1. Background
Suicide is the act or an instance of taking one's own life voluntarily and intentionally that may lead to a non-fatal or fatal outcome (1). It is the tenth leading cause of death worldwide (2). In recent decades, the average annual rate of suicide attempts (SA) was estimated from 2.6 to 1100 per 100,000 persons per year, and the annual mortality rate of suicide is 14.5 deaths per 100,000 people (3, 4). Also, 10% - 18% of the general population has suicidal thoughts, and 3% - 5% of them have a history of SA during their lifetime (5). Suicide and SA were considered as the most important social problems in developed countries; however, it is increasing in developing countries, as well. As an instance, among the general population of the United States, the rate of SA was reported 0.3 to 4.6% (6).
According to recently published studies with an overall trend of 20 years, Iran, as a developing country, suffers from an enhancement in suicidal deaths with an estimated average rate of 9.9 per 100,000 persons per year (7). In Iran, on average, it was 200 years of life lost (YLL) per 100,000 individuals due to suicide behaviors (SBs) and self-inflicted violence (8). It is noteworthy that the most frequent method of suicide in Iran is drug use and the prevalence of suicide is greatest in the summer with a 35.2% occurrence, which is almost 13% higher than other seasons. Regarding gender, females are much more likely to SA. Compared with the rural attempters, the urban population has shown more likely to commit suicide (9). There is an association between natural disasters and committing suicide due to mental distress. Therefore, there might be a relationship between exposure to natural disasters and suicide (10).
As mentioned, stressful life events (SLEs) as one of the main risk factors for SBs are increasing as a global prevalence, and often have been linked to impulsive SA (11-13). Individuals with a history of suicide or SA are at high risk for SLEs in their lifetime (11). SLEs, such as family or marital disagreement and conflicts, unexpected loss of loved ones, early marriage, serious financial problems, and other stress factors are increasing in Iran and worldwide and are extremely associated with suicide and SA (9). Studies conducted in Iran have indicated that early marriage and family conflicts are the most stressful social problems with high prevalence; unfortunately, more than 7.7% of girls in Tehran and 40% in Sistan and Baluchestan Province got married before the age of 18 (14, 15). Although an association was found between SLEs and risk of cancers (16), very few studies have been done to explore the role of various types of SLEs, particularly on suicide and suicide prevention in Iran and developing countries. Although the predictors and causality of suicide and SA are different, few studies have addressed this issue, at least in developing countries (17).
2. Objectives
As noted above, the number of studies on the correlation between SLEs and suicide or SA is limited and most of them have been conducted in western societies (11, 13). Also, studies in western countries have focused on investigating the relationship between SLEs and SA rather than suicide. Likewise, the current study aimed at assessing the role of SLEs in suicide and SAs while making comparisons among different factors in Malekan County, East Azerbaijan Province, Iran.
3. Methods
3.1. Study Design
This descriptive-analytical study was performed based on SBs records obtained from the registration system of the bureau of mental health service in Malekan County, East Azerbaijan, Iran, from 2014 to 2016. In Iran, all SBs were registered in the national registration system, which has been launched since March 2009. Out of 624 cases with a history of suicidal behaviors, 186 samples were selected through random quota sampling based on the frequency of SBs occurred. Among these samples, 32 cases committed suicide, and others (154) only had SAs. Individuals who did not reside in the studied geographical location, and those who were not willing to participate in the study were excluded.
3.2. Data Collection
A standard checklist was used to collect primary data from all cases with a history of SB by Farabi Hospital, health homes, and health centers. Since the primary data of SBs were collected at the time of the occurrence of the event by emergency or community health workers in health homes, all SBs data were registered.
Semi-structured interviews were conducted using a valid and reliable Life Event questionnaire (LEQ), developed by Holms and Rahe, with a Cronbach’s Alpha of 0.762 to assess SLEs, which previously was used in its Persian version (16). This self-report LEQ is a 43-item of various common types of SLEs in the last 12 months, including loss of loved ones (parents, offspring, spouse, and first-degree relatives), any family-oriented problems or conflicts (with first- and second-degree family members), marital conflicts (disputes, divorce, or separation), unemployment for more than 6 months, serious financial and occupational problems, failures in (studying or working), exposure to new conditions, early marriage (before the age of 18), being immigrant or refugee, and emotional problems with the opposite sex.
After each SB, the subjects were invited to the health center or a hospital in order to conduct semi-structured face to face interviews by trained interviewers (clinical psychologists) one day later. The face to face interview lasted at least half an hour; each interview was done separately and confidentially at a single sitting to identify the risk factors and motivations for SA. Furthermore, to make an attempt to delve into minds of those who died after suicide, we consulted with native community health workers (Behvarz in Persian) to obtain the initial information, especially, facts concerning the closest emotional person to deceased cases, such as their family members, including parents, spouse, or siblings to be interviewed. It is worth mentioning that native community health workers (Behvarz) in Iranian rural areas who are available in all villages in health homes are fully aware of socio-demographic and health situations of all people living in the village or covered area.
3.3. Statistical Analysis
The SPSS software (version 19.0, Chicago, IL, USA) was used for data analysis. Also, the Kolmogorov-Smirnov test was applied to check the normal distribution of data, chi-square (χ2) test to assess the relationship between suicide and dichotomous and nonparametric variables, and independent t-test and Man-Whitney test to compare SLEs scores between two groups of SA and suicide. In addition, the point-biserial correlation coefficient was utilized for measuring the association between SLEs scores and the outcome of SA. Multiple logistic regression analysis was used to estimate the adjusted odds ratio (OR) with a 95% confidence interval (CI) for the risk factors and suicide. In all tests, the confidence interval was considered 95%, and P value < 0.05 was significant.
3.4. Ethical Approval
This study was funded by the Social Determinants of Health Research Center (SDHRC) and approved by the Ethics Committee of Tabriz University of Medical Sciences (code: IR.TBZMED.REC.1394.674). Informed consent was obtained from all subjects before the interview. All participants’ names and information were entered into the computer as a code, and the names were anonymous, and the information kept strictly confidential.
4. Results
According to the findings, out of 186 SBs in this study, 154 cases had SAs, and 32 individuals committed suicide. Women were found roughly two times more likely to attempt suicide (64.2% of SAs); however, men were approximately three times more likely to die from suicide (71.8%).
The prevalence of SA was highest among individuals aged 10 - 25 years, which was over half of the incidences (61.68%), whereas the age group of 26 - 40 years suffered from the most frequent rate of suicide (56.25%). Age and sex had a significant association with suicide (P = 0.003, P = 0.001). Significant differences were also found between occupation, marital disagreement, income level, place of residence, and suicide. Additionally, no participant was younger than the age of ten or over 75 years (Table 1).
Table 1.Selected Socio-Demographic Characteristic of the Studied Participantsa
| Variables | Suicide Attempts (N = 154) | Suicides (N = 32) | P Value |
|---|---|---|---|
| Gender | 0.001 | ||
| Female | 99 (64.28) | 9 (28.12) | |
| Male | 55 (35.72) | 23 (71.9) | |
| Age | 0.003 | ||
| 10 - 25 | 95 (61.69) | 9 (28.125) | |
| 26 - 40 | 45 (29.22) | 18 (56.25) | |
| ≥ 40 | 14 (9.1) | 5 (15.63) | |
| Occupation | 0.001 | ||
| Student | 34 (22.08) | 7 (21.87) | |
| Farmer or agricultural-related jobs | 4 (2.6) | 2 (6.25) | |
| Housewife | 102 (66.23) | 5 (15.63) | |
| Others | 14 (9.09) | 18 (56.25) | |
| Marital status | 0.028 | ||
| Single | 26 (16.88) | 10 (31.25) | |
| Married | 115 (74.67) | 21 (65.63) | |
| Widow and divorced | 13 (8.45) | 1 (3.12) | |
| Educational level | 0.247 | ||
| Primary school | 52 (33.76) | 10 (31.25) | |
| Secondary school | 80 (51.95) | 19 (59.38) | |
| High school and academic | 22 (14.28) | 3 (9.37) | |
| Family size | 0.445 | ||
| ≤ 2 | 29 (18.83) | 4 (12.5) | |
| 3 - 4 | 83 (53.9) | 16 (50.00) | |
| ≥ 4 | 42 (27.27) | 12 (37.5) | |
| Incomeb | 0.006 | ||
| < 500 | 72 (46.75) | 8 (25.00) | |
| 500 - 1000 | 57 (37.01) | 13 (40.62) | |
| 1000 - 2000 | 17 (11.04) | 4 (12.5) | |
| > 2000 | 8 (5.19) | 7 (21.88) | |
| Resident | 0.039 | ||
| Urban | 31 (20.13) | 2 (6.25) | |
| Rural | 123 (79.87) | 30 (93.75) | |
| Living alone | 0.188 | ||
| Yes | 8 (5.2) | 0 (0) | |
| No | 146 (94.8) | 32 (100) |
aValues are expressed as No. (%).
bPer 10000 Iranian Rials.
Table 2 presents various types of SLEs in SAs and suicides. In univariate analysis, family conflicts, marital disagreement, financial problems, emotional problems, migration, and exposure to new conditions, and early marriage indicated a statistically significant relationship with suicide.
Table 2.Comparison of Various Types of Stressful Life Events and Their Scores in Suicide Attempts and Suicidesa
| Variables | Suicide Attempts (N = 154) | Suicides (N = 32) | P Value |
|---|---|---|---|
| Stressful life events score | 447 ± 27.06 | 552 ± 23.75 | 0.001b |
| Family conflict | 0.001 | ||
| Yes | 38 (24.67) | 19 (59.38) | |
| No | 116 (75.33) | 13 (40.62) | |
| Marital disagreement | 0.028 | ||
| Yes | 59 (38.31) | 19 (59.38) | |
| No | 95 (61.69) | 13 (40.62) | |
| Loss of dears | 0.295 | ||
| Yes | 31 (2013) | 4 (12.50) | |
| No | 123 (79.87) | 28 (87.50) | |
| Financial problems | 0.001 | ||
| Yes | 10 (6.50) | 15 (46.88) | |
| No | 144 (93.50) | 17 (53.12) | |
| Life failures | 0.653 | ||
| Yes | 7 (4.55) | 2 (6.25) | |
| No | 147 (95.45) | 30 (93.75) | |
| Emotional problems | 0.003 | ||
| Yes | 9 (5.84) | 8 (25.00) | |
| No | 145 (94.15) | 24 (75.00) | |
| Exposure to the new conditions | 0.064 | ||
| Yes | 3 (1.95) | 3 (9.37) | |
| No | 151 (98.05) | 29 (90.63) | |
| Early Marriagec | 0.011 | ||
| Yes | 20 (12.98) | 10 (31.25) | |
| No | 134 (87.01) | 22 (68.75) | |
| Unemployment of > 6 months | 0.134 | ||
| Yes | 22 (14.28) | 8 (25.00) | |
| No | 132 (85.72) | 24 (75.00) |
aValues are expressed as No. (%).
bMann-Whitney test.
cBefore the age of 18.
Similarly, mean and standard deviation (12) of the SLEs scores in suicide (447 ± 27.06) were found to be significantly (P value < 0.001) more than SA (552 ± 23.75). The point-Biserial correlation was 0.739 in the association between suicide and SLEs scores (Table 3).
Table 4 demonstrates the results of multiple logistic regression analysis for adjusted ORs and 95% CIs for suicide and demographic characteristics with a P value of < 0.2. After adjusting for marital status, a significant association was found between suicide and the age of 26 - 40 years (OR = 6.34; 95% CI = 2.1 - 19.15), male gender (OR = 3.48; 95% CI = 3.48 - 9.24), income level (more than 20 million per month) (OR = 9.5; 95% CI = 1.49 - 60.29), and being self-employed (OR = 6.88; 95% CI = 1.73 - 27.53).
Table 4.The Association Between Suicide and Selected Demographic Characteristic by Multiple Logistic Regression Analysisa
| Variables | Suicide Attempts (N = 154) | Suicides (N = 32) | Crude OR (95% CI) | Adjusted ORb (95% CI) |
|---|---|---|---|---|
| Age | ||||
| 10 - 25 | 95 (61.69) | 9 (28.125) | -b | -b |
| 26 - 40 | 45 (29.22) | 18 (56.25) | 4.22 (1.75-10.15) | 6.34 (2.1-19.15) |
| P value | 0.001 | 0.001 | ||
| ≥ 40 | 14 (9.1) | 5 (15.63) | 3.76 [1.1 - 12.92] | 4.92 [0.8 - 30.58] |
| P value | 0.035 | 0.088 | ||
| Gender | ||||
| Female | 99 (64.28) | 9 (28.12) | -b | -b |
| Male | 55 (35.72) | 23 (71.9) | 4.6 (1.99 - 10.63) | 3.48 (1.32 - 9.24) |
| Income, million Rial | 0.001 | 0.012 | ||
| ≤ 5 | 72 (46.75) | 8 (25.00) | -b | -b |
| 5 - 10 | 57 (37.01) | 13 (40.62) | 2.05 (0.79 - 5.3) | 2.68 (0.76 - 9.41) |
| P value | 0.138 | 0.123 | ||
| 10 - 20 | 17 (11.04) | 4 (12.5) | 2.11 (0.56 - 7.88) | 1.68 (0.29 - 9.67) |
| P value | 0.263 | 0.562 | ||
| ≥ 20 | 8 (5.19) | 7 (21.88) | 7.87 (2.24 - 27.57) | 9.5 (1.49 - 60.29) |
| P value | 0.001 | 0.017 | ||
| Occupation | ||||
| Student | 34 (22.08) | 7 (21.87) | -b | -b |
| Farmer or agricultural-related jobs | 4 (2.6) | 2 (6.25) | 2.42 (0.36 - 16.03) | 2.49 (0.138 - 45.05) |
| P value | 0.357 | 0.535 | ||
| Housewife | 102 (66.23) | 5 (15.63) | 0.23 (0.07 - 0.80) | 0.198 (0.045 - 0.86) |
| P value | 0.021 | 0.032 | ||
| Self-employed | 8 (5.19) | 7 (21.88) | 6.24 (2.13 - 18.29) | 6.88 (1.73 - 27.53) |
| P value | 0.001 | 0.006 |
aValues are expressed as No. (%).
bRef, adjusted for marital status.
Final analysis by multiple logistic regression analysis for adjusted ORs and 95% CIs indicated that among various types of SLEs, financial problems had the largest OR (OR = 11.9; 95% CI = 4.00 - 35.85) and significantly increased the odds of suicide 11.9 times more than SA. Other types of SLEs, such as early marriage (OR = 4.97; 95% CI = 1.68 - 14.65), being exposed to the new conditions (OR = 8.79; 95% CI = 1.3 - 59.22), and family conflicts (OR = 2.53; 95% CI = 1.23 - 6.53) increased the odds of suicide after adjusting for marital conflicts, emotional problems, and unemployment of > 6 months (Table 5).
Table 5.Crude and Adjusted ORs and 95% CIs of the Association Between Suicide and Various Types of Stressful Life Events by Multiple Logistic Regression Analysisa
| Variables | Suicide Attempts (N = 154) | Suicides (N = 32) | Crude OR (95% CI) | Adjusted OR (95% CI)b |
|---|---|---|---|---|
| Family conflicts | 4.46 (2.01 - 9.9) | 2.53 (1.23 - 6.53) | ||
| Yes | 38 (24.67) | 19 (59.38) | ||
| No | 116 (75.33) | 13 (40.62) | ||
| P value | 0.001 | 0.041 | ||
| Financial problems | 12.7 (4.92 - 32.71) | 11.9 (4 - 35.85) | ||
| Yes | 10 (6.50) | 15 (46.88) | ||
| No | 144 (93.50) | 17 (53.12) | ||
| P value | 0.001 | 0.0001 | ||
| Expose to new conditions | 5.2 (1 - 27.2) | 8.79 (1.31 - 59.22) | ||
| Yes | 3 (1.95) | 3 (9.37) | ||
| No | 151 (98.05) | 29 (90.63) | ||
| P value | 0.050 | 0.028 | ||
| Early marriagec | 3.04 (1.25 - 7.38) | 4.97 (1.68 - 14.65) | ||
| Yes | 20 (12.98) | 10 (31.25) | ||
| No | 134 (87.01) | 22 (68.75) | ||
| P value | 0.014 | 0.004 |
Abbreviations: CI, confidence interval; OR, odds ratio.
aValues are expressed as No. (%).
bAdjusted for spouse disagreement, emotional problems, and unemployment of > 6 months.
cBefore the age of 18.
5. Discussion
This study aimed at investigating the association between SLEs, and suicide and SA in Malekan County, Iran. After adjusting for the confounders, the findings revealed that SLEs were strongly associated with committing suicide. SLEs were found as one of the main predictors for suicide and SA risk. However, the highest SLEs scores were recorded for subjects who had suicide outcomes.
Only a few studies have been carried out to assess the relationship between SLEs and risks of suicide, and this study is one of them on SLEs and suicide in Iran. Some other relevant studies have been conducted worldwide, including a study in China (18, 19), a population-based study in Denmark (12), and a study in the USA (11). Also, most of the studies in western countries have examined SLEs in SAs (3, 12, 20), whereas the current study explored both suicide and SAs. The same results were found in the present study and Paul and Wang studies in the USA (18, 21), as well as in a meta-analysis study (22). Findings of the European surveys have shown a positive relationship between the history of SLEs and SB (12, 23). Likewise, other studies have pointed out that psychological distress and SLEs were highly associated with SBs among university students (24). However, there are few studies that could not observe any correlation between suicide and stressful events; for instance, Jaiswal et al. (25) in India realized that suicide was associated with help-seeking behavior.
Although suicide rates appear to be lower in most of the Islamic countries (13), not only suicide-related deaths are increasing in Iran but also it has one of the highest rates among Eastern Mediterranean Region and Islamic countries during the recent decade (7, 26). Ten years trend (2006 - 2015) of years of life lost due to suicide in Iran was estimated to be 23.35 per 1000 persons in both sexes (27).
In this study, financial problems had a higher prevalence in the suicide group than those in the SA group. This relationship was also seen for the households’ economic levels. In addition, while individuals with an income of fewer than ten million Rials per month had the highest rate of SAs, but suicide was highly frequent among high-income individuals, which was significant. In this regard, Ahmadi et al. (28) have reported financial problems as one of the major determinants and risk factors for SBs. Besides, other studies have shown a significant and positive relationship between financial problems, unemployment, and income level, and suicide (29, 30).
The present study, as well as other studies (18, 31-34) suggest that marital conflicts and family disputes are the most important risk factors for SAs in Iranian communities; particularly, among couples who suffer from early marriages with the lack of skills for life management and poor levels of education. Some systematic reviews (32, 33) and a case-control study (34) in Iran have revealed that the family and marital conflicts are the most important factors for SA. Forced marriages at a young age often lead to separation from family members, friends, lack of freedom and interaction with peers, and losing educational opportunities, which can result in SAs or SBs.
Other risk factors identified for suicide and SA in this study were being exposed to new conditions, such as new living conditions, migration, being a refugee, and changing in the workplace, or work responsibilities. Park et al. (35) study conducted in six countries, including China, South Korea, Malaysia, Singapore, Thailand, and Taiwan showed that exposure to new conditions in life was associated with SAs and suicide. Studies on the relationship between employment status and suicide have also confirmed our findings (36).
The current study had several limitations. First, we investigated and compared SLEs association between those committed suicide and SA. However, those committed suicide were not accessible and had died. Accordingly, we interviewed their closest family members, such as parents, spouses, siblings, etc. The other limitation arose from the uncommon nature of some of the events in the studied subjects that resulted in high Cls in ORs. Therefore, we assessed SLEs quantitatively with a valid and efficient tool among suicide and SA groups of the participants.
Based on the obtained findings, it seems that SLEs management and interventions made by health systems may be imperative to prevent SBs and suicide. Prevention of early marriages, marital skills training for accommodation, and coping with negative life events and crises seem to be essential to reduce suicide rates and SBs in high-risk groups. Longitudinal and holistic studies are highly recommended for better understanding and assessing SLEs effects and suicide prevention program with case management of people with SBs in the primary health care system.
