Statistical significance in the logistic regression model was assessed using the Wald statistic and 95% confidence intervals computed using the Gaussian approximation to the log likelihood of the rate. 3. Results 3.1. Participants During the enrollment period, from June 2007 to January 2008, 403 suicide attempt episodes were treated at the target emergency rooms. Of those, 366 individuals met the criteria for inclusion in the study; seven cases were excluded due to repeat attempts because we only wanted to evaluate the current episode. Among the 359
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different patients, 239 (59.3%) completed the full evaluation; 29 left early before they could be approached by the research team, 90 refused to participate, and 1 did not provide all of the data needed for analysis. There were no statistical differences in gender (p=0.72), age (p=0.97), or years of education (p=0.07) between the included and excluded patients. 3.2. Sociodemographic characteristic of the suicide attempters with suicidal ideation and without suicidal ideation Of the 239 patients, we identified 166 (69.46%) as having suicidal ideation and 73 (30.54%) did not have suicidal ideation. A comparison of demographic characteristics for each group is shown in Table 1. There were no significant differences between the two groups in race, living situation, annual family income, or educational level. However, age (mean±SD, Without suicidal ideation: 28.47±11.71; Suicidal ideation: 34.31±14.51), gender (n,%, Men without suicidal ideation: 23, 31.50%; Men with suicidal ideation: 30, 18.10%) , marital status (n,%, Never married without suicidal ideation: 35, 47.90%; Never married with suicidal ideation: 55, 33.10%), employment status(n,%, Unemployed without suicidal ideation: 14, 19.20%; Unemployed with suicidal ideation: 52, 31.30%), and religious beliefs (n,%, Having religious beliefs without suicidal ideation: 1, 1.40%; Having religious beliefs with suicidal ideation:19, 11.40%) were statistically different between the two groups. Compared to suicide attempters without suicidal ideation, the suicide attempters with suicidal ideation were more likely to be older (p=0.01), female (p=0.02), divorced or separated (p=0.001), unemployed or a housewife (p=0.000), and to report having religious beliefs (p=0.02).
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3.3. Clinical characteristics Table 2 presents a comparison of clinical characteristics for each group. No significant difference was observed between the two groups in the method of attempted suicide. Self-poisoning was prominent for both groups (92.2% and 91.8%, respectively), and the majority of patients who overdosed used psychotropic drugs. There were also no significant differences between the two groups in family history of suicide attempts, alcohol use at the time of the episode or up to 12 h previous to the attempt, writing a suicide note, making funeral arrangements, or seeking help. However, the suicide attempters without suicidal ideation had significantly more self-rescue (p=0.001) and were more impulsive (p=0.000) than the suicide attempters with suicidal ideation. Compared to suicide attempters without suicidal ideation, those with suicidal ideation were more likely to have a suicide attempt history (p=0.01) and a psychiatric diagnosis (p=0.000). Motives for suicide attempts differed significantly between the two groups (p=0.000). The suicide attempters without suicidal ideation were more likely to threaten or intend revenge on others than the suicide attempters with suicidal ideation (p=0.000); those with suicidal ideation were more likely to be motivated by a desire to reduce the pain and the burden of life. Table 3 shows the comparison of depression scale scores for each group. Suicide attempters with suicidal ideation had significantly higher depression scores on the HAMD (p=0.000) and lower scores on life quality (p=0.000) than the suicide attempters without suicidal ideation. 3.4. Result of logistic regression analysis
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We applied a logistic regression model to examine factors associated with the suicide attempts of those with suicidal ideation among all suicide attempters, with suicidal ideation as the dependent variable (Table 4). The unconditional logistic regression analysis identified the following independent predictors of suicidal ideation: a higher score on HAMD (OR [odds ratio]=1.12, 95% CI=1.41-1.19), having religious beliefs (OR=11.40, 95% CI=1.31-99.10), having impulsive suicide attempts (OR=0.29, 95% CI=0.14-0.62), and having a psychiatric diagnosis (OR=2.65, 95% CI=1.10-6.42). 4. Discussion 4.1. Main findings The main findings in the present study were that the suicide attempters with suicidal ideation and without suicidal ideation shared some demographic and clinical characteristics, in particular, living situation, annual family income, educational level, method of attempted suicide, family history of suicide attempts, alcohol use at the time of the episode or up to 12 h prior to the attempt, writing a suicide note, making funeral arrangements, and seeking help. Those outcomes are similar to other research (Mars et al., 2014) indicating that many risk factors were common to self-harm both with and without suicidal intent. Importantly, however, we found differences in demographic and clinical characteristics of suicide attempters with suicidal ideation and without suicidal ideation. First, our results indicated that the suicide attempters with suicidal ideation were older and more often female than those without suicidal ideation. Furthermore, the
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older women were more likely to have suicidal ideation before the attempt. This finding of an apparent age effect is similar to a Japanese study (Matsuishi et al., 2005). But this is not consistent with Western studies that have found that suicidal ideation before the attempt (Margarit Soler et al., 2016) was more prevalent in males and that children and adolescents had higher rates of suicidal ideation than adults (Gallego et al., 2015). In addition, other work suggests that young African-American adult women were at high risk for suicidal ideation (Richardson-Vejlgaard et al., 2009). Those inconsistencies may be a result of cultural factors. Obvious cultural differences exist between China and other countries and regions. For example, In developed countries, the male-to-female ratio for suicide is between two to one and four to one, and the number seems to be increasing (Hawton and van Heeringen, 2009). Second, the present study indicated that the suicide attempters with suicidal ideation were more likely to be divorced or separated and unemployed. Collectively, those factors may be seen as negative or stressful life events. At the same time, our results indicated that the suicide attempters with suicidal ideation had significantly lower scores on life quality than the suicide attempters without suicidal ideation, again suggesting negative or stressful life circumstances. This pattern is consistent with previous research in China that documented that patients reporting suicidal thoughts, plans, or attempts experienced a significantly greater number of stressful life events and that female patients without any suicidality were significantly more likely to be married and employed (Bi et al., 2012). We also found that the suicide attempters with suicidal ideation were more frequently housewives, an outcome
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which is entirely consistent with the above result that the suicide attempters with suicidal ideation were more often female. Third, we also found that the suicide attempters with suicidal ideation were more likely to have religious beliefs than those without suicidal ideation. One study also suggested religion is a risk factor for suicide attempts and suicide ideation among depressed patients (Lawrence et al., 2016). However, this fiinding is not consistent with widely accepted thought that individuals with religious beliefs are less likely to have suicidal ideation (Cole-Lewis et al., 2016). In addition, a report found no relationship between religious affiliation and suicidal ideation (Hovey, 1999). The topic needs future study to explore whether religious belief is related to suicidal ideation in different countries. Fourth, this study demonstrated that the suicide attempters with suicidal ideation were more likely to have histories of previous suicide attempts than those who attempted suicide but who did not have suicidal ideation. Other studies (Choi et al., 2013; Margarit Soler et al., 2016) also came to a similar conclusion. Our results on the motives for suicide attempts suggested that the suicide attempters with suicidal ideation were more likely to intend to reduce the pain and the burden of life. By contrast, the suicide attempters without suicidal ideation were more likely to intend their attempt as a means to threaten or take revenge on others. This finding suggests that those with suicidal ideation had a greater wish to die, but those who did not have suicidal ideation, at some deep level, did not wish to die. This is similar to previous findings (McAuliffe et al., 2007; Perquier et al., 2017). Moreover, we also found that
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the suicide attempters without suicidal ideation had significantly more self-rescue and were more impulsive than those with suicidal ideation. One explanation of this situation may be the different motives for suicide attempts between two groups. The suicide attempters without suicidal ideation had lower expectations of death or less expectation of lethality; thus, they wanted to be helped, when they attempted to commit suicide. Further, they were more impulsive, as a result of their motive to threaten or take revenge on others. This is consistent with the previous study (Baca-Garcia et al., 2005). Some studies (Carli et al., 2010; McGirr et al., 2008) reported that suicide may be associated in individuals with higher impulsivity, which may also explain that some suicide attempts were without suicidal ideation. On the contrary, suicide attempters with suicidal ideation were more likely to result in death and less impulsive as a result of the mental illness of the subject. Fifth, our findings suggested that the suicide attempters with suicidal ideation were more likely to have a psychiatric diagnosis. The proportion of psychiatric diagnosis of suicide attempters with suicidal ideation was higher than for those without suicidal ideation. This is consistent with other studies (Lim et al., 2014; Margarit Soler et al., 2016). As other studies have found (Bi et al., 2012; Ozdel et al., 2009; Pompili et al., 2010; Wang et al., 2015), our results indicated that the suicide attempters with suicidal ideation had significantly higher depression scores than those without suicidal ideation. For instance, patients diagnosed with major depression were almost twice as likely to report suicidal ideation at the psychiatric interview as paired patients without major depression (Pompili et al., 2010). Suicide attempts with depression were
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associated with high scores on the suicide intent scale (Ozdel et al., 2009). In summary, the suicide attempters with suicidal ideation and without suicidal ideation shared some characteristics. However, suicide attempters with suicidal ideation were more likely to be depressed, older, female, divorced or separated, unemployed, and housewives. Further, they more frequently reported having religious beliefs, making previous suicide attempts, having a psychiatric diagnosis, experiencing lower life quality, and aiming to reduce the pain and the burden of life as the motive of the suicide attempt. By contrast, the suicide attempters without suicidal ideation were more likely to be younger, more impulsive, self-rescue, and threaten or intend revenge against others as the motive for the suicide attempt. However, they were less likely to have a psychiatric diagnosis. 4.2. Predictor of suicide attempters by those with suicidal ideation Using the unconditional logistic regression analysis, we found that significant predictors of suicide attempts by those with suicidal ideation were higher scores on the HAMD, religious beliefs, non-impulsive suicide attempts, and a psychiatric diagnosis. The results suggest that suicide attempters with higher depression scores, no impulsive suicide attempts, and a psychiatric diagnosis were more likely to exhibit suicidal ideation. This is consistent with previous studies (Baca-Garcia et al., 2005; Margarit Soler et al., 2016; Ozdel et al., 2009; Pompili et al., 2010). Having religious beliefs is the strongest factor associated with suicide attempts by those with suicidal ideation. Studies mentioned earlier from China and other countries have shown that the relationship between religion and suicidal ideation were different. A recent review
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also reported that whether religious affiliation protects against suicide attempts may depend on the culture-specific implications of affiliating with a particular religion, since minority religious groups can feel socially isolated (Lawrence et al., 2015). Why that predictor should be so prominent is not clear. It needs future study to explain it concretely in China. 4.3. Strengths There are several strengths in this study. This study is one of the few studies focused on the detailed assessment and comparison between suicide attempters with suicidal ideation and without suicidal ideation treated in the emergency departments of general hospitals in China. The samples are representatives of emergency outpatient departments at general hospitals in a large urban municipality in northern China. The assessment about suicide attempters was based on a clinical structured interview and standardized instruments, rather than on a psychological autopsy study. The diagnosis was based on the administration of SCID by trained researchers who had excellent inter-rater reliability and rigorous quality control measures were enforced throughout the study. The healthcare delivery system in Shenyang is similar to that in other urban areas of China, so we believe that the results can be extrapolated to other urban areas in China. 4.4. Limitations We acknowledge several limitations of the present study, however. First, we had limited data on suicide attempters who did not participate in our study. Second, we only assessed the Axis I disorders according to the DSM-IV but not the diagnosis of
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the borderline personality disorder or other personality disorders which may influence the results in our study. Third, the findings are based on a relatively small sample from regional hospitals, raising the question of whether the results can be generalized. Generalizability is also difficult in this population from Shenyang because some suicide attempters may not be present to the hospital setting. Fourth, some of those who attempted suicide that were classified as not having suicidal ideation may have had unreported suicidal ideation. Finally, our study cohort was limited to an urban population, and different outcomes might be expected in a rural population. Thus, a multicenter study focusing on multiple sites would be desirable to demonstrate current trends in attempted suicide in China. Despite these limitations, the present study provided evidence that will help understand the characteristics of suicide attempters with suicidal ideation and without suicidal ideation in China and help develop the interventions to prevent future suicide. 4.5. Conclusions In the current study, the patients in the emergency departments of general hospitals in China who attempted suicide with suicidal ideation and those who attempted suicide who did not have suicidal ideation shared some similar demographic and clinical characteristics; however, they also exhibited unique characteristics of suicide behavior. The findings from this study may have unique cultural and regional implications and be useful in understanding cultural manifestations and development of suicide attempts in China. It is important to develop different kinds of interventions for the two types of people who attempt suicide to prevent future suicides in China.
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Conflict of interest None of the authors have any conflict of interest related to the content of this paper. Acknowledgments This project was part of the “Small Grants Program to Improve the Quality and Implementation of Suicide Research in China”, which was supported by the China Medical Board of New York (grant number 05-813) and coordinated by Professor Michael Phillips of the Shanghai Jiao Tong University School of Medicine. We would like to thank the four participating hospitals in Shenyang for their active support of the project. References Aaltonen, K., Naatanen, P., Heikkinen, M., Koivisto, M., Baryshnikov, I., Karpov, B., et al. 2016. Differences and similarities of risk factors for suicidal ideation and attempts among patients with depressive or bipolar disorders. J. Affect. Disord. 193, 318-330. Arango, A., Opperman, K.J., Gipson, P.Y., King, C.A., 2016. Suicidal ideation and suicide attempts among youth who report bully victimization, bully perpetration and/or low social connectedness. J. Adolesc. 51, 19-29. Baca-Garcia, E., Diaz-Sastre, C., Garcia Resa, E., Blasco, H., Braquehais Conesa, D., Oquendo, M.A., et al. 2005. Suicide attempts and impulsivity. Eur. Arch Psychiatry Clin. Neurosci. 255 (2), 152-156. Beck, A.T., Kovacs, M., Weissman, A., 1979. Assessment of suicidal intention: the Scale for Suicide Ideation. J. Consult. Clin. Psychol. 47 (2), 343-352. Bi, B., Tong, J., Liu, L., Wei, S., Li, H., Hou, J., et al. 2010. Comparison of patients with and
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Psychol. Rep. 85 (1), 171-177. Joo, S.H., Wang, S.M., Kim, T.W., Seo, H.J., Jeong, J.H., Han, J.H., et al. 2016. Factors associated with suicide completion: A comparison between suicide attempters and completers. Asia Pac. Psychiatry 8 (1), 80-86. Kemball, R.S., Gasgarth, R., Johnson, B., Patil, M., Houry, D., 2008. Unrecognized suicidal ideation in ED patients: are we missing an opportunity? Am. J. Emerg. Med. 26 (6), 701-705. Kuo, W.H., Gallo, J.J., Tien, A.Y., 2001. Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland. Psychol. Med. 31 (7), 1181-1191. Lawrence, R.E., Brent, D., Mann, J.J., Burke, A.K., Grunebaum, M.F., Galfalvy, H.C., et al. 2016. Religion as a risk factor for suicide attempt and suicide ideation among depressed patients. J. Nerv. Ment. Dis. 204 (11), 845-850. Lawrence, R.E., Oquendo, M.A., Stanley, B., 2015. Religion and suicide risk: a systematic review. Arch. Suicide Res. 20 (1), 1-21. Lim, M., Kim, S.W., Nam, Y.Y., Moon, E., Yu, J., Lee, S., et al. 2014. Reasons for desiring death: examining causative factors of suicide attempters treated in emergency rooms in Korea. J. Affect. Disord. 168, 349-356. Margarit Soler, A., Martinez Sanchez, L., Martinez Monseny, A., Trenchs Sainz de la Maza, V., Picouto Gonzalez, M.D., Villar Cabeza, F., et al. 2016. Epidemiological characteristics in suicidal adolescents seen in the Emergency Department. An Pediatr (Barc). 85 (1), 13-17. Mars, B., Heron, J., Crane, C., Hawton, K., Kidger, J., Lewis, G., et al. 2014. Differences in risk
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factors for self-harm with and without suicidal intent: findings from the ALSPAC cohort. J. Affect. Disord. 168, 407-414. Matsuishi, K., Kitamura, N., Sato, M., Nagai, K., Huh, S.Y., Ariyoshi, K., et al. 2005. Change of suicidal ideation induced by suicide attempt. Psychiatry Clin. Neurosci. 59 (5), 599-604. McAuliffe, C., Arensman, E., Keeley, H.S., Corcoran, P., Fitzgerald, A.P., 2007. Motives and suicide intent underlying hospital treated deliberate self-harm and their association with repetition. Suicide Life Threat. Behav. 37 (4), 397-408. McGirr, A., Renaud, J., Bureau, A., Seguin, M., Lesage, A., Turecki, G., 2008. Impulsive-aggressive behaviours and completed suicide across the life cycle: a predisposition for younger age of suicide. Psychol. Med. 38 (3), 407-417. Nordstrom, P., Asberg, M., Aberg-Wistedt, A., Nordin, C., 1995. Attempted suicide predicts suicide risk in mood disorders. Acta Psychiatr. Scand. 92 (5), 345-350. Ozdel, O., Varma, G., Atesci, F.C., Oguzhanoglu, N.K., Karadag, F., Amuk, T., 2009. Characteristics of suicidal behavior in a Turkish sample. Crisis 30 (2), 90-93. Parra Uribe, I., Blasco-Fontecilla, H., Garcia-Pares, G., Giro Batalla, M., Llorens Capdevila, M., Cebria Meca, A., et al. 2013. Attempted and completed suicide: not what we expected? J. Affect. Disord. 150 (3), 840-846. Perquier, F., Duroy, D., Oudinet, C., Maamar, A., Choquet, C., Casalino, E., et al. 2017. Suicide attempters examined in a Parisian Emergency Department: Contrasting characteristics associated with multiple suicide attempts or with the motive to die. Psychiatry Res. 253, 142-149. Phillips, M.R., Li, X., Zhang, Y., 2002. Suicide rates in China, 1995-99. Lancet 359 (9309),
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835-840. Pompili, M., Innamorati, M., Del Casale, A., Serafini, G., Forte, A., Lester, D., et al. 2009. No cathartic effect in suicide attempters admitted to the emergency department. J. Psychiatr. Pract. 15 (6), 433-441. Pompili, M., Innamorati, M., Giupponi, G., Pycha, R., Serafini, G., Del Casale, A., et al. 2010. Patients with mood disorders admitted for a suicide attempt to an emergency ward. Neuropsychiatr. 24 (1), 56-63. Pompili, M., Innamorati, M., Serafini, G., Forte, A., Cittadini, A., Mancinelli, I., et al. 2011. Suicide attempters in the emergency department before hospitalization in a psychiatric ward. Perspect. Psychiatr. Care 47 (1), 23-34. Richardson-Vejlgaard, R., Sher, L., Oquendo, M.A., Lizardi, D., Stanley, B., 2009. Moral objections to suicide and suicidal ideation among mood disordered Whites, Blacks, and Hispanics. J. Psychiatr. Res. 43 (4), 360-365. Sharma, B.R., Gupta, M., Sharma, A.K., Sharma, S., Gupta, N., Relhan, N., et al. 2007. Suicides in Northern India: comparison of trends and review of literature. J. Forensic Leg. Med. 14 (6), 318-326. Shi, Q.C., Zhang, J.M., Xu, F.Z., Phillips, M.R., Xu, Y., Fu, Y.L., et al. 2005. Epidemiological survey of mental illnesses in the people aged 15 and older in Zhejiang Province, China. Zhonghua Yu Fang Yi Xue Za Zhi 39 (4), 229-236. Wang, Y.Y., Jiang, N.Z., Cheung, E.F., Sun, H.W., Chan, R.C., 2015. Role of depression severity and impulsivity in the relationship between hopelessness and suicidal ideation in patients with major depressive disorder. J. Affect. Disord. 183, 83-89.
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Wei, S., Liu, L., Bi, B., Li, H., Hou, J., Chen, W., et al. 2013. Comparison of impulsive and nonimpulsive suicide attempt patients treated in the emergency departments of four general hospitals in Shenyang, China. Gen. Hosp. Psychiatry 35 (2), 186-191. Williams, J.B., 1988. A structured interview guide for the Hamilton Depression Rating Scale. Arch. Gen. Psychiatry 45 (8), 742-747. Younes, N., Melchior, M., Turbelin, C., Blanchon, T., Hanslik, T., Chee, C.C., 2015. Attempted and completed suicide in primary care: not what we expected? J. Affect. Disord 170, 150-154.
Table1 Sociodemographic characteristics of suicide attempters with suicidal ideation and without suicidal ideation
Age years (mean, SD)
Without suicidal ideation
Suicidal ideation
(n=73)
(n=166)
n
%
n
%
χ2
P
28.47
11.71
34.31
14.51
-3.04*
.003
11.50
0.01
5.30
0.02
1.13
0.29
18.93
0.001
21.09
0.000
Age group 15–24
35
47.90
45
27.10
25–44
31
42.50
90
54.20
45–59
6
8.20
21
12.70
60+
1
1.40
10
6.00
Men
23
31.50
30
18.10
Women
50
68.50
136
81.90
Gender
Race Han
70
95.90
151
91.00
Minority
3
4.10
15
9.00
Marital status Never married
35
47.90
55
33.10
Married
31
42.50
74
44.60
Cohabitation
7
9.60
15
9.00
Divorced/separated
0
0
13
7.80
Widowed
0
0
9
5.40
Employment status Employment
43
58.90
89
53.60
25
Unemployment
14
19.20
52
31.30
Student
16
21.90
12
7.20
Housewife
0
0
13
7.80
3
4.10
16
9.60
Living situation Solitary Shared accommodation
7
9.60
19
11.40
Living with family
55
75.30
116
69.90
Cohabitation
8
11.00
15
9.00
Low (≤10 000)
9
12.30
36
21.70
Medium (10 001–50 000)
41
56.20
85
51.20
High (＞50 000)
23
31.50
45
27.10
Illiterate
3
4.10
14
8.40
Elementary school
37
50.70
79
47.60
High school
25
34.20
43
25.90
College
8
11.00
30
18.10
Annual income of family
Educational level
Religious beliefs No
72
98.60
147
88.60
Yes
1
1.40
19
11.40
2.52
0.47
2.94
0.23
4.29
0.23
5.46
0.02
* T values
Table2 Clinical characteristics of patients who attempted suicide with suicidal ideation and without suicidal ideation
Characteristics
Without suicidal ideation
Suicidal ideation
(n=73)
(n=166)
n
%
n
%
Method of suicide attempts Self-poisoning
67
91.80
153
92.20
Self-injury
6
8.20
11
6.60
Other
0
0
2
1.20
Previous episodes of suicide attempts No
63
86.30
118
71.10
Yes
10
13.70
48
28.90
Family history of suicide attempts No
72
98.60
159
95.80
Yes
1
1.40
7
4.20
Alcohol use at the time of the episode or up to 12 h before No
63
86.30
148
89.20
Yes
10
13.70
18
10.80
Self-rescue No
61
83.60
160
96.40
Yes
12
16.40
6
3.60
Motive of suicide attempt
χ2
P
1.64
0.44
6.39
0.01
0.54
0.26
0.40
0.53
11.97
0.001
35.72
0.000
26
Deceased pain and burden
19
26.00
111
66.90
Threatened or revenged others
40
54.80
35
21.10
Other
14
19.20
20
12.00
Suicide note No
70
95.90
146
88.00
Yes
3
4.10
20
12.00
Funeral arrangements No
73
100.00
159
95.80
Yes
0
0
7
4.20
Seeking for help No
52
71.20
136
81.90
Yes
21
28.80
30
18.10
Impulsive suicide attempts No
18
24.70
114
68.70
Yes
55
75.30
52
31.30
Psychiatric diagnosis No
47
64.40
26
15.70
Yes
26
35.60
140
84.30
2.81
0.09
1.86
0.17
3.46
0.06
39.73
0.000
56.73
0.000
27
Table 3 Means and standard deviations of depression and life quality scale scores of patients who attempted suicide with suicidal ideation
and without suicidal ideation
Without suicidal ideation (n=73)
Suicidal ideation (n=166)
Mean
(n=73)SD
Mean
SD
T
P
Score on HAMD*
8.18
6.52
19.69
10.14
-10.50
0.000
Score on life quality
56.28
12.39
45.93
12.08
6.05
0.000
Note: HAMD, Hamilton Depression Rating Scale.
Table 4 Result of logistic regression analysis: Predictors of categorization of suicide attempters as having suicidal ideation (n = 166) or
not having suicidal ideation (n = 73)
Predictors
B
S.E.
P
OR (Odds ratio)
95% CI (confidence intervals)
HAMD* score
0.11
0.03
0.001
1.12
1.41 – 1.19
Religious beliefs
2.43
1.10
0.03
11.40
1.31 – 99.10
Impulsive suicide attempts
-1.23
0.38
0.001
0.29
0.14 – 0.62
Psychiatric diagnosis
0.98
0.45
0.03
2.65
1.10 – 6.42
Note: HAMD (Hamilton Depression Rating Scale) was the only continuous variable used in the regression; all the other variables were
dichotomous.
28
Highlights The suicide attempters with and without suicidal ideation shared some similar characteristics. The suicide attempters with and without suicidal ideation demonstrated unique characteristics. Different kinds of interventions are necessary for suicide attempters with and without suicidal ideation to prevent future suicide.
29
PII: DOI: Reference:
S0165-1781(17)30887-9 https://doi.org/10.1016/j.psychres.2018.02.007 PSY11181
To appear in: Psychiatry Research Received date: 21 May 2017 Revised date: 26 January 2018 Accepted date: 2 February 2018 Cite this article as: Shengnan Wei, Haiyan Li, Jinglin Hou, Wei Chen, Shanyong Tan, Xu Chen and Xiaoxia Qin, Comparing characteristics of suicide attempters with suicidal ideation and those without suicidal ideation treated in the emergency departments of general hospitals in China, Psychiatry Research, https://doi.org/10.1016/j.psychres.2018.02.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Comparing characteristics of suicide attempters with suicidal ideation and those without suicidal ideation treated in the emergency departments of general hospitals in China
Shengnan Weia,b, Haiyan Lic, Jinglin Houc, Wei Chenc, Shanyong Tanc, Xu Chenc, Xiaoxia Qinc,*
a
Brain Function Research Section, First Affiliated Hospital, China Medical University,
Shenyang, Liaoning, PR China b
Department of Radiology, First Affiliated Hospital, China Medical University,
Shenyang, Liaoning, PR China c
Department of Psychiatry, First Affiliated Hospital, China Medical University,
Shenyang, PR China
*
Corresponding author:
Xiaoxia Qin, Department of Psychiatry, The First Affiliated
Hospital, China Medical University, Shenyang, PR China, 155 Nanjing Road North, Shenyang,
Liaoning,
China
110001.
Telephone:
86-24-8328-2184.
E-mail:
[email protected]
Abstract Suicide attempts are more frequent than suicides, and suicidal ideation has been
1
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. Keywords: Suicidal ideation; Attempted suicide; General hospital; Emergency department
1. Introduction Suicide is a major public health problem worldwide (Chishti et al., 2003; Sharma et
2
al., 2007) and a leading cause of death worldwide, with more than one million deaths by suicide per year. In China, suicide was the fifth leading cause of death and accounted for 3.6% of all deaths, with a rate of 23 per 100,000 (Phillips et al., 2002). The number of past suicide attempts is the single strongest predictor of suicide (Brown et al., 2000; Fawcett et al., 1990; Nordstrom et al., 1995), and suicide attempts are more frequent than suicides, occurring almost 20 times as often. There are approximately 2 million suicide attempts per year in China. Previous studies have concluded that those who commit suicide and those who attempt suicide are overlapping populations (Parra Uribe et al., 2013; Younes et al., 2015). Detailed information on precursors to suicide attempts could be of help in preventing suicide. Suicidal ideation, defined as thoughts of engaging in behavior intended to end one’s life, has been identified as an important precursor of both attempted suicide and suicide (Brown et al., 2000; Crandall et al., 2006; Kuo et al., 2001). Suicidal ideation added incremental validity to the prediction of future suicide attempts beyond the influence of a past suicide attempt (Horwitz et al., 2015). The previous study indicated that the risk of suicidal ideation was 9 times higher among those who attempt suicide than in a control group of those who do not (Pompili et al., 2009). However, suicidal ideation may vary in persistence, content, methods, and intent, among other characteristics. Past research has also shown that numerous factors from multiple risk factor domains associated with suicidal ideation and attempts (Aaltonen et al., 2016). In adolescents, the duration of suicidal thoughts may be particularly important for risk of suicidal behavior (Gipson et al., 2015). Other research reported
3
that higher suicidal ideation was related to the desire to die in the month preceding an attempt among suicide attempters (Perquier et al., 2017) and that reasons for living were negatively associated with suicidal intent (Flowers et al., 2014). In addition, some studies have examined relationships between suicidal ideation and psychological disorders. For example, participants who were identified with psychiatric symptoms by a psychiatrist had more severe and intense suicidal ideation and more determined suicidal intention (Lim et al., 2014). Hospitalized patients with major depression with suicidal ideation had received significantly less education (Bi et al., 2012) and were almost 2 times more likely to have been admitted for a suicide attempt (Pompili et al., 2010), and patients with higher impulsivity appeared to be more likely to have suicidal ideations, even when they were less depressed (Wang et al., 2015). The complexity of factors motivates a closer examination of suicidal ideation. While suicidal ideation has been documented as an important risk factor for suicidal behavior, detailed comparisons of suicide attempters with suicidal ideation and those without suicidal ideation are sparse. However, some studies have indicated characteristics that differentiate the two groups. For instance, adolescent suicide attempters were more likely to show suicidal ideation before the attempt if they had any of the following characteristics: male, psychiatric history, history of previous suicide attempts, or clinical toxicity at the time of the visit to the emergency department (Margarit Soler et al., 2016). Self-harm with and without suicidal intent include some overlapping behaviors, but with some distinct characteristics, indicating
4
the importance of fully exploring vulnerability factors, motivations, and intentions of adolescents who self-harm (Mars et al., 2014). Decreasing the intensity of suicide ideation in suicide attempters might be important in preventing them from committing suicide (Joo et al., 2016). Therefore, assessing suicidal ideation and past suicide attempts as important risk indicators is likely to improve sensitivity in predicting completed suicide, and suicide attempts with suicidal ideation and without suicidal ideation are notably important sub-categories. However, studies are few that compare characteristics of suicide attempters with suicidal ideation and without suicidal ideation in China. Previous studies reported that suicide attempters were more likely to report ongoing suicidal ideation during psychiatric evaluation in the emergency departments (Pompili et al., 2011). Suicidal ideation was self-disclosed frequently by patients in emergency department waiting rooms and patients who disclosed suicidal ideation did not always receive referrals for mental health services (Kemball et al., 2008). Therefore, emergency departments are increasingly an important setting for introducing suicide prevention measures, and studies have focused on developing effective interventions to initiate during emergency department stays for patients who have attempted suicide (Boudreaux et al., 2013; Hirayasu et al., 2009). The increasing number of emergency department visits for suicide is and will continue to be a significant challenge (Arango et al., 2016). Logically, then, research on suicidal behavior in emergency departments is highly desirable. The present study compared characteristics of suicide attempters exhibited suicidal
5
ideation with attempters who did not show suicidal ideation. We specifically targeted individuals who presented for treatment in the emergency departments of general hospitals in China. A better understanding of the similarities and differences in sociodemographic and psychological characteristics of suicide attempters between the two groups may provide a basis for developing suicide prevention plans. Such plans may be specific to China, as an immediate focus, but also may be helpful in other countries, as well. 2. Methods 2.1. Design and settings The individuals enrolled in this study were patients treated for attempted suicide (as reported by the patient or family members) in the emergency departments of 4 tertiary-level general hospitals in Shenyang (a city with a population of 6.9 million residents), Liaoning Province, in northeastern China. The hospitals were randomly selected from 15 tertiary general hospitals located in Shenyang. The 4 hospitals are the First Affiliated Hospital of China Medical University, ShenYang First People’s Hospital, ShenYang Fourth People’s Hospital, and Central Hospital Affiliated with ShenYang Medical College, and all are academic affiliated hospitals. All individuals who came to the emergency departments after having made a suicide attempt were identified and approached by a trained research assistant. Participants who were 15 years of age or older, who were able to understand the study procedures, who had at least one contact person (to enable follow-up), and who provided written informed consent, were enrolled. The study was approved by the Institutional Review Board of
6
the China Medical University. 2.2. Materials The 239 individuals and their accompanying family members were independently interviewed by two trained researchers. The comprehensive suicide attempt interview schedule that was used included several components that took a total of two hours to complete, as follows: (1) a detailed structured questionnaire to assess the patients’ sociodemographic characteristics (age, gender, employment status, marital status, residence, annual family income, educational level, and religious beliefs), the characteristics of the attempt (method of self-harm, alcohol use at the time of the episode, reported motive, time suicide had been considered before acting, presence or absence of a suicide note, and help-seeking prior to the attempt), and self-reports of prior attempts and suicidal history among family members or associates; (2) the Beck 19-item Scale for Suicide Ideation (Beck et al., 1979) to evaluate the intensity of patients' attitudes, behaviors, and plans to commit suicide, with each of the items providing three options graded 0–2 according to the intensity of the suicidality, and higher scores indicating stronger suicide ideation; (3) the 24-item Hamilton Depression Rating Scale (HAMD) (Hamilton, 1960; Williams, 1988); and (4) a quality of life rating scale covering the month prior to the attempt, on which respondents assess six characteristics of the attempter (physical health, psychological health, economic circumstances, work, family relationships, and relationships with non-family associates) on a scale of 1 (very poor) to 5 (excellent). In addition, attempters received a psychiatric diagnosis made according to the
7
Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), as assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). The Chinese translation of the SCID has been shown to be reliable and valid (Shi et al., 2005). This version of the SCID allowed for the inclusion of “not otherwise specified” (NOS) categories of illness for subjects who had clinically significant symptoms combined with social dysfunction, but did not meet the full criteria of a specific disorder (which is fairly common in China), and for the recording of multiple diagnoses ranked according to clinical importance. The six psychiatric researchers who participated in the study attended a 4-week training course in the use of the SCID; their interrater reliability at the end of training, using 16 taped interviews of different types of patients, was excellent (intra-class correlation coefficient = 0.95). In the study, the presence of suicidal ideation was the outcome variable based on the Beck 19-item Scale for Suicide Ideation; we used the item about suicidal ideation found in the Beck 19-item Scale for Suicide Ideation to stratify our patients. The suicide attempters divided into groups with suicidal ideation and without suicidal ideation. 2.3. Data analysis We compared the sociodemographic and clinical characteristics of suicide attempters with suicidal ideation and without ideation. To examine the mean differences between the two groups in the study variables, for example, age, gender, employment status, marital status, and so on, we used frequency distributions, Student's t tests, chi-square tests, and Fisher's exact tests with the assistance of SPSS
8
for Windows Version 11.5 (SPSS, Chicago, IL, USA). The critical level of statistical significance was set at 0.05 and the analysis was two-tailed. A logistic regression model examined factors associated with suicide attempters with suicidal ideation, with suicidal ideation as the dependent variable. Independent variables in the model included age; gender; years of education; religious beliefs; previous episodes of suicide attempts; alcohol use at the time of the episode or up to 12 h prior to the attempt; self-rescue; psychiatric diagnosis; impulsivity; depression; and life quality. First, we entered all eleven variables into unconditional logistic regression analyses (the 11 variables were chosen based on p-values from correlation analysis and our previous studies; Bi et al., 2010; Wei et al., 2013). The significant independent predictors from the analyses were then selected for possible use in a final model. In this analysis process, we selected a concrete option of method (Forward: Conditional), and we also examined confounding variables or any interactions in the model. Statistical significance in the logistic regression model was assessed using the Wald statistic and 95% confidence intervals computed using the Gaussian approximation to the log likelihood of the rate. 3. Results 3.1. Participants During the enrollment period, from June 2007 to January 2008, 403 suicide attempt episodes were treated at the target emergency rooms. Of those, 366 individuals met the criteria for inclusion in the study; seven cases were excluded due to repeat attempts because we only wanted to evaluate the current episode. Among the 359
9
different patients, 239 (59.3%) completed the full evaluation; 29 left early before they could be approached by the research team, 90 refused to participate, and 1 did not provide all of the data needed for analysis. There were no statistical differences in gender (p=0.72), age (p=0.97), or years of education (p=0.07) between the included and excluded patients. 3.2. Sociodemographic characteristic of the suicide attempters with suicidal ideation and without suicidal ideation Of the 239 patients, we identified 166 (69.46%) as having suicidal ideation and 73 (30.54%) did not have suicidal ideation. A comparison of demographic characteristics for each group is shown in Table 1. There were no significant differences between the two groups in race, living situation, annual family income, or educational level. However, age (mean±SD, Without suicidal ideation: 28.47±11.71; Suicidal ideation: 34.31±14.51), gender (n,%, Men without suicidal ideation: 23, 31.50%; Men with suicidal ideation: 30, 18.10%) , marital status (n,%, Never married without suicidal ideation: 35, 47.90%; Never married with suicidal ideation: 55, 33.10%), employment status(n,%, Unemployed without suicidal ideation: 14, 19.20%; Unemployed with suicidal ideation: 52, 31.30%), and religious beliefs (n,%, Having religious beliefs without suicidal ideation: 1, 1.40%; Having religious beliefs with suicidal ideation:19, 11.40%) were statistically different between the two groups. Compared to suicide attempters without suicidal ideation, the suicide attempters with suicidal ideation were more likely to be older (p=0.01), female (p=0.02), divorced or separated (p=0.001), unemployed or a housewife (p=0.000), and to report having religious beliefs (p=0.02).
10
3.3. Clinical characteristics Table 2 presents a comparison of clinical characteristics for each group. No significant difference was observed between the two groups in the method of attempted suicide. Self-poisoning was prominent for both groups (92.2% and 91.8%, respectively), and the majority of patients who overdosed used psychotropic drugs. There were also no significant differences between the two groups in family history of suicide attempts, alcohol use at the time of the episode or up to 12 h previous to the attempt, writing a suicide note, making funeral arrangements, or seeking help. However, the suicide attempters without suicidal ideation had significantly more self-rescue (p=0.001) and were more impulsive (p=0.000) than the suicide attempters with suicidal ideation. Compared to suicide attempters without suicidal ideation, those with suicidal ideation were more likely to have a suicide attempt history (p=0.01) and a psychiatric diagnosis (p=0.000). Motives for suicide attempts differed significantly between the two groups (p=0.000). The suicide attempters without suicidal ideation were more likely to threaten or intend revenge on others than the suicide attempters with suicidal ideation (p=0.000); those with suicidal ideation were more likely to be motivated by a desire to reduce the pain and the burden of life. Table 3 shows the comparison of depression scale scores for each group. Suicide attempters with suicidal ideation had significantly higher depression scores on the HAMD (p=0.000) and lower scores on life quality (p=0.000) than the suicide attempters without suicidal ideation. 3.4. Result of logistic regression analysis
11
We applied a logistic regression model to examine factors associated with the suicide attempts of those with suicidal ideation among all suicide attempters, with suicidal ideation as the dependent variable (Table 4). The unconditional logistic regression analysis identified the following independent predictors of suicidal ideation: a higher score on HAMD (OR [odds ratio]=1.12, 95% CI=1.41-1.19), having religious beliefs (OR=11.40, 95% CI=1.31-99.10), having impulsive suicide attempts (OR=0.29, 95% CI=0.14-0.62), and having a psychiatric diagnosis (OR=2.65, 95% CI=1.10-6.42). 4. Discussion 4.1. Main findings The main findings in the present study were that the suicide attempters with suicidal ideation and without suicidal ideation shared some demographic and clinical characteristics, in particular, living situation, annual family income, educational level, method of attempted suicide, family history of suicide attempts, alcohol use at the time of the episode or up to 12 h prior to the attempt, writing a suicide note, making funeral arrangements, and seeking help. Those outcomes are similar to other research (Mars et al., 2014) indicating that many risk factors were common to self-harm both with and without suicidal intent. Importantly, however, we found differences in demographic and clinical characteristics of suicide attempters with suicidal ideation and without suicidal ideation. First, our results indicated that the suicide attempters with suicidal ideation were older and more often female than those without suicidal ideation. Furthermore, the
12
older women were more likely to have suicidal ideation before the attempt. This finding of an apparent age effect is similar to a Japanese study (Matsuishi et al., 2005). But this is not consistent with Western studies that have found that suicidal ideation before the attempt (Margarit Soler et al., 2016) was more prevalent in males and that children and adolescents had higher rates of suicidal ideation than adults (Gallego et al., 2015). In addition, other work suggests that young African-American adult women were at high risk for suicidal ideation (Richardson-Vejlgaard et al., 2009). Those inconsistencies may be a result of cultural factors. Obvious cultural differences exist between China and other countries and regions. For example, In developed countries, the male-to-female ratio for suicide is between two to one and four to one, and the number seems to be increasing (Hawton and van Heeringen, 2009). Second, the present study indicated that the suicide attempters with suicidal ideation were more likely to be divorced or separated and unemployed. Collectively, those factors may be seen as negative or stressful life events. At the same time, our results indicated that the suicide attempters with suicidal ideation had significantly lower scores on life quality than the suicide attempters without suicidal ideation, again suggesting negative or stressful life circumstances. This pattern is consistent with previous research in China that documented that patients reporting suicidal thoughts, plans, or attempts experienced a significantly greater number of stressful life events and that female patients without any suicidality were significantly more likely to be married and employed (Bi et al., 2012). We also found that the suicide attempters with suicidal ideation were more frequently housewives, an outcome
13
which is entirely consistent with the above result that the suicide attempters with suicidal ideation were more often female. Third, we also found that the suicide attempters with suicidal ideation were more likely to have religious beliefs than those without suicidal ideation. One study also suggested religion is a risk factor for suicide attempts and suicide ideation among depressed patients (Lawrence et al., 2016). However, this fiinding is not consistent with widely accepted thought that individuals with religious beliefs are less likely to have suicidal ideation (Cole-Lewis et al., 2016). In addition, a report found no relationship between religious affiliation and suicidal ideation (Hovey, 1999). The topic needs future study to explore whether religious belief is related to suicidal ideation in different countries. Fourth, this study demonstrated that the suicide attempters with suicidal ideation were more likely to have histories of previous suicide attempts than those who attempted suicide but who did not have suicidal ideation. Other studies (Choi et al., 2013; Margarit Soler et al., 2016) also came to a similar conclusion. Our results on the motives for suicide attempts suggested that the suicide attempters with suicidal ideation were more likely to intend to reduce the pain and the burden of life. By contrast, the suicide attempters without suicidal ideation were more likely to intend their attempt as a means to threaten or take revenge on others. This finding suggests that those with suicidal ideation had a greater wish to die, but those who did not have suicidal ideation, at some deep level, did not wish to die. This is similar to previous findings (McAuliffe et al., 2007; Perquier et al., 2017). Moreover, we also found that
14
the suicide attempters without suicidal ideation had significantly more self-rescue and were more impulsive than those with suicidal ideation. One explanation of this situation may be the different motives for suicide attempts between two groups. The suicide attempters without suicidal ideation had lower expectations of death or less expectation of lethality; thus, they wanted to be helped, when they attempted to commit suicide. Further, they were more impulsive, as a result of their motive to threaten or take revenge on others. This is consistent with the previous study (Baca-Garcia et al., 2005). Some studies (Carli et al., 2010; McGirr et al., 2008) reported that suicide may be associated in individuals with higher impulsivity, which may also explain that some suicide attempts were without suicidal ideation. On the contrary, suicide attempters with suicidal ideation were more likely to result in death and less impulsive as a result of the mental illness of the subject. Fifth, our findings suggested that the suicide attempters with suicidal ideation were more likely to have a psychiatric diagnosis. The proportion of psychiatric diagnosis of suicide attempters with suicidal ideation was higher than for those without suicidal ideation. This is consistent with other studies (Lim et al., 2014; Margarit Soler et al., 2016). As other studies have found (Bi et al., 2012; Ozdel et al., 2009; Pompili et al., 2010; Wang et al., 2015), our results indicated that the suicide attempters with suicidal ideation had significantly higher depression scores than those without suicidal ideation. For instance, patients diagnosed with major depression were almost twice as likely to report suicidal ideation at the psychiatric interview as paired patients without major depression (Pompili et al., 2010). Suicide attempts with depression were
15
associated with high scores on the suicide intent scale (Ozdel et al., 2009). In summary, the suicide attempters with suicidal ideation and without suicidal ideation shared some characteristics. However, suicide attempters with suicidal ideation were more likely to be depressed, older, female, divorced or separated, unemployed, and housewives. Further, they more frequently reported having religious beliefs, making previous suicide attempts, having a psychiatric diagnosis, experiencing lower life quality, and aiming to reduce the pain and the burden of life as the motive of the suicide attempt. By contrast, the suicide attempters without suicidal ideation were more likely to be younger, more impulsive, self-rescue, and threaten or intend revenge against others as the motive for the suicide attempt. However, they were less likely to have a psychiatric diagnosis. 4.2. Predictor of suicide attempters by those with suicidal ideation Using the unconditional logistic regression analysis, we found that significant predictors of suicide attempts by those with suicidal ideation were higher scores on the HAMD, religious beliefs, non-impulsive suicide attempts, and a psychiatric diagnosis. The results suggest that suicide attempters with higher depression scores, no impulsive suicide attempts, and a psychiatric diagnosis were more likely to exhibit suicidal ideation. This is consistent with previous studies (Baca-Garcia et al., 2005; Margarit Soler et al., 2016; Ozdel et al., 2009; Pompili et al., 2010). Having religious beliefs is the strongest factor associated with suicide attempts by those with suicidal ideation. Studies mentioned earlier from China and other countries have shown that the relationship between religion and suicidal ideation were different. A recent review
16
also reported that whether religious affiliation protects against suicide attempts may depend on the culture-specific implications of affiliating with a particular religion, since minority religious groups can feel socially isolated (Lawrence et al., 2015). Why that predictor should be so prominent is not clear. It needs future study to explain it concretely in China. 4.3. Strengths There are several strengths in this study. This study is one of the few studies focused on the detailed assessment and comparison between suicide attempters with suicidal ideation and without suicidal ideation treated in the emergency departments of general hospitals in China. The samples are representatives of emergency outpatient departments at general hospitals in a large urban municipality in northern China. The assessment about suicide attempters was based on a clinical structured interview and standardized instruments, rather than on a psychological autopsy study. The diagnosis was based on the administration of SCID by trained researchers who had excellent inter-rater reliability and rigorous quality control measures were enforced throughout the study. The healthcare delivery system in Shenyang is similar to that in other urban areas of China, so we believe that the results can be extrapolated to other urban areas in China. 4.4. Limitations We acknowledge several limitations of the present study, however. First, we had limited data on suicide attempters who did not participate in our study. Second, we only assessed the Axis I disorders according to the DSM-IV but not the diagnosis of
17
the borderline personality disorder or other personality disorders which may influence the results in our study. Third, the findings are based on a relatively small sample from regional hospitals, raising the question of whether the results can be generalized. Generalizability is also difficult in this population from Shenyang because some suicide attempters may not be present to the hospital setting. Fourth, some of those who attempted suicide that were classified as not having suicidal ideation may have had unreported suicidal ideation. Finally, our study cohort was limited to an urban population, and different outcomes might be expected in a rural population. Thus, a multicenter study focusing on multiple sites would be desirable to demonstrate current trends in attempted suicide in China. Despite these limitations, the present study provided evidence that will help understand the characteristics of suicide attempters with suicidal ideation and without suicidal ideation in China and help develop the interventions to prevent future suicide. 4.5. Conclusions In the current study, the patients in the emergency departments of general hospitals in China who attempted suicide with suicidal ideation and those who attempted suicide who did not have suicidal ideation shared some similar demographic and clinical characteristics; however, they also exhibited unique characteristics of suicide behavior. The findings from this study may have unique cultural and regional implications and be useful in understanding cultural manifestations and development of suicide attempts in China. It is important to develop different kinds of interventions for the two types of people who attempt suicide to prevent future suicides in China.
18
Conflict of interest None of the authors have any conflict of interest related to the content of this paper. Acknowledgments This project was part of the “Small Grants Program to Improve the Quality and Implementation of Suicide Research in China”, which was supported by the China Medical Board of New York (grant number 05-813) and coordinated by Professor Michael Phillips of the Shanghai Jiao Tong University School of Medicine. We would like to thank the four participating hospitals in Shenyang for their active support of the project. References Aaltonen, K., Naatanen, P., Heikkinen, M., Koivisto, M., Baryshnikov, I., Karpov, B., et al. 2016. Differences and similarities of risk factors for suicidal ideation and attempts among patients with depressive or bipolar disorders. J. Affect. Disord. 193, 318-330. Arango, A., Opperman, K.J., Gipson, P.Y., King, C.A., 2016. Suicidal ideation and suicide attempts among youth who report bully victimization, bully perpetration and/or low social connectedness. J. Adolesc. 51, 19-29. Baca-Garcia, E., Diaz-Sastre, C., Garcia Resa, E., Blasco, H., Braquehais Conesa, D., Oquendo, M.A., et al. 2005. Suicide attempts and impulsivity. Eur. Arch Psychiatry Clin. Neurosci. 255 (2), 152-156. Beck, A.T., Kovacs, M., Weissman, A., 1979. Assessment of suicidal intention: the Scale for Suicide Ideation. J. Consult. Clin. Psychol. 47 (2), 343-352. Bi, B., Tong, J., Liu, L., Wei, S., Li, H., Hou, J., et al. 2010. Comparison of patients with and
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Table1 Sociodemographic characteristics of suicide attempters with suicidal ideation and without suicidal ideation
Age years (mean, SD)
Without suicidal ideation
Suicidal ideation
(n=73)
(n=166)
n
%
n
%
χ2
P
28.47
11.71
34.31
14.51
-3.04*
.003
11.50
0.01
5.30
0.02
1.13
0.29
18.93
0.001
21.09
0.000
Age group 15–24
35
47.90
45
27.10
25–44
31
42.50
90
54.20
45–59
6
8.20
21
12.70
60+
1
1.40
10
6.00
Men
23
31.50
30
18.10
Women
50
68.50
136
81.90
Gender
Race Han
70
95.90
151
91.00
Minority
3
4.10
15
9.00
Marital status Never married
35
47.90
55
33.10
Married
31
42.50
74
44.60
Cohabitation
7
9.60
15
9.00
Divorced/separated
0
0
13
7.80
Widowed
0
0
9
5.40
Employment status Employment
43
58.90
89
53.60
25
Unemployment
14
19.20
52
31.30
Student
16
21.90
12
7.20
Housewife
0
0
13
7.80
3
4.10
16
9.60
Living situation Solitary Shared accommodation
7
9.60
19
11.40
Living with family
55
75.30
116
69.90
Cohabitation
8
11.00
15
9.00
Low (≤10 000)
9
12.30
36
21.70
Medium (10 001–50 000)
41
56.20
85
51.20
High (＞50 000)
23
31.50
45
27.10
Illiterate
3
4.10
14
8.40
Elementary school
37
50.70
79
47.60
High school
25
34.20
43
25.90
College
8
11.00
30
18.10
Annual income of family
Educational level
Religious beliefs No
72
98.60
147
88.60
Yes
1
1.40
19
11.40
2.52
0.47
2.94
0.23
4.29
0.23
5.46
0.02
* T values
Table2 Clinical characteristics of patients who attempted suicide with suicidal ideation and without suicidal ideation
Characteristics
Without suicidal ideation
Suicidal ideation
(n=73)
(n=166)
n
%
n
%
Method of suicide attempts Self-poisoning
67
91.80
153
92.20
Self-injury
6
8.20
11
6.60
Other
0
0
2
1.20
Previous episodes of suicide attempts No
63
86.30
118
71.10
Yes
10
13.70
48
28.90
Family history of suicide attempts No
72
98.60
159
95.80
Yes
1
1.40
7
4.20
Alcohol use at the time of the episode or up to 12 h before No
63
86.30
148
89.20
Yes
10
13.70
18
10.80
Self-rescue No
61
83.60
160
96.40
Yes
12
16.40
6
3.60
Motive of suicide attempt
χ2
P
1.64
0.44
6.39
0.01
0.54
0.26
0.40
0.53
11.97
0.001
35.72
0.000
26
Deceased pain and burden
19
26.00
111
66.90
Threatened or revenged others
40
54.80
35
21.10
Other
14
19.20
20
12.00
Suicide note No
70
95.90
146
88.00
Yes
3
4.10
20
12.00
Funeral arrangements No
73
100.00
159
95.80
Yes
0
0
7
4.20
Seeking for help No
52
71.20
136
81.90
Yes
21
28.80
30
18.10
Impulsive suicide attempts No
18
24.70
114
68.70
Yes
55
75.30
52
31.30
Psychiatric diagnosis No
47
64.40
26
15.70
Yes
26
35.60
140
84.30
2.81
0.09
1.86
0.17
3.46
0.06
39.73
0.000
56.73
0.000
27
Table 3 Means and standard deviations of depression and life quality scale scores of patients who attempted suicide with suicidal ideation
and without suicidal ideation
Without suicidal ideation (n=73)
Suicidal ideation (n=166)
Mean
(n=73)SD
Mean
SD
T
P
Score on HAMD*
8.18
6.52
19.69
10.14
-10.50
0.000
Score on life quality
56.28
12.39
45.93
12.08
6.05
0.000
Note: HAMD, Hamilton Depression Rating Scale.
Table 4 Result of logistic regression analysis: Predictors of categorization of suicide attempters as having suicidal ideation (n = 166) or
not having suicidal ideation (n = 73)
Predictors
B
S.E.
P
OR (Odds ratio)
95% CI (confidence intervals)
HAMD* score
0.11
0.03
0.001
1.12
1.41 – 1.19
Religious beliefs
2.43
1.10
0.03
11.40
1.31 – 99.10
Impulsive suicide attempts
-1.23
0.38
0.001
0.29
0.14 – 0.62
Psychiatric diagnosis
0.98
0.45
0.03
2.65
1.10 – 6.42
Note: HAMD (Hamilton Depression Rating Scale) was the only continuous variable used in the regression; all the other variables were
dichotomous.
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Highlights The suicide attempters with and without suicidal ideation shared some similar characteristics. The suicide attempters with and without suicidal ideation demonstrated unique characteristics. Different kinds of interventions are necessary for suicide attempters with and without suicidal ideation to prevent future suicide.
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