OMEGA, Vol. 69(3) 311-321, 2014
ATTRIBUTION OF MENTAL DISORDERS IN SUICIDE OCCURRENCE
MEHRAN BABANEJAD ALI DELPISHEH KHAIROLLAH ASADOLLAHI ALI KHORSHIDI KOUROSH SAYEHMIRI Ilam University of Medical Sciences, Ilam, Iran
ABSTRACT
The present study aimed to determine attribution of mental disorders in suicide occurrence. By a cross-sectional study, all suicide records (n = 5188), between 1993 and 2009 in Ilam province, were investigated. Multiple logistic regression analysis was adopted. Totally, 27.5% of the suicides occurred due to mental disorders. This was significantly higher in males (29.3%), individuals born in 1996 (44%) and 1990s (30.3%), those aged 30 years and above (33.2%) and suicide attempters (28.3%), respectively and separately. The risk of suicide due to mental disorders was observed for females (OR = 0.85, CI = 0.74-0.97), those born in 1994 (OR = 2.82, CI = 1.27-6.24), completed suicides (OR = 0.81, CI = 0.68-0.97) and the age group 25 to 29 years old (OR = 0.82, CI = 0.66-1.01). Suicide due to mental disorders was higher among males compared to females, the rate of which was directly proportional to attempted suicide and age. It is therefore recommended that health educations be seriously carried on targeted groups.
311 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/OM.69.3.f http://baywood.com
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INTRODUCTION Although multiple factors are known to be associated with suicide, including social and environmental factors (Partonen, Haukka, Nevonlinna, & Lönnqvist, 2004) and infections (Fabregas, Moura, Marciano, Carmo, & Teixeira, 2009; Keiser, Spoerri, Brinkhof, Hasse, Gayet-Ageron, Tissot, et al., 2010), mental disorders are suggested as an independent factor (Hirokawa, Kawakami, Matsumoto, Inagaki, Eguchi, Tsuchiya, et al., 2012; King, Semlyen, Tai, Killaspy, Osborn, Popelyuk, et al., 2008; Sørensen, Mortensen, Wang, Juel, Silverton, & Mednick, 2009; Tidemalm, 2010; Yen, Juang, Leong, Hung, Ku, Lin, et al., 2012) so that in 90% of suicide victims a diagnosable and potentially treatable mental disorder or unusual mental condition is present at the time of event (Jenkins & Singh, 2008). Suicide is a leading cause of death amongst men and women in the world (Hawton & van Heeringen, 2009) and World Health Organization (WHO) declared that suicide occurs in approximately 16.7 per 100,000 persons per year, so that each year nearly one million people die from suicide worldwide (WHO, 2007). Mental disorders (including emotional disorders, substance abuse, and antisocial behaviors) and the past psychopathology state that to reduce suicidal behaviors, all issues should focus on the improved detection and treatment of mental disorders (Beautrais, 2001). There is a gender difference in terms of mental disorder diagnosis that should be considered in suicide attempts (Yen et al., 2012). Women, in all ages and social classes, are much more open to talk about emotions compared to men. Men are much less likely to have a positive vision of counseling or therapy than women and are therefore more exposed to the act of suicide (Kennelly & Connolly, 2012). Mental disorders have considerable effect on the rate of attempted suicides (Currier & Oquendo, 2011). Therefore, increased access to mental health services in assessment of attempted suicide is necessary (Jenkins & Singh, 2008). War activities have led to an enhanced number of suicide records among people suffering from mental disorders, which can be evidence to confirm that suicide is a multi-dimensional problem (Loncar, Definis-Gojanovic, Dodig, Jakovljevic, Franic, Mercinko, et al., 2004). Apart from bad living conditions related either to the quality of life or unavailability of health services, unmet needs can increase the risk of suicide in mental patients (Tidemalm, 2010). Ilam province, with a total population of 540,000, as estimated in 2005, is located in the southwest part of Iran ([Online] Available from: http://en.wikipedia. org/wiki/Ilam_Province on 15 January 2013). The 8 years of Iran–Iraq war (1980-88; Karsh, 2002) had a big toll on Ilam province, and Iraq’s intense bombings completely ruined the economy and health structure of the province (Alaghehbandan, Lari, Joghataei, Islami, & Motavalian, 2011). There have only been a few studies on the association between suicide and mental disorders on Iranian suicide victims, especially in Ilam province. The first aim of the present study was to develop a comprehensive knowledge about the
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epidemiological factors influencing suicides associated with mental disorders. The second aim of this study was to estimate, according to the related factors, the adjusted risk of the suicide act due to mental disorders in the Ilam province. METHODS By a cross sectional study and using census methods, completed and attempted suicide data from systematic registration of suicide in Ilam province were recruited during 1993 to 2009, missing data from the years 2000 and 2002. In order to establish a comprehensive system, a center for prevention of psychosocial injuries was formed in Ilam province. All the suspected cases of suicide were initially reported to headquarters by authorities (hospitals across the province, forensics and other similar organizations). Some trained experts were then responsible to follow the reported cases and record the new approved events in a check list. The report included demographic data (age, gender, marital status, educational level), the time of incident by year, season, and month, method taken by the victim, reason and outcome of the suicide (completed or attempted). Using face to face interviews by an expert with attempters or nearest relatives of the person lost by suicide, the major reasons of the suicides were recorded as addiction (alcohol addiction, substance abuse, etc), economic constrains, family conflicts, physical defects, educational failures, honor issues, unemployment, indiscretion, mental disorders, and other problems. Eventually, to estimate the risk of suicide due to mental disorders, all reasons except mental disorders were considered as suicides due to non mental events. The age factor was classified into the following categories: < 15, 15-19, 20-24, 25-29, and $ 30 years. Marital status was dichotomized into married and not married at the time of death. Educational level was considered as illiterate, elementary, junior high school (between elementary and high school), high school, diploma, and academic. In epidemiology studies, Chi-square test (P2) and multiple logistic regressions are among the most commonly used methods for assaying suicides including those associated with mental disorders (Altamura, VanGastel, Pioli, Mannu, & Maes, 1999; Hirokawa et al., 2012; Sun, Guo, Ma, Zhang, Jia, & Xu, 2011; Tsai, 2010; Zhang, Gao, & Jia, 2011). The P2 test was used to estimate the differences in the frequency of suicides due to mental disorders and a multiple logistic regression model was applied to estimate the differences in the risk of total suicides due to mental disorders, applying different variables including age group, gender, year of suicide and the outcome (completed or attempted). In general, predictors in logistic regression model were as follows: $ 30 years as the age groups, females as gender, completed suicide as outcome, and 2009 as the year of outcome. The criterion for comparison of the total suicide risk was odds ratio (OR). These analyses were performed using the SPSS software (version 16). A p-value of < 0.05 was considered as statistically significant.
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RESULTS A total number of 5188 registered cases were analyzed in this study. In general, during the 15 years of study, 1427 cases (27.5%) were recorded to commit suicide due to mental disorders (completed and attempts). Among all the suicide events, individuals aged $ 30 years had the maximum frequency of mental disorders (33.2%, p < 0.0001). In terms of gender, males met the highest diagnostic criteria for mental disorders (29.3 %, p = 0.01). In addition, attempted suicides had the highest frequency rate among patients with mental disorders (28.3%, p = 0.01). (See Table 1.) Eventually, 1996 (44%, p < 0.0001) and 1990s (30.3%, p = 0.008) were the years in which the highest rate of suicide due to mental disorders was estimated. (See Table 2.) The highest rate of suicide due to mental disorders was amongst illiterate peoples (30.3%), singles (27.9%), those happened in March (31.7%) and spring (28.8%), but no statistically significant (see Tables 1 and 2). Table 1. Characteristics of Suicide Records Due to Mental Disorders Mental disorder Variables
Yes, N (%)
No, N (%)
Age group (year) < 15 15-19 20-24 25-29 ³ 30
9 (18.4) 368 (23.0) 435 (26.9) 269 (30.5) 346 (33.2)
40 (81.6) 1230 (77.0) 1183 (73.1) 613 (69.5) 695 (66.8)
Gender Female Male
786 (26.2) 641 (29.3)
2218 (73.8) 1543 (70.7)
0.01
Marital status Single Married
892 (27.9) 522 (26.6)
2303 (72.1) 1441 (73.4)
0.3
Educational level Illiterate Elementary Junior high school High school Diploma Academic
181 (30.3) 185 (27.0) 285 (29.7) 228 (28.1) 339 (26.7) 101 (28.9)
416 (69.7) 500 (73.0) 676 (70.3) 584 (71.9) 930 (73.3) 248 (71.1)
242 (24.3) 1178 (28.3)
753 (75.7) 2988 (71.7)
Suicide outcome Completed Attempt
p-value
< 0.0001
0.5
0.01
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Table 2. Suicide Due to Mental Disorders by the Time of Occurrence Mental disorder Variables
Yes, N (%)
No, N (%)
p-value
Year 1993 1994 1995 1996 1997 1998 1999 2001 2003 2004 2005 2006 2007 2008 2009
22 (17.7) 15 (41.7) 61 (31.3) 103 (44.0) 93 (34.3) 51 (27.7) 54 (19.9) 97 (30.2) 67 (25.6) 77 (23.2) 90 (26.7) 93 (26.1) 28 (20.7) 318 (27.7) 258 (26.3)
102 (82.3) 21 (58.3) 134 (68.7) 131 (56.0) 178 (65.7) 133 (72.3) 217 (80.1) 224 (69.8) 195 (74.4) 255 (76.8) 247 (73.3) 264 (73.9) 107 (79.3) 830 (72.3) 723 (73.7)
< 0.0001
Seasons Spring Summer Autumn Winter
347 (28.8) 407 (25.6) 355 (28.7) 318 (27.5)
858 (71.2) 1180 (74.4) 884 (71.3) 839 (72.5)
Months March April May June July August September October November December January February
99 (31.7) 124 (28.4) 124 (27.2) 106 (24.4) 132 (27.8) 169 (24.9) 131 (26.8) 110 (28.4) 114 (31.3) 97 (26.8) 112 (28.3) 109 (27.3)
213 (68.3) 313 (71.6) 332 (72.8) 328 (75.6) 343 (72.2) 509 (75.1) 757 (73.2) 277 (71.6) 250 (68.7) 265 (73.2) 284 (71.7) 290 (72.7)
2 Decades First Second
399 (30.3) 1028 (26.5)
916 (69.7) 2845 (73.5)
0.2
0.48
0.008
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Considering the highest risk of suicide due to mental disorders in the age group 30 years and older, those who were 25 to 29 years were most likely to commit suicide due to mental disorders. In addition, the risk of suicide due to mental disorders was estimated to be lower among females than males (completed and attempts). People who had died from suicide were less likely to have mental disorders. In other words, attempters had the maximum risk of suicide due to mental disorders compared to completed suicide victims. Eventually, among all years of study, the risk rate of all suicides due to mental disorders was 2.8 fold for the year 1994 compared to the reference year (see Table 3).
Table 3. Results of Logistic Regressions for Suicides Due to Mental Disorders B
SE
OR
95% CI
Age group (year) < 15 15-19 20-24 25-29 ³ 30
–1.01 –0.58 –0.35 –0.19 Reference
0.39 0.95 0.93 0.10
0.36 0.55 0.70 0.82
0.16-0.78 0.46-0.67 0.58-0.84 0.66-1.01
Gender Female Male
–0.15 Reference
0.67
0.85
0.74-0.97
Outcome Complete Attempt
–0.2 Reference
0.89
0.81
0.68-0.97
Year 1993 1994 1995 1996 1997 1998 1999 2001 2003 2004 2005 2006 2007 2008 2009
–0.84 1.03 0.46 0.90 0.46 0.13 –0.22 0.19 0.01 –0.19 0.10 0.05 –0.34 0.11 Reference
0.28 0.40 0.18 0.15 0.15 0.18 0.17 0.14 0.16 0.15 0.15 0.14 0.24 0.10
0.91 2.82 1.59 2.47 1.59 1.14 0.80 1.21 1.01 0.82 1.11 1.05 0.70 1.11
0.52-1.59 1.27-6.24 1.11-2.28 1.81-3.36 1.17-2.17 0.79-1.64 0.56-1.13 0.90-1.62 0.73-1.41 0.60-1.11 0.82-1.49 0.79-1.40 0.43-1.14 0.91-1.36
Constant
–0.43
0.14
0.64
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DISCUSSION Epidemiological study designs are of great value to assay suicides (Cantor, 2008). The present study aimed to assess the epidemiological factors affecting suicides due to mental disorders among 1427 registered suicide cases (out of a total suicide number of 5188 cases) from 1993 to 2009. These statistics, compared to the current total population of Ilam province, (i.e., 540 000 people) is an urgent condition. In the present study, 27.5% of the total suicide records were estimated to have been suffering from some kinds of mental disorder. This figure is very close to that reported in a study on Kurdish people in Iran which showed that 27% of the victims had some psychiatric problems (Mofidi, Ghazinour, Araste, Jacobsson, & Richter, 2008). On the other side, the prevalence rate of suicide due to mental disorders in this study was lower than those reported in previous studies in Iran; for example, in one study performed in Tabriz, 80.4% of the suicide victims had some kinds of mental disorder (Khazaei & Parvizifard, 2003). Other studies conducted in Japan (Hirokawa et al., 2012) and China (Zhang, Xiao, & Zhou, 2010) suggested that 65% and 48% of people who committed suicide had some kinds of mental disorders, respectively. In western countries over 90% of the suicide rates are related to mental disorders (Jenkins & Singh, 2008; Mann, Apter, Bertolote, Beautrais, Currier, Haas, et al., 2005). Comparing the present data to that of other studies, our findings show a lower rate of mental disorders in suicide events compared to that worldwide. Total rate of suicide due to mental disorders was significantly high in males. Similarly, Lawrence et al. (2008) and Zhang et al. (2010) found that male mental patients were more likely to commit suicide compared with female patients. Other studies have shown that females were more susceptible to have a mental disorder at the time of event (Rocchi, Sisti, Cascio, & Preti, 2007). The gender difference in death by suicide indicated that men are three times more susceptible to die than women and are most likely to experience multiple risk factors for suicide, interacting in overwhelming combinations. In addition, men tend to show greater loneliness compared to women, even while they are not communally isolated. The social networks are less supportive for men and they have less successful friendships (Kennelly & Connolly, 2012). As confirmed by many studies, it was shown that attempted suicides were most related to mental disorders (Claes, Muehlenkamp, Vandereycken, Hamelinck, Martens, & Claes, et al., 2010; Suominen, Henriksson, Suokas, Isometsä, Ostamo, & Lönnqvist, 1996). There is a need for better mental health supervision of suicide attempters and also for additional experimental researches on the prevention of suicide repetition. Even though it is believed that suicide attempters are at high risk for future suicidal actions, successful socio-economic empowerment strategies or general health support policies are still lacking for the prevention of suicidal acts (Kerkhof, 2008).
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In general, the highest rate of suicide due to mental disorders was estimated for 1990s. People living in Ilam province have experienced an 8-year war between Iran and Iraq during 1980-88 (Karsh, 2002) and in fact they are still suffering from poor living conditions and poor mental health retained from the wartime periods. These factors, as confirmed by some other studies (Cersovsky, 2011; Frueh & Smith, 2012; Griffith, 2012; Omalu, Hammens, Bailes, Hamilton, Kamboh, Webster, et al., 2011) may, in turn, result in suicide. The present study faced some limitations. The main limitation of this study was the absence of data related to the years 2000 and 2002. The second limitation was the fact that cross-sectional studies cannot explain the causation and changes over time in suicidal behaviors. There are needs for further research that follows people at risk of suicide, including attempted suicides. These researches should be able to track any changes in the suicidal behaviors of the followed people suffering from any mental disorders. The third limitation of this study was the fact that the majority of cases were attempters (about 4,000) compared to a comparatively small number of completed suicides (nearly 1,000). The large volume of suicide literature suggested that attempters differ from those who die by suicide in a number of ways (Janghorbani & Sharifirad, 2005; Soulas, Gurruchaga, Palfi, Cesaro, Nguyen, & Fenelon, 2008; Yamada, Kawanishi, Hasegawa, Sato, Konishi, Kato, et al., 2007). The combination of the two categories of suicidal acts may tell us far more about attempters than it does about those who die by suicide. It is worth mentioning that the recruiting system, and hence some register organizations, used in this study were completed at the final years of the study, meaning that the actual number of recorded suicides might have been higher than that reported. Suicide due to mental disorders was higher in males than in females. The rate of suicide was increased by increasing age. Attempted suicides were more likely to be related with mental disorders. Finally, health education activities should focus on males, as a susceptible group to suicide acts and attention needs to be paid at the early ages of life. In addition, if preventive measures focus on attempted suicides, the next suicide events may decrease considerably. REFERENCES Alaghehbandan, R., Lari, A. R., Joghataei, M. T., Islami, A., & Motavalian, A. (2011). A prospective population-based study of suicidal behavior by burns in the province of Ilam, Iran. Burns, 37(1), 164-169. Altamura, C., VanGastel, A., Pioli, R., Mannu, P., & Maes, M. (1999). Seasonal and circadian rhythms in suicide in Cagliari, Italy. Journal of affective disorders, 53(1), 77-85. Beautrais, A. L. (2001). Risk factors for suicide and attempted suicide among young people. Australian and New Zealand Journal of Psychiatry, 34(3), 420-436. Cantor, C. H. (2008). Suicide in the western world. The International Handbook of Suicide and Attempted Suicide, 9-28.
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Direct reprint requests to: Koroush Sayehmiri, Ph.D. Faculty of Medicine Ilam University of Medical Sciences Ilam, Iran e-mail: [email protected]
ATTRIBUTION OF MENTAL DISORDERS IN SUICIDE OCCURRENCE
MEHRAN BABANEJAD ALI DELPISHEH KHAIROLLAH ASADOLLAHI ALI KHORSHIDI KOUROSH SAYEHMIRI Ilam University of Medical Sciences, Ilam, Iran
ABSTRACT
The present study aimed to determine attribution of mental disorders in suicide occurrence. By a cross-sectional study, all suicide records (n = 5188), between 1993 and 2009 in Ilam province, were investigated. Multiple logistic regression analysis was adopted. Totally, 27.5% of the suicides occurred due to mental disorders. This was significantly higher in males (29.3%), individuals born in 1996 (44%) and 1990s (30.3%), those aged 30 years and above (33.2%) and suicide attempters (28.3%), respectively and separately. The risk of suicide due to mental disorders was observed for females (OR = 0.85, CI = 0.74-0.97), those born in 1994 (OR = 2.82, CI = 1.27-6.24), completed suicides (OR = 0.81, CI = 0.68-0.97) and the age group 25 to 29 years old (OR = 0.82, CI = 0.66-1.01). Suicide due to mental disorders was higher among males compared to females, the rate of which was directly proportional to attempted suicide and age. It is therefore recommended that health educations be seriously carried on targeted groups.
311 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/OM.69.3.f http://baywood.com
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INTRODUCTION Although multiple factors are known to be associated with suicide, including social and environmental factors (Partonen, Haukka, Nevonlinna, & Lönnqvist, 2004) and infections (Fabregas, Moura, Marciano, Carmo, & Teixeira, 2009; Keiser, Spoerri, Brinkhof, Hasse, Gayet-Ageron, Tissot, et al., 2010), mental disorders are suggested as an independent factor (Hirokawa, Kawakami, Matsumoto, Inagaki, Eguchi, Tsuchiya, et al., 2012; King, Semlyen, Tai, Killaspy, Osborn, Popelyuk, et al., 2008; Sørensen, Mortensen, Wang, Juel, Silverton, & Mednick, 2009; Tidemalm, 2010; Yen, Juang, Leong, Hung, Ku, Lin, et al., 2012) so that in 90% of suicide victims a diagnosable and potentially treatable mental disorder or unusual mental condition is present at the time of event (Jenkins & Singh, 2008). Suicide is a leading cause of death amongst men and women in the world (Hawton & van Heeringen, 2009) and World Health Organization (WHO) declared that suicide occurs in approximately 16.7 per 100,000 persons per year, so that each year nearly one million people die from suicide worldwide (WHO, 2007). Mental disorders (including emotional disorders, substance abuse, and antisocial behaviors) and the past psychopathology state that to reduce suicidal behaviors, all issues should focus on the improved detection and treatment of mental disorders (Beautrais, 2001). There is a gender difference in terms of mental disorder diagnosis that should be considered in suicide attempts (Yen et al., 2012). Women, in all ages and social classes, are much more open to talk about emotions compared to men. Men are much less likely to have a positive vision of counseling or therapy than women and are therefore more exposed to the act of suicide (Kennelly & Connolly, 2012). Mental disorders have considerable effect on the rate of attempted suicides (Currier & Oquendo, 2011). Therefore, increased access to mental health services in assessment of attempted suicide is necessary (Jenkins & Singh, 2008). War activities have led to an enhanced number of suicide records among people suffering from mental disorders, which can be evidence to confirm that suicide is a multi-dimensional problem (Loncar, Definis-Gojanovic, Dodig, Jakovljevic, Franic, Mercinko, et al., 2004). Apart from bad living conditions related either to the quality of life or unavailability of health services, unmet needs can increase the risk of suicide in mental patients (Tidemalm, 2010). Ilam province, with a total population of 540,000, as estimated in 2005, is located in the southwest part of Iran ([Online] Available from: http://en.wikipedia. org/wiki/Ilam_Province on 15 January 2013). The 8 years of Iran–Iraq war (1980-88; Karsh, 2002) had a big toll on Ilam province, and Iraq’s intense bombings completely ruined the economy and health structure of the province (Alaghehbandan, Lari, Joghataei, Islami, & Motavalian, 2011). There have only been a few studies on the association between suicide and mental disorders on Iranian suicide victims, especially in Ilam province. The first aim of the present study was to develop a comprehensive knowledge about the
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epidemiological factors influencing suicides associated with mental disorders. The second aim of this study was to estimate, according to the related factors, the adjusted risk of the suicide act due to mental disorders in the Ilam province. METHODS By a cross sectional study and using census methods, completed and attempted suicide data from systematic registration of suicide in Ilam province were recruited during 1993 to 2009, missing data from the years 2000 and 2002. In order to establish a comprehensive system, a center for prevention of psychosocial injuries was formed in Ilam province. All the suspected cases of suicide were initially reported to headquarters by authorities (hospitals across the province, forensics and other similar organizations). Some trained experts were then responsible to follow the reported cases and record the new approved events in a check list. The report included demographic data (age, gender, marital status, educational level), the time of incident by year, season, and month, method taken by the victim, reason and outcome of the suicide (completed or attempted). Using face to face interviews by an expert with attempters or nearest relatives of the person lost by suicide, the major reasons of the suicides were recorded as addiction (alcohol addiction, substance abuse, etc), economic constrains, family conflicts, physical defects, educational failures, honor issues, unemployment, indiscretion, mental disorders, and other problems. Eventually, to estimate the risk of suicide due to mental disorders, all reasons except mental disorders were considered as suicides due to non mental events. The age factor was classified into the following categories: < 15, 15-19, 20-24, 25-29, and $ 30 years. Marital status was dichotomized into married and not married at the time of death. Educational level was considered as illiterate, elementary, junior high school (between elementary and high school), high school, diploma, and academic. In epidemiology studies, Chi-square test (P2) and multiple logistic regressions are among the most commonly used methods for assaying suicides including those associated with mental disorders (Altamura, VanGastel, Pioli, Mannu, & Maes, 1999; Hirokawa et al., 2012; Sun, Guo, Ma, Zhang, Jia, & Xu, 2011; Tsai, 2010; Zhang, Gao, & Jia, 2011). The P2 test was used to estimate the differences in the frequency of suicides due to mental disorders and a multiple logistic regression model was applied to estimate the differences in the risk of total suicides due to mental disorders, applying different variables including age group, gender, year of suicide and the outcome (completed or attempted). In general, predictors in logistic regression model were as follows: $ 30 years as the age groups, females as gender, completed suicide as outcome, and 2009 as the year of outcome. The criterion for comparison of the total suicide risk was odds ratio (OR). These analyses were performed using the SPSS software (version 16). A p-value of < 0.05 was considered as statistically significant.
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RESULTS A total number of 5188 registered cases were analyzed in this study. In general, during the 15 years of study, 1427 cases (27.5%) were recorded to commit suicide due to mental disorders (completed and attempts). Among all the suicide events, individuals aged $ 30 years had the maximum frequency of mental disorders (33.2%, p < 0.0001). In terms of gender, males met the highest diagnostic criteria for mental disorders (29.3 %, p = 0.01). In addition, attempted suicides had the highest frequency rate among patients with mental disorders (28.3%, p = 0.01). (See Table 1.) Eventually, 1996 (44%, p < 0.0001) and 1990s (30.3%, p = 0.008) were the years in which the highest rate of suicide due to mental disorders was estimated. (See Table 2.) The highest rate of suicide due to mental disorders was amongst illiterate peoples (30.3%), singles (27.9%), those happened in March (31.7%) and spring (28.8%), but no statistically significant (see Tables 1 and 2). Table 1. Characteristics of Suicide Records Due to Mental Disorders Mental disorder Variables
Yes, N (%)
No, N (%)
Age group (year) < 15 15-19 20-24 25-29 ³ 30
9 (18.4) 368 (23.0) 435 (26.9) 269 (30.5) 346 (33.2)
40 (81.6) 1230 (77.0) 1183 (73.1) 613 (69.5) 695 (66.8)
Gender Female Male
786 (26.2) 641 (29.3)
2218 (73.8) 1543 (70.7)
0.01
Marital status Single Married
892 (27.9) 522 (26.6)
2303 (72.1) 1441 (73.4)
0.3
Educational level Illiterate Elementary Junior high school High school Diploma Academic
181 (30.3) 185 (27.0) 285 (29.7) 228 (28.1) 339 (26.7) 101 (28.9)
416 (69.7) 500 (73.0) 676 (70.3) 584 (71.9) 930 (73.3) 248 (71.1)
242 (24.3) 1178 (28.3)
753 (75.7) 2988 (71.7)
Suicide outcome Completed Attempt
p-value
< 0.0001
0.5
0.01
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Table 2. Suicide Due to Mental Disorders by the Time of Occurrence Mental disorder Variables
Yes, N (%)
No, N (%)
p-value
Year 1993 1994 1995 1996 1997 1998 1999 2001 2003 2004 2005 2006 2007 2008 2009
22 (17.7) 15 (41.7) 61 (31.3) 103 (44.0) 93 (34.3) 51 (27.7) 54 (19.9) 97 (30.2) 67 (25.6) 77 (23.2) 90 (26.7) 93 (26.1) 28 (20.7) 318 (27.7) 258 (26.3)
102 (82.3) 21 (58.3) 134 (68.7) 131 (56.0) 178 (65.7) 133 (72.3) 217 (80.1) 224 (69.8) 195 (74.4) 255 (76.8) 247 (73.3) 264 (73.9) 107 (79.3) 830 (72.3) 723 (73.7)
< 0.0001
Seasons Spring Summer Autumn Winter
347 (28.8) 407 (25.6) 355 (28.7) 318 (27.5)
858 (71.2) 1180 (74.4) 884 (71.3) 839 (72.5)
Months March April May June July August September October November December January February
99 (31.7) 124 (28.4) 124 (27.2) 106 (24.4) 132 (27.8) 169 (24.9) 131 (26.8) 110 (28.4) 114 (31.3) 97 (26.8) 112 (28.3) 109 (27.3)
213 (68.3) 313 (71.6) 332 (72.8) 328 (75.6) 343 (72.2) 509 (75.1) 757 (73.2) 277 (71.6) 250 (68.7) 265 (73.2) 284 (71.7) 290 (72.7)
2 Decades First Second
399 (30.3) 1028 (26.5)
916 (69.7) 2845 (73.5)
0.2
0.48
0.008
315
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Considering the highest risk of suicide due to mental disorders in the age group 30 years and older, those who were 25 to 29 years were most likely to commit suicide due to mental disorders. In addition, the risk of suicide due to mental disorders was estimated to be lower among females than males (completed and attempts). People who had died from suicide were less likely to have mental disorders. In other words, attempters had the maximum risk of suicide due to mental disorders compared to completed suicide victims. Eventually, among all years of study, the risk rate of all suicides due to mental disorders was 2.8 fold for the year 1994 compared to the reference year (see Table 3).
Table 3. Results of Logistic Regressions for Suicides Due to Mental Disorders B
SE
OR
95% CI
Age group (year) < 15 15-19 20-24 25-29 ³ 30
–1.01 –0.58 –0.35 –0.19 Reference
0.39 0.95 0.93 0.10
0.36 0.55 0.70 0.82
0.16-0.78 0.46-0.67 0.58-0.84 0.66-1.01
Gender Female Male
–0.15 Reference
0.67
0.85
0.74-0.97
Outcome Complete Attempt
–0.2 Reference
0.89
0.81
0.68-0.97
Year 1993 1994 1995 1996 1997 1998 1999 2001 2003 2004 2005 2006 2007 2008 2009
–0.84 1.03 0.46 0.90 0.46 0.13 –0.22 0.19 0.01 –0.19 0.10 0.05 –0.34 0.11 Reference
0.28 0.40 0.18 0.15 0.15 0.18 0.17 0.14 0.16 0.15 0.15 0.14 0.24 0.10
0.91 2.82 1.59 2.47 1.59 1.14 0.80 1.21 1.01 0.82 1.11 1.05 0.70 1.11
0.52-1.59 1.27-6.24 1.11-2.28 1.81-3.36 1.17-2.17 0.79-1.64 0.56-1.13 0.90-1.62 0.73-1.41 0.60-1.11 0.82-1.49 0.79-1.40 0.43-1.14 0.91-1.36
Constant
–0.43
0.14
0.64
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DISCUSSION Epidemiological study designs are of great value to assay suicides (Cantor, 2008). The present study aimed to assess the epidemiological factors affecting suicides due to mental disorders among 1427 registered suicide cases (out of a total suicide number of 5188 cases) from 1993 to 2009. These statistics, compared to the current total population of Ilam province, (i.e., 540 000 people) is an urgent condition. In the present study, 27.5% of the total suicide records were estimated to have been suffering from some kinds of mental disorder. This figure is very close to that reported in a study on Kurdish people in Iran which showed that 27% of the victims had some psychiatric problems (Mofidi, Ghazinour, Araste, Jacobsson, & Richter, 2008). On the other side, the prevalence rate of suicide due to mental disorders in this study was lower than those reported in previous studies in Iran; for example, in one study performed in Tabriz, 80.4% of the suicide victims had some kinds of mental disorder (Khazaei & Parvizifard, 2003). Other studies conducted in Japan (Hirokawa et al., 2012) and China (Zhang, Xiao, & Zhou, 2010) suggested that 65% and 48% of people who committed suicide had some kinds of mental disorders, respectively. In western countries over 90% of the suicide rates are related to mental disorders (Jenkins & Singh, 2008; Mann, Apter, Bertolote, Beautrais, Currier, Haas, et al., 2005). Comparing the present data to that of other studies, our findings show a lower rate of mental disorders in suicide events compared to that worldwide. Total rate of suicide due to mental disorders was significantly high in males. Similarly, Lawrence et al. (2008) and Zhang et al. (2010) found that male mental patients were more likely to commit suicide compared with female patients. Other studies have shown that females were more susceptible to have a mental disorder at the time of event (Rocchi, Sisti, Cascio, & Preti, 2007). The gender difference in death by suicide indicated that men are three times more susceptible to die than women and are most likely to experience multiple risk factors for suicide, interacting in overwhelming combinations. In addition, men tend to show greater loneliness compared to women, even while they are not communally isolated. The social networks are less supportive for men and they have less successful friendships (Kennelly & Connolly, 2012). As confirmed by many studies, it was shown that attempted suicides were most related to mental disorders (Claes, Muehlenkamp, Vandereycken, Hamelinck, Martens, & Claes, et al., 2010; Suominen, Henriksson, Suokas, Isometsä, Ostamo, & Lönnqvist, 1996). There is a need for better mental health supervision of suicide attempters and also for additional experimental researches on the prevention of suicide repetition. Even though it is believed that suicide attempters are at high risk for future suicidal actions, successful socio-economic empowerment strategies or general health support policies are still lacking for the prevention of suicidal acts (Kerkhof, 2008).
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In general, the highest rate of suicide due to mental disorders was estimated for 1990s. People living in Ilam province have experienced an 8-year war between Iran and Iraq during 1980-88 (Karsh, 2002) and in fact they are still suffering from poor living conditions and poor mental health retained from the wartime periods. These factors, as confirmed by some other studies (Cersovsky, 2011; Frueh & Smith, 2012; Griffith, 2012; Omalu, Hammens, Bailes, Hamilton, Kamboh, Webster, et al., 2011) may, in turn, result in suicide. The present study faced some limitations. The main limitation of this study was the absence of data related to the years 2000 and 2002. The second limitation was the fact that cross-sectional studies cannot explain the causation and changes over time in suicidal behaviors. There are needs for further research that follows people at risk of suicide, including attempted suicides. These researches should be able to track any changes in the suicidal behaviors of the followed people suffering from any mental disorders. The third limitation of this study was the fact that the majority of cases were attempters (about 4,000) compared to a comparatively small number of completed suicides (nearly 1,000). The large volume of suicide literature suggested that attempters differ from those who die by suicide in a number of ways (Janghorbani & Sharifirad, 2005; Soulas, Gurruchaga, Palfi, Cesaro, Nguyen, & Fenelon, 2008; Yamada, Kawanishi, Hasegawa, Sato, Konishi, Kato, et al., 2007). The combination of the two categories of suicidal acts may tell us far more about attempters than it does about those who die by suicide. It is worth mentioning that the recruiting system, and hence some register organizations, used in this study were completed at the final years of the study, meaning that the actual number of recorded suicides might have been higher than that reported. Suicide due to mental disorders was higher in males than in females. The rate of suicide was increased by increasing age. Attempted suicides were more likely to be related with mental disorders. Finally, health education activities should focus on males, as a susceptible group to suicide acts and attention needs to be paid at the early ages of life. In addition, if preventive measures focus on attempted suicides, the next suicide events may decrease considerably. REFERENCES Alaghehbandan, R., Lari, A. R., Joghataei, M. T., Islami, A., & Motavalian, A. (2011). A prospective population-based study of suicidal behavior by burns in the province of Ilam, Iran. Burns, 37(1), 164-169. Altamura, C., VanGastel, A., Pioli, R., Mannu, P., & Maes, M. (1999). Seasonal and circadian rhythms in suicide in Cagliari, Italy. Journal of affective disorders, 53(1), 77-85. Beautrais, A. L. (2001). Risk factors for suicide and attempted suicide among young people. Australian and New Zealand Journal of Psychiatry, 34(3), 420-436. Cantor, C. H. (2008). Suicide in the western world. The International Handbook of Suicide and Attempted Suicide, 9-28.
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Direct reprint requests to: Koroush Sayehmiri, Ph.D. Faculty of Medicine Ilam University of Medical Sciences Ilam, Iran e-mail: [email protected]
