Profile of Suicide Attempters Admitted in an Emergency Unit.

Dinorah Quiles, MD; Claudia López, MD; Adalis Millán, MD

Department of Psychiatry

Medical Science Campus, University of Puerto Rico

San Juan, Puerto Rico

 

Summary

This study describes the demographic, psychosocial and clinical characteristics of 250 suicidal attempters visiting an emergency room in Puerto Rico. The population was mostly young, unemployed and without a partner.  In the male gender population, 44.6 % claimed that they were unemployed, compared to 35.2% in the female gender (p:0.039).  In addition, 76.2% of the male population reported use of illicit drugs vs. 25.5% of females (p:0.000).  Interpersonal problems were identified by 72.8% of the population as the stressor for the attempt. The findings of the study suggest that the importance of risk factors for suicidal acts differs in men and women. But in general terms the suicide attempters profile is similar to the profiles described in the literature.

Keywords: suicide attempts, gender differences, illicit substances, interpersonal problems.

Introduction

The suicide represents a public health problem. It is an emotional, economical and social burden to family, friends and society. In Puerto Rico (PR) the rate of death (per 100,000 persons) by suicide for the year 2000 and 2003, was 8.3 and 7.0 respectively (PR Vital Statistics). The preceding literature report that two thirds of suicides tend to occur on the first attempt (Gaynes et al 2004). A summary of evidence for the US Preventive Service Task Force report that: Annually, approximately 500,000 individuals required emergency department treatment in US medical centers following attempted suicide (Gaynes et al. 2004).

The suicide attempts can be described in terms of demographic, psychiatric and psychosocial characteristics. Studies reveal that suicidal attempts are more common among younger age group and females (Mann et al. 2005, Walrath et al 2001, Crosby et al. 1999). High rates of unemployment, being single, previous suicide attempts, family history of suicide, previous and current substance abuse have been reported in persons who have attempted suicide ((Mann et al. 2005, APA 2003, Walrath et al 2001, Crosby et al. 1999).

The most common psychiatric condition associated with suicide or serious suicide attempt is mood disorders (Gaynes et al. 2004).

Some studies indicate that the types of life events experimented by persons who attempt suicide vary with age. The interpersonal problems tend to be more common among adolescents and young adults (Pearson et al 2002, Heikkinen et al 1995).

In PR the data about suicide attempters is very limited. This retrospective study examines the demographic, psychosocial and psychiatric profiles of suicide attempters seen in the general emergency room of a regional hospital affiliated to a university. In addition to contribute with more information about the suicide attempters, this information may improve suicide risk evaluation and guide future research on suicide assessment and prevention.

Methods and Aims

Setting

The University of PR (UPR) Hospital is a university-affiliated teaching hospital whose emergency room (ER) serves as the regional emergency care facility for the north eastern area of the island. It serves mainly low socioeconomic classes and publicly insured population. It offers psychiatric consultation service in the ER 24 hour a day, year round. In the ER, the medical student or mostly the psychiatry resident under the supervision of the attending psychiatrist, evaluate the consulted patients and charted the assessment data using the DSM-IV TR. For all suspected suicidal attempts a psychiatrist/psychiatry resident is consulted.

Population

The data were obtained retrospectively from the psychiatric consults of all the patients who were evaluated at UPR Hospital Emergency Room for suicidal attempt between January 2005 and December 2005.  We considered a suicidal attempt all self-injurious behavior with a nonfatal outcome accompanied by evidence, either implicit or explicit, that the person intended to die (APA 2003).

Of the 294 consults reviewed, 26 were excluded because the evaluator documented that the patient denied intention to die. Of the remaining 268, 18 were excluded because the information available in the psychiatric consult was incomplete. At last 250 (ages from 8 to 74 years of age) were used for analysis.

Procedure

The procedure for the study was revised and approved by the IRB. Using the psychiatric consults for the period of time previously stated the information was retrieved on our data collection sheet. The sheet was developed taking into consideration the risk factors described in the literature. It includes: date of attempt, age, sex, marital status, children, education, occupation, disability, Axis I and II diagnosis, psychiatric treatment, medications, medical history, toxic habits, family history of psychiatric illness and suicide, past suicidal attempts, suicidal ideation, and precipitants identified. The division of the precipitants was developed taking into consideration the literature available (Pearson et al 2002, Mann 2002, Heikkinen et al 1995). The precipitants were divided in: interpersonal, medical/psychiatric, work/school related, financial problems, legal problems, death of significant other, intoxication with psychoactive substance, and domestic violence.

Data Analysis

Data analysis was done using Statistical Package for the Social Sciences (SPSS). Pearson Chi-Square and Fisher’s Exact Test were used to measure significance of relations. For calculation of percentages, missing values was excluded.

Results

Demographic and psychosocial characteristics of suicide attempters

The months with less suicidal attempts were December with 6.4%, January with 3.9% and February with 4%. The higher number of suicidal attempts was on July with 11.6%, August with 12.4% and October with 12%.

The population was composed of 61.6% females and 37.4% males with a male/female ratio of 1:1.6.  The age group of 15-24 years was the largest one, accounting for 33.6%; followed by the age group of 25-34 years, which accounted for 23.2%; and the third one was the age group of 35-44 years, which accounted for 22.4%.

Table 1 Demographic and psychosocial profile of suicide attempters

Variables	All (N=250)	%	Males  (N=96)	%	Females (N=154)	%
Age
Mean	31.3		30.2		32.0
Median	29		28		31.5
Mode	19		19		16
Std. Deviation	12.9		12.4		13.1
Range of Age	8-74		8-70		9-74
Marital Status
Without Partner	140	61.1	58	67.4	82	57.3
Partner	89	38.9	28	32.6	61	42.7
Offspring	122	58.4	39	52.0	83	61.9
Education
0-9	28	18.0	14	25.9	14	13.9
10-12	81	52.3	31	57.4	50	49.5
≥ 13	46	29.7	9	16.7	37	36.6
Occupation
Unemployed (includes     housewife)	87	38.7	37	44.6*	50	35.2*
Employed	73	32.4	27	32.5	46	32.4
Retired/Incapacitated	17	7.6	9	10.8	8	5.6
Student	48	21.3	10	12.1	38	26.8

*p:0.039

In Table 1, we present the information on demographic and psychosocial factors.  The higher rate of unemployment observed in the male population, was statistically significant (chi2: 8.385, df: 3, p: 0.039) when compared to the female population. The 98.6% of the population denies any disability, physical or mental.  

Psychiatric profile of suicide attempters

In the population under study 61.6% had an Axis I diagnosis at the moment of evaluation (Table 2). The mood disorders were the most prevalent mainly in the female group. A personality disorder was described only in 3.1% of the patients.

Table 2 Psychiatric Profile of Suicide Attempters

Variables	All (N=250)	%	Males  (N=96)	%	Females (N=154)	%
Axis I Diagnosis	146	61.6	60	65.2	86	59.3
Mood	111	76	34	56.7	77	89.5
Psychotic	17	11.6	10	16.7	7	8.1
Substance	21	14.4	19	31.7	2	2.3
Anxiety	3	2.1	2	3.3	1	1.2
Disruptive	7	4.8	5	8.3	2	2.3
Axis II Diagnosis	7	3.1	1	1.1	6	4.5
Psychiatric Treatment	98	42.1	39	43.8	59	41
Medication	86	38.2	26	30.6	60	42.9
Antidepressant	67	77.9	20	76.9	47	78.3
Antipsychotic	32	37.2	9	34.6	23	38.3
Mood Stabilizer	26	30.2	5	19.2	21	35.0
Benzodiazepines	56	65.1	15	57.7	41	68.3
Others	10	11.6	2	7.7	8	13.3
Family History of Psychiatric Illness	125	57.9	48	59.3	77	57
Family History of Suicide	21	12.5	11	17.7	10	9.4
Past Suicide Attempts History	115	53.2	39	50	76	55.5
Suicidal Ideation	96	44.7	40	48.8	56	42.1

In the toxic habits (Table 3) the 50.6% of the studied population report some habit. When we compare by gender we found that 68.5% of the males report some toxic habit vs. 39% of the females, the difference was statistically significant (chi2: 19.761, df: 1, p: 0.000). In the male group 76.2% report use of illicit drugs compared to the female group with 25.5%. The higher rate of illicit drug use in the male population compared to the females was statistically significant (chi2: 36.102, df: 1, p: 0 .000)

Table 3 Toxic Habits Profile

Variables	All (N=250)	%	Males  (N=96)	%	Females (N=154)	%
Toxic Habits	118	50.6	63	68.5*	55	39*
Alcohol	59	50	30	47.6	29	52.7
Tobacco	85	72	48	76.2	37	67.3
Opioids	19	16.1	13	20.6	6	10.9
Cannabis	16	13.6	12	19	4	7.3
Benzo-     diazepines	5	4.2	4	6.3	1	1.8
Cocaine	27	22.9	23	36.5	4	7.3
Others1	0	0	0	0	0	0

* p:0.000

1This category includes Hallucinogens, Amphetamines, Barbiturics

Precipitants identified by suicide attempters

The 72.8% of the population identified interpersonal problems as the precipitant for the suicidal attempt (Table 4). The interpersonal problems consist of fight/rupture with partner, problems/ difficulties with the family or friends. The second most common precipitant (9.8%) was medical/psychiatric, that includes poor compliance/change of medication, hallucinations, and difficulty coping with medical or psychiatric condition was identified by 13.5% of male patients.

 

Table 4. Profile of Precipitants Identified by the Patient

Variables	All (N=250)	%	Males  (N=96)	%	Females (N=154)	%
Interpersonal Problems	171	72.8	54	60.7	117	80.1
Medical/Psychiatric problems	23	9.8	12	13.5	11	7.5
Work/School Problems	6	2.6	4	4.5	2	1.4
Financial Problems	18	7.7	7	7.9	11	7.5
Legal Problems	10	4.3	9	10.1	1	.7
Death of significant other	8	3.4	3	3.4	5	3.4
Intoxication with psychoactive substance	12	5.1	9	10.1	3	2.1
No Information Provided	26	11.1	10	11.2	16	11.0

Discussion

In a study of Oquendo et al. (2004) with the Hispanic groups at US, the Puerto Ricans show the higher rates of depression and suicidal attempts when compared with other Hispanics. Despite these facts, the information about suicide attempts in Puerto Ricans mainland is limited. To the best knowledge of the authors, the present study represents the first attempt to explore the nature of the factors associated with suicide attempts in persons using the emergency room of a university community hospital.

In the study the females attempting suicide outnumbered males by 1.6 to 1, in accordance with the preceding literature, which reports a higher number of females attempting suicide vs. a higher number of males completing suicide (APA 2003, Gaynes et al. 2004). The age group between 15 to 44 years accounted for 79.2% of the population, which matches previous studies that identify younger age groups with high rates of suicidal attempts (APA 2003, Crosby et al. 1999). The early adulthood (20-39 y/o) is a difficult stage of development characterized by the assumption of major social roles (occupation and marriage) and the evolution of an adult self and life structure, which can be a great source of stress.

Patients without a partner accounted for 61.1% of the population; it was higher for males 67.4% than for females 57.3%. Being single is another well known risk factor for suicide (APA 2003, Gaynes et al. 2004). The 38.7% of the population was unemployed; this is also a well known risk factor for suicide (APA 2003, Gaynes et al. 2004). When we compare genders, the percentage of unemployment was higher for males 44.6% than for females 35.2% p: 0.039 by Pearson Chi-Square. The literature describes that the unemployment was more common between younger men than females (Heikkinen et al 1995). The unemployment and single status are closely related to the two major social roles that the early adult is expected to assume and the failure to fulfill these goals is possibly contributing to the suicide attempts.

More than 90% of suicide victims have a diagnosable psychiatric illness, and most persons who attempt suicide have a psychiatric disorder (Fortuna et al 2007, Mann 2002). The most common psychiatric conditions associated with suicide or serious suicide attempt are mood disorders (Mann 2002). Of the population under study, 61.6% presented a history of an Axis I diagnosis, with mood disorders in the first place, accounting for 76%, followed by substance related disorders with 14.4%. For the male population, the percentage of persons with substance disorder increased to 31.7%.

Only in the 3.1% of the population an Axis II diagnosis was recorded, this may represent under reporting because previous studies have shown overall rates of about 40% for individuals who attempt suicide (APA 2003). A possible explanation to this low percent of Axis II diagnosis may be that the evaluation was the result of only one encounter done in the emergency room close to the suicidal attempt, and possibly the clinician didn’t feel comfortable diagnosing an Axis II with the limited amount of information available.

Previous studies report that suicide and suicide attempts in patients with depression are associated with no treatment or inadequate prescription or consumption of antidepressant (Gibbons et al 2005). In our population only 42.1% was under psychiatric treatment at the moment of attempt and only 38.2% were taking psychotropic medications. From those taking medication, the 45.1 % was on a SSRI at the moment of attempt; but interestingly the 65.1% was on a benzodiazepine. The percentage of patients taking benzodiazepines was higher in the females (68.3%) than in the males (57.7%). The benzodiazepines are associated with disinhibition, especially if taken concurrently with alcohol. Of the population 50.6% report some toxic habit, and 50% report alcohol use. The combination of alcohol and benzodiazepines may be is of great relevance when impulsivity is mediating in the suicidal attempts, but this needs further research because the variable impulsivity was not measured in the study.

The 76.2% of those males with toxic habits reported tobacco use which support studies that identified a relationship between cigarette smoking as predictor of suicidal acts in men (Oquendo et al 2007). In the male group 76.2% reported use of illicit drugs compared to the female group with 25.5% p: .000. This finding support studies that correlate substance abuse with suicidal behavior particularly in men (Crosby et al. 1999).

The 72.8% of our population identified the interpersonal problems as a stressor for the suicidal attempt. This was most significant to the females when compared to the male population. The medical and financial problems were the second stressor most identified in the population. Heikkinen ME et al. (1995) identified that the unemployment and financial problems were more common between younger men. In our study the percentage of males and females identifying the financial problems as a stressor was really close. The male population also identified the legal problems and intoxication with psychoactive substance as stressors influencing at the moment of the attempt.    

There is compelling evidence wich indicates that adequate prevention and treatment of depression, alcohol and substance abuse can reduce suicide rates; as reported by the WHO (WHO SUPRE 2007). At the level of prevention we need to reinforce school-based interventions involving crisis management, self-esteem enhancement and the development of coping skills and healthy decision making to reduce the risk of attempted suicide, especially among the youth.

In the limitations, this study includes the complete population of suicide attempters presenting to a general emergency room for a complete year, which minimizes the bias. Patient’s interview was not a standardized one and diagnoses were not determined with standardized instruments and since the study was a review of consults some of them might have not been identified. Do to the relative small size of the sample and that the information comes from only a region of PR, the generalization of the findings should be made with caution. Thus, findings should be considered preliminary and replication in larger studies is necessary.

Conclusion

We conclude that the profile of the suicide attempters presenting to an Emergency Unit of a university affiliated community hospital at Puerto Rico is very similar to the profiles described in the literature. The findings of the study suggest that the importance of risk factors for suicidal acts differs in men and women. This knowledge may improve suicide risk evaluation and guide future research on suicide assessment and prevention.

Acknowledgements

 “This study was supported by the UPR School of Medicine Endowed Health Services Research Center, Grant 5S21MD000242, from the National Center for Minority Health and Health Disparities, NIH. Its contents are sole the responsibility of the authors and do not necessarily represent the official views of NCMHD-NIH”

Thanks to the Dr. Miguel González Manrique for his mentorship in the development of this project.

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