The investigation of the relationship between probability of suicide and reasons for living in psychiatric inpatients.

AIM: This study was carried out to determine the reasons of the suicide probability and reasons for living of the inpatients hospitalized at the psychiatry clinic and to analyze the relationship between them.
MATERIALS AND METHODS: The sample of the study consisted of 192 patients who were hospitalized in psychiatric clinics between February and May 2016 and who agreed to participate in the study. In collecting data, personal information form, suicide probability scale (SPS), reasons for living inventory (RFL), and Beck's depression inventory (BDI) were used. Stepwise regression method was used to determine the factors that predict suicide probability.
RESULTS: In the study, as a result of analyses made, the median score on the SPS was found 76.0, the median score on the RFL was found 137.0, the median score on the BDI of the patients was found 13.5, and it was found that patients with a high probability of suicide had less reasons for living and that their depression levels were very high. As a result of stepwise regression analysis, it was determined that suicidal ideation, reasons for living, maltreatment, education level, age, and income status were the predictors of suicide probability (F = 61.125; P < 0.001). DISCUSSION: It was found that the patients who hospitalized in the psychiatric clinic have high suicide probability and the reasons of living are strong predictors of suicide probability in accordance with the literature.

INTRODUCTION

Nowadays, the purpose of psychiatry clinics is to help a patient to recognize the psychiatric problems that cause the patient to be hospitalized and to help them recover.[12] Although hospitalization in hospitals has been on the decline from weeks to days, hospitalization continues as an option for treatment of individuals with emotional crises and mental disorders.[34] In psychiatry clinics, individuals who committed suicide, who are at high risk for damaging to environment, or who need acute care for a short time due to loss of function are given priority.[5] Although one of the reasons of hospitalization is to prevent suicide, it is reported that the suicide rate in psychiatric hospitals is quite high compared to the rate of suicide in the society.[26789] The presence of psychiatric illness is one of the risk factors which are reported consistently and consistently for suicidal behavior. In high-income countries, 90% of people who died from suicide have psychiatric disorders, whereas in the 10% group with no explicit diagnosis, the psychiatric symptoms are similar to those who died from suicide.[10]

Major depression, bipolar disorder, and alcohol use disorders were found to significantly increase risk of suicidal ideation; substance abuse, panic disorder, and general anxiety disorder were found to significantly increase risk for suicide attempts.[11] Suicides take place in all parts of the world and throughout life and can be seen in a wide range of populations, ranging from healthy people who respond to stressful life events to those with severe mental illness.[12] It is stated that suicide is a public health problem with universal importance because about one million people die every year from suicide worldwide. Although suicides are preventable, one individual in every 40 s dies somewhere in the world because of suicide, and many people are attempting suicide.[13] It is stated that approximately 45% of the people who died as a result of the suicide refer to the primary care physician within the 1st month of their death.[14] The fact that suicide is a preventable cause of death makes it very important to evaluate the suicide risk.

As a result of researches related to suicidal behavior, risk factors for suicide are sorted as sex, despair, suicide attempt story in individual and family, psychiatric disorder, impulsivity, and childhood abuse, and to decrease suicide rates, targets for these risk factors are determined. However, it is seen that these methods are inadequate and that few studies focus on protective factors.[151617]

While suicide-related studies are generally focused on the “negative cognitions,” “reasons for living inventory (RFL)” developed by Linehan et al. focus on “positive cognitions” that protect people from suicidal behavior. There are belief systems which separate people who committed suicide and people who do not commit suicide from each other and these belief systems are named as reasons for living. The reasons for living are the reasons that the individual is bound to “do not kill himself” and “live.”[18] It is argued that the reasons for living are reducing the power of the relationship between suicidal thoughts and hopelessness and protecting the individuals from negative effects of despair.[1920] Studies made in this area have indicated that most patients with suicidal ideation or suicide attempts may be less likely to die of suicide by choosing life rather than death.[2122232425]

Suicide resulted in death is more tragic than the death of the natural causes and affects both the environment of a person and the society where s/he lives, both materially and spiritually.[26] Therefore, by evaluating suicidal risk, it becomes extremely important to know and prevent suicide extremely. For this reason, this study was conducted as a descriptive study to determine reasons of suicide probability and reasons for living of patients hospitalized at the psychiatry clinic and to analyze the relationship between them.

MATERIALS AND METHODS

The study was conducted as a descriptive study. The study was conducted in Turkey at 2 education and research and 1 psychiatric clinic affiliated to a university hospital. The sample of the study consisted of 192 patients who were hospitalized between February and May 2016. The necessary approvals were obtained from the institutions where the study carried out, and the approval of the ethics committee was taken from an ethics committee in Turkey.

Patient selection criteria for the study

Accepting voluntarily participation to the work

Being older than 18

Mental and general medical condition to be in accordance with psychiatric consultation

Having at least one psychiatric diagnosis according to the DSM-V

Being approved by a psychiatrist to participate to the study

Being hospitalized in psychiatry clinic.

Patients who were determined in this way and the patients whose duration of hospitalization was <1 day were not included to the study.

Data collection methods used in the research

For collecting data, personal information form, suicide probability scale (SPS),[27] RFL,[28] Beck's depression inventory (BDI),[29] and volunteer form were used.

Personal information form

Within the scope of the research, the “personal information form” consisting of 13 questions prepared by the researcher in accordance with the literature was used to determine the demographic characteristics of the group consisting of patients who were hospitalized.[133031] In this form, there are questions about the participants’ age, gender, education, marital status, child ownership, job, people living together at home, economic levels, and past experiences of stressful events.

Suicide probability scale

It is a 36-item self-assessment scale developed by Cull and Gill, rated 1–4 Likert type.[32] The scale was developed to assess risk of suicide in adolescents and adults. It is aimed to determine the behavioral, cognitive, and emotional components of suicide. The score range is between 36 and 144, and high scores on the scale indicate high suicide probability. In our country, the studies conducted on the scale include findings that this scale is valid and reliable.[27] The Cronbach alpha reliability coefficient of the scale was 0.95. As a result of the factor analysis, three factors explaining 51.9% of the total variance were found.[27] The internal consistencies of the subscales of SPS in this study were found SPS anger as 0.70; SPS breakage from life loyalty as 0.69; and SPS negative self-evaluation and exhaustion as 0.83.[2831]

Reasons for living inventory

This scale was developed to determine the reasons that connect people to life and it has been adapted to our culture using Linehan et al.'s “RFL” 48-item self-assessment scale.[2833] In this study, RFL was adapted to our culture and was used with 28-item form.[27] The item-total correlation coefficients of the scale were ranged from 0.21 to 0.70. According to the discriminant analysis results, it was found that the correct discrimination rate of the scale between normal and depressive groups was 72.7%; the discrimination rate of suicide group and depressive group was 72.2%, and the rate of discrimination between suicide group and normal group was 61.1%.[27] The internal consistencies of the subscales of the RFL in this study were found to be RFL commitment to life as 0.89; RFL hope and social support as 0.87; RFL religious obstacle as 0.61; and RFL struggle as 0.49.

Beck's depression inventory

The BDI was developed by Beck in 1961.[34] Then, the scale was re-examined by Beck in 1978, and it became 21-item self-assessment questionnaire with the 4-point Likert type, scores ranging from 0 to 3. The 1978 version of the scale was adapted to Turkish by Hisli in 1989.[29] The total score obtained from the scale ranges from 0 to 63. The high score obtained from the scale indicates an increase in depressive symptoms objectively. In this study, the Cronbach alpha coefficient was found as 0.92.

The evaluation of research data

The obtained research data were analyzed with using number, percentage, frequency, median, mean, standard deviation, Kruskal–Wallis H, Mann–Whitney U, correlation, and stepwise regression method in the IBM SPSS 21.0 package programs and the statistical significance was accepted as P < 0.05.

RESULTS

The demographic characteristics of the patients hospitalized in the psychiatric clinic constituting the study group are shown in Table 1.

Table 1

Clinical and Demographic Characteristics of the sample (n=192)

There was no significant difference between the SPS median scores according to gender, age groups, marital status, persons living together at home, having children, experiencing suicide attempt by a relative, and losing a relative due to an accident (P > 0.05). According to the study, the significant difference was found between features such as level of education, working status in a job with income, economic status, having a depression diagnosis, suicidal thought and suicide attempt story, overcoming a life-threatening situation, being treated badly, or losing a relative from suicide (P < 0.05).

In the study, the RFL scale median score of the patients hospitalized in the psychiatry clinic was found as 137.0, the SPS scale median score was found as 76.0, and BDI scale median score was found as 13.5. It was found that there was a moderate, negative, and significant relationship between the RFL total score and the SPS total score medians of the patients (0.40 < | rho = 0.448 | < 0.69; [P < 0.001]), and as the RFL total score median increases, the SPS total score median decreases, and there was found a positive, strong (high), and significant relationship between BDI total score and SPS total score (0.70 < | rho = 0.755 | < 0.89; [P < 0.001]) [Table 2].

Table 2

Correlations between suicide probability scale, Beck's depression inventory, and reasons for living

SPS-dependent variable was investigated by stepwise regression method using gender, age, marital status, having children, education level, income level, people living together at home, suicide ideation, story of suicide, overcoming a life-threatening situation, being treated badly or losing a relative from suicide, reasons for living and depression as independent variables. As a result of stepwise regression, the independent variables that were predicted to have a significant impact on the SPS total score medians were found depression, suicidal thoughts, reasons for living, being treated badly, education level, income status, and age. With these determined independent variables, the explanatory coefficient of the model was found to be R2 = 0.728, and it was found that the model was statistically significant (F = 61.125; [P < 0.001]) [Table 3].

Table 3

Stepwise regression analysis for suicide probability

DISCUSSION

Considering studies conducted on the possibility of clinical or nonclinical suicide, to be a woman, to be young, to have no income, to experience feelings of depression, loneliness, and hopelessness, and to have fewer reasons for living can be seen as important risk factors. In this study, a series of analyses were conducted to examine the suicide probability and associated factors of the patients hospitalized at the psychiatric clinic.

According to the findings obtained from this study, the suicide probabilities of the university graduates are lower than the other education level individuals. Previous studies in the literature show that low education level is a risk for suicide and that individuals with low education level have high suicide probability.[3536] It can be said that individuals with low educational level are inadequate in the problems they face and the ability to cope with stress. As the level of education of the individual increases, the self-esteem also increases and it is thought that individuals with high self-esteem have more control over life situations and solve their problems with effective coping methods.

There are also studies showing that suicide attempts are most frequent in the working group as well as studies[373839] that indicate that individuals who do not work in any way have a high probability of suicide.[40] In this study, it was found that individuals with low income are more likely to commit suicide. Unemployment and low-income levels are said to increase the probability of suicide.[4142] In addition to determining the standard of life for the individuals, the level of financial income provides financial resources for solving many problems. Job loss with financial losses, loss of housing, and loss of interpersonal relationships can cause emotional stress. In the relationship between unemployment and income level and suicide, it is thought that a number of factors, such as physical or mental illnesses, harmonious personality traits, and bad childhood experiences have a role.

In this study, suicide probability of individuals with depression was found to be higher than those of the other diagnostic groups, and the reasons for living were lower. In other words, the probability of suicide increases as their depression level increases and reasons for living decreases. Similar studies made in clinical and nonclinical settings have also shown that the reasons for living reduce the power of suicidal thoughts, depression, and hopelessness and protect individuals from negative effects of despair.[192043444546] Suicide is reported to be more common in psychiatric patients according to the general population and especially patients who have hospitalized in psychiatric clinics have higher risk for suicide.[4748] In previous studies, individuals who were diagnosed with depression and undergoing inpatient treatment were found to have high suicide probability and low reasons for living. It is thought that the results obtained from this study are consistent with the literature, and it is considered that the risk of suicide is increased by adding negative expectations about hopelessness, pessimism, and future to the symptoms of depression.[79213049505152] Factors such as social isolation, job loss, loss of family members, loss of interpersonal relationships, hopelessness, use of substance or alcohol, ineffective problem-solving skills, and loss of ability can lead to an increase in suicide probability in individuals with any psychiatric disorder. It is believed that the ability to cope with hopelessness and pessimism will be a contribution to the development of reasons for living and will protect against the risk of suicide by ensuring that sick individuals focus on positive thinking and what they have in their lives such as family and children.

In the literature, it is stated that suicidal thoughts and suicide attempts are a strong factor in increasing the probability of suicide in hospitalized patients.[85354] Similar studies have also shown that suicide ideation and story of suicide attempt increase suicide risk.[5556575859] Individuals with suicide ideation and story of suicide attempt have fewer reasons for living and high suicide probability and depression levels.[21256061] In this study, it was found that individuals with suicidal thoughts and story of suicide have higher probability of suicide and fewer reasons for living in accordance with the literature. Individuals with suicide attempts have high levels of depression and are accompanied by psychiatric disorders such as substance use disorders and anxiety and mood disorders.[62] Depression and hopelessness are strong risk factors for suicidal thoughts and behaviors, and reasons for living seem to be a protective cognitive factor against the possibility of suicide. Treatment of psychiatric disorders and evaluation of suicidal ideation are thought to be helpful in preventing suicide attempts.

In this study, it has been found that individuals who overcoming a life-threatening situation, being treated badly, losing a relative from suicide, experiencing suicide attempt by a relative, and losing a relative due to an accident have higher suicide probability and individuals who lose his/her relative because of suicide have more reasons for living. In traumatic life events, it is stated that the reasons for living related to determining the probability of suicide have not any effect alone.[60] Lizardi et al. found that individuals who have suicide stories in their families had high levels of anger and fewer reasons for living.[44] In the study performed with individuals who have previously attempted suicide and who have not attempted suicide, Jokinen et al. have concluded that individuals who have previously attempted suicide have subjected to ill treatment during their childhood or adulthood.[63] In a study conducted by Ajdacic-Gross et al. to determine the probability of suicide of patients hospitalized at psychiatry clinics, 74% of individuals who applied to the hospital for suicide were found to experience stressful life events.[64] Negative life events disrupt the mental balance of the individual, reducing their vulnerability and making them more susceptible to psychiatric disorders. It is thought that because depressive individuals with story of suicide in their families are more impulsive and angry, they have high probability of suicide and model suicidal behavior as coping skills.

In this study, independent variables that were predicted to have a significant effect on the probability of suicide were depression, suicidal ideation, reasons for living, being treated badly, education level, income status and age, all of which were found to have significant effects in consequence of stepwise regression analysis. In similar studies, it was found that depression, suicidal ideation, reasons for living, being treated badly, education level, income status, and age are significant predictors of suicide probability.[364044506566] It was determined that in the study by Mohammadkhani et al.,[24] reasons for living; in the study by Edelstein et al.,[22] depression, age, and reasons for living; in the study by O’Connor et al.,[23] suicidal ideation and reasons for living; in the study by Qin et al.,[66] low-income level; in the study by Oquendo et al.,[25] depression, life situations, suicidal ideation, and reasons for living are predictor factors of suicide probability.

Limitations of the study

The most important limitation of our study was the number of sample group. It is thought that it would be useful to expand the sample and work with the control group in future studies. The study is an opportunity to determine the risk factors of suicide as well as the protective factors in the clinical practice and to monitor the patient in this context.

CONCLUSIONS

According to the results of the study, the evaluation of age, education level, income status, traumatic life story, depression level, suicide ideation, suicide attempt, and reasons for living of the patients hospitalized at psychiatry clinics were found to be effective in preventing suicide. It is thought that the nurses who are in the mental health personnel in psychiatry clinics can contribute to the safety of the patients and the therapeutic environment by observing these results during patient observation, patient interviews, and patient treatment within the mental health service. It is considered necessary to know and monitor the protective factors as well as the factors that increase the risk of suicide in the prevention of suicide.

Financial support and sponsorship

3128 projects were supported by the project by Ankara Yildirim Beyazit University Scientific Research Projects Unit.

Conflicts of interest

There are no conflicts of interest.