Abstract
Background:
Suicide, as a leading cause of death, needs more attention to discover different aspects of its occurrence and to implement proper programs for prevention and control.Objectives:
This study aimed to assess psychological risk factors of suicidal attempts in patients referred to the hospitals.Methods:
In this cross-sectional study, demographic characteristics, environmental stressors and three questionnaires [beck scale of suicide ideation (BSSI), quality of life (SF-12), and symptom checklist 90-R (SCL-90-R)], have been collected in all of the patients who were referred to emergency departments affiliated to Babol University of Medical Sciences, during 6 months.Results:
One hundred and forty one patients had been included. Mean age of the patients was 26.7 ± 11.2 (range 11 - 75) years; 54.6% of the patients were in the age-group of 21 - 40 years; females had more suicide attempts and 58.1% of the patients had low education level. The most common method for suicide was drug ingestion (92.9% of the patients). A significant correlation had been observed between quality of life and suicidal ideation (r = - 0.48; P < 0.0001). Depression and hostility had the highest mean score among SCL-90-R subscales.Conclusions:
More frequent suicides in the second to fourth decades of life, especially in women and the persons who had lower quality of life suggests a need for proper social supports and psychiatric interventions for early detection of suicidal thoughts and necessary treatments for prevention of complete suicide.Keywords
1. Background
Suicide can be defined as a voluntary action to harm or kill oneself and can lead to death [1]. According to the world health organization, while over 800,000 people die due to suicide each year, the annual rate of suicide attempts is much higher. Suicide can be committed at any age. In 2015, suicide was reported as the second leading cause of death among the 15-29-year-olds around the world. Meanwhile, 78% of all suicides occur in low- and middle-income countries. Suicide accounted for 1.4% of all deaths worldwide, making it the 15th leading cause of death in 2012 [2]. In recent years, researchers in Iran and some other countries have evaluated the rate of suicide, suicide attempts, and related risk factors [3-16]. A review study in Iran calculated the weighted mean rate of suicide attempts as 26.5 in 100,000 people. The average rate of death by suicide was 6.7 in 100,000 population [15].
Different biological, psychological, socioeconomic, and cultural factors can affect the incidence of suicide attempts [3, 4, 17]. Ethnic difference is another important factor [6]. In a recent research in South Korea which has been conducted among nearly 5300 adult persons who had suicidal ideation, age was negatively associated with suicide attempts; educational level, daily activity limitation and drinking alcohol were reported as predictors of suicide attempts in under 50 years old group; malignancy and smoking as predictors in over 50 years old group [18]. Turecki reported that parental neglect, childhood physical, sexual or emotional abuse are risk factors for suicide attempts [19]; and Vijayakumar represented that living in rural regions was a risk factor for suicide in developing Asian countries. He showed that this association could be due to economic hardship, lack of social support, isolation and access to lethal means like pesticides, also, he reported that religion - or the absence of religious belief - exerted an influence on the pattern of suicides [20]. A number of psychological disorders, including depression, schizophrenia, alcohol and substance abuse, and personality disorders; and physical conditions, e.g. hemodialysis, chronic obstructive pulmonary disease, malignancies, acquired immune deficiency syndrome (AIDS), quadriplegia, multiple sclerosis (MS), severe burns of the whole body, and congestive heart failure (CHF), can also lead to suicide attempts [21].
Apparently, interventional approaches are required to decrease the significant prevalence of suicide attempts [22, 23]. The development of such approaches would, in turn, depend on the identification of factors leading to suicide [24-26]. Although significant improvements have been made in the knowledge about this important public health problem, some gaps have been remained in knowledge about suicide risk factors; and analysis of epidemiologic surveys and administrative data sets can advance the understanding of its risk factors [27]; therefore, this study was conducted to assess the possible psychological risk factors of suicide. Obviously, the results can be effective in adopting an intervention strategy to improve the current situation.
2. Methods
This observational cross-sectional study was performed in 2016. Considering confidence level of 95%, prevalence of psychological risk factors - according to previous studies- 40% [28] and d = 0.08, sample size was calculated as 144; therefore, all of 141 adult patients who were admitted to emergency departments of all hospitals affiliated to Babol University of Medical Sciences (Babol, Iran) due to suicide attempts in the first half of the year 2015 were enrolled in this study by census. The patients were interviewed when they were conscious enough. Three standard self-report questionnaires, including beck scale for suicidal ideation (BSSI), the quality of life questionnaire-short form (SF-12), and symptoms checklist-90-revised (SCL-90-R), were used for data collection. The participants were also asked about their demographic and educational characteristics and recent environmental stressors such as family disputes, economic failure, and loss of a loved one.
BSSI is a 19-item scale which measures the intensity of a person’s attitudes, behaviors, and suicidal ideation in the past week. It has been used in several studies [29, 30] and the psychometric properties of its Persian version have been approved in the research of Esfahani in which Cronbach’s alpha coefficient of the screening part and the whole scale was reported more than 0.8 [31].
The SF-12 is a short scale for the assessment of quality of life (QOL). It comprises eight subdomains in physical and mental health. The overall QOL of the respondent is determined based on the total scores (ranging between 12 and 48). Score 12 - 24, 25 - 36, and 37 - 48 indicate poor, fair, and good QOL, respectively [32]. The validity and reliability of SF-12 have been evaluated in previous studies. Melville reported that SF-36 provides important quantitative information about the impact of diseases on health related quality of life [33] and Gandek reported that its internal consistency reliability was 0.83 to 0.93 for the eight scales and 0.94 and 0.89, respectively, for the physical and mental component summary measures [34].
The SCL-90-R is a 90-item self-report instrument designed to measure nine psychiatric symptoms including somatization, obsessive-compulsive disorder (OCD), interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Items are scored on a five-point scale (0 = not at all, 1 = a little, 2 = some, 3 = very, and 4 = severe). The validity and reliability of SCl-90-R have been examined in several studies [35, 36]. Ransom reported that the internal consistency coefficients for the 9 subscales were 0.76 - 0.90 [37]. The global severity index (GSI), representing the average severity score of all 90 items, is used to quantify the severity of psychiatric symptoms. Higher GSI values suggest more severe dysfunction, i.e. GSI values < 2 and > 2 indicate mild and severe psychiatric disturbances, respectively [38].
All analyses were performed using SPSS 21 (SPSS Inc., Chicago, IL, USA). Chi-square and Pearson’s correlation coefficient were applied for data analysis. The Kolmogorov-Smirnov test was used to evaluate the normal distribution of quantitative data. Considering that data did not have normal distribution (P value less than 0.05), we used non-parametric statistical tests (spearman’s correlation coefficient) to analyze the correlation between variables. Spearman’s rank correlation coefficient (r) has been reported in related results. Also, we reported median and interquartile range (IQR) besides to mean and standard deviation.
3. Results
A total of 141 patients were included in this study. The mean age of the patients was 26.7 ± 11.2 years (range: 11 - 75 years). Their demographic characteristics are presented in Table 1. As seen, 54.6% of the patients aged 21 - 40 years. Suicide attempts were more prevalent among women (68.8%) and individuals with low levels of education (58.1%).
Demographic Characteristics of the Patients
| Variable | Number (%) |
|---|---|
| Gender | |
| Male | 44 (31.2) |
| Female | 97 (68.8) |
| Age (years) | |
| < 20 | 50 (35.5) |
| 21 - 40 | 77 (54.6) |
| > 40 | 14 (9.9) |
| Place of residence | |
| Urban areas | 97 (68.8) |
| Rural areas | 44 (31.2) |
| Marital Status | |
| Single | 62 (44) |
| Married | 79 (56) |
| Level of educational | |
| Illiterate | 14 (9.9) |
| Below high school diploma | 68 (48.2) |
| High school diploma | 50 (35.5) |
| Academic education | 9 (6.4) |
| Job | |
| Housewife | 45 (31.9) |
| Self-employed | 39 (27.7) |
| Student | 32 (22.7) |
| Unemployed | 25 (17.7) |
Six participants reported opium abuse.
The most common method of suicide was drug ingestion (92.9%).
Of the 63 patients (44.7%) who filled out BSSI, 24 individuals (38.1%) had suicidal ideation; 22 (34.9%) had plans for suicide, and 17 (27%) had a suicide attempt.
The mean total QOL score for the 50 persons (35.5%) who filled out the SF-12 was 32.5 ± 7.1 (range: 18 - 48). The participants’ mean, standard deviation (SD), and range of scores in the eight subdomains of the SF-12 are presented in Table 2. As seen, 12%, 62%, and 26% of the patients had poor, fair, and good QOL, respectively.
The Scores of the Quality of Life Questionnaire Short Form 12 (SF-12) Subdomains
| Measure | Mean ± SD | Median (IQR) | P Value |
|---|---|---|---|
| General perception of health | 2.6 ± 1.2 | 3.0 (2.0 - 3.0) | 0.094 |
| Physical activity | 5.1 ± 1.1 | 6.0 (4.0 - 6.0) | < 0.001 |
| Physical health | 3.5 ± 0.9 | 4.0 (3.0 - 4.0) | < 0.001 |
| Emotional problems | 2.6 ± 0.9 | 2.0 (2.0 - 3.25) | < 0.001 |
| Somatic pain | 4.1 ± 0.9 | 4.0 (3.75 - 5.0) | 0.004 |
| Social functioning | 3.9 ± 1.3 | 4.0 (3.0 - 5.0) | 0.135 |
| Vitality and energy | 3.5 ± 1.3 | 3.0 (2.75 - 5.0) | 0.001 |
| Mental health | 7.0 ± 2.4 | 7.0 (5.0 - 9.0) | 0.453 |
None of the evaluated demographic variables (age, gender, place of residence, marital status, level of education, and occupation) had significant associations with suicidal ideation. However, a significant correlation was observed between QOL and suicidal ideation (r = -0.48; P < 0.0001; Table 3).
Associations of Quality of Life (QOL) and Suicidal Ideation-Based on Beck Scale for Suicidal Ideation (BSSI)
| BSSI | Poor QOL, N (%) | Fair QOL, N (%) | Good QOL, N (%) | P Value |
|---|---|---|---|---|
| Suicidal thoughts | 1 (5.3) | 10 (52.6) | 8 (42.1) | < 0.001 |
| Suicidal plans | 2 (12.5) | 9 (56.3) | 5 (31.3) | |
| Suicidal attempt | 3 (20) | 12 (80) | 0 |
The mean scores of the 35 patients (24.8%) who completed the SCL-90-R and their correlation with suicidal ideation are presented in Table 4. As seen, among the nine subscales of the SCL-90-R, depression and hostility had the highest mean scores.
The Scores of the Subscales of the Symptoms Checklist-90-Revised (SCL-90-R) and their Correlation with Suicidal Ideation
| SCL-90-R Subscales | Mean ± SD | Median (IQR*) | Spearman´s Correlation Coefficient (r) | P Value |
|---|---|---|---|---|
| Somatization | 0.81 ± 0.54 | 0.67 (0.33 - 1.17) | 0.131 | 0.454 |
| Obsessive-compulsive disorder | 1.01 ± 0.57 | 1.10 (0.50 - 1.40) | 0.632 | < 0.001 |
| Interpersonal sensitivity | 0.96 ± 0.80 | 0.73 (0.47 - 1.33) | 0.488 | 0.003 |
| Depression | 1.35 ± 0.91 | 1.15 (0.62 - 2.0) | 0.480 | 0.004 |
| Anxiety | 1.02 ± 0.77 | 0.89 (0.44 - 1.44) | 0.462 | 0.005 |
| Hostility | 1.33 ± 0.96 | 1.0 (0.67 - 2.0) | 0.620 | < 0.001 |
| Phobic anxiety | 0.44 ± 0.44 | 0.13 (0.00 - 0.75) | 0.220 | 0.204 |
| Paranoid ideation | 0.88 ± 0.78 | 0.67 (0.33 - 1.33) | 0.544 | < 0.001 |
| Psychoticism | 0.57 ± 0.65 | 0.40 (0.10 - 0.80) | 0.366 | 0.030 |
| Global severity index (GSI) | 0.96 ± 0.61 | 0.84 (0.51 - 1.42) | 0.520 | < 0.001 |
GSI values < 2 (mild psychiatric disturbance) and > 2 (severe psychiatric disturbance) were seen in 31 (88.6%) and four (11.2%) patients, respectively. Suicidal ideation had significant correlations with OCD, interpersonal sensitivity, depression, anxiety, hostility, paranoid ideation, and psychoticism subdomains of the SCL-90-R.
4. Discussion
This study evaluated patients who were admitted to emergency departments due to suicide attempt. Most patients (nearly 55%) were 21 - 40 years old. Owing to family and work life responsibilities, this period is a critical stage of life for both men and women [39, 40]. Previous studies in Iran reported similar findings [41-43]. According to ministry of health and medical education of Iran, an estimated 13 cases of suicide (with an average age of 29 years) occur in the country every day [41].
In our study, suicide was more prevalent among women. In contrast, another study in Iran reported a higher suicide rate (per 100,000 people) in males [14]. Higher frequency of suicides in women might be attributed to not only hormonal differences and higher prevalence of depressive disorders in women, but also greater psychosocial distresses in female populations of low- and middle-income countries and the adaptation mechanisms utilized by these women [44-46]. In our research, suicide attempts were more common in married individuals, those living in urban areas, and those with lower levels of education. Similarly, in Korea, Song found women, married individuals, and subjects with low education to be at higher risk of suicidal ideation and attempt [3]. Hendin reported that suicides were more frequent in rural areas of several Asian countries including India, Sri Lanka, Japan, Taiwan, and China because of relative deprivation, stigma and/or insufficient knowledge of mental health, social isolation and disconnection, difficulty in accessing medical services, and ready access to lethal means of suicide (e.g., pesticides) [47]. The higher prevalence of suicide among the residents of urban areas in our study can be related to their lifestyle and related distresses such as occupation, household income, family conflicts, traffic, environmental pollution, and related physical and mental disorders [4, 8, 48].
Although the rate of suicide is low in Muslim countries, available evidence suggests an increasing trend in its rate [15]. A previous meta-analysis in Iran reported suicide attempts to be correlated with family conflicts (30%), marital disorders (26%), economic problems (12%), and educational failures (5%). It found family conflicts to be the most common social factor in individuals with suicide attempts [17]. In another study in Iran, single men, married women, medium educational level and age range of 15 - 25 years were presented as the most high-risk groups with suicide attempts who referred to emergency departments [49].
In this study, drug ingestion was the most common method of suicide. This can reflect the accessibility of drugs and impulsive behaviors of the patient. Chen concluded that the availability of different methods had a significant effect on suicide. For instance, in some Asian countries, such as China, India, Sri Lanka, South Korea and Taiwan, where pesticides are highly available, especially in rural areas, pesticide poisoning is the most common method of suicide [48]. Different methods of suicide are used in different regions. For instance, jumping from a height is the most common method of suicide in Hong Kong and Singapore. Hanging is the most common method of suicide in some countries, e.g. Western countries, Japan, Korea, and Taiwan. These different methods can be related to various factors including easy access to particular methods, cultural factors, and imitating others [48]. Family members should have greater supervision on drug programs of patients with mental health problems. Moreover, legal limitations should be applied on the delivery of drugs to individuals who visit drugstores and ask for drugs without a prescription [50].
In this research, 4.3% of the participants reported opium abuse. Yasamy, however, reported 28% of patients with suicide attempts to be substance abusers [51]. The low prevalence of drug abuse in our study can be justified by the fact that opium abuse was assessed through self-report and no panel drug test was administered.
We found suicidal ideation, plans, and attempts in 38%, 34.9%, and 27% of our participants, respectively. This significant percentage of patients who are truly determined to commit suicide highlights the need for immediate admission of these individuals and implementation of relevant psychiatric interventions for the treatment of their underlying disorders and prevention of future suicide attempts.
Among the subscales of the SCL-90-R, our participants had the highest mean scores in depression and hostility. Menon suggested hostility scores as a predictor for suicide intention [52]. Werth found associations between clinical depression and suicidal ideation, attempts, and deaths [53]. These associations should be considered in the surveillance of patients with depressed mood or hostility trait.
We detected a significant association between QOL and suicidal ideation. Similar findings were reported by Cotrena [54] and Xiang [55]. OCD, interpersonal sensitivity, depression, anxiety, hostility, paranoid ideation, and psychoticism were identified as factors which could affect suicidal ideation and attempts. On the other hand, persons who have suicidal thoughts and plans have lower levels of perception about their physical and mental health. This can, in turn, decrease their QOL.
This research shows that clinicians should screen for the presence of the common risk factors, which are known to be associated with increased risk of suicide, included mental disorders, a previous suicide attempt, impulsivity, precipitating factors such as the break-up of a romantic relationship, conflict with family or peers, academic disappointment, legal involvements, history of physical or sexual abuse and lack of connection to psychosocial support.
4.1. Conclusion
More frequent suicides during the second to fourth decades of life, especially among women and individuals with lower QOL, underscores the need for proper social support, psychiatric interventions for early detection of suicidal thoughts, and treatments for the prevention of suicide.
Acknowledgements
References
-
1.
Klonsky ED, May AM, Saffer BY. Suicide, Suicide Attempts, and Suicidal Ideation. Annu Rev Clin Psychol. 2016;12:307-30. [PubMed ID: 26772209]. https://doi.org/10.1146/annurev-clinpsy-021815-093204.
-
2.
World Health Organization. Mental health. Suicide data, World health organization. Geneva: World Health Organization; 2017. Available from: http://www.who.int/mediacentre/factsheets/fs398/en.
-
3.
Song HB, Lee SA. Socioeconomic and lifestyle factors as risks for suicidal behavior among Korean adults. J Affect Disord. 2016;197:21-8. [PubMed ID: 26967916]. https://doi.org/10.1016/j.jad.2016.02.035.
-
4.
Racine M, Sanchez Rodriguez E, Galan S, Tome Pires C, Sole E, Jensen MP, et al. Factors associated with suicidal ideation in patients with chronic non cancer pain. Pain Med. 2017;18(2):283-93. [PubMed ID: 28204732]. https://doi.org/10.1093/pm/pnw115.
-
5.
Seo HJ, Wang HR, Jun TY, Woo YS, Bahk WM. Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality. Gen Hosp Psychiatry. 2016;39:91-6. [PubMed ID: 26804773]. https://doi.org/10.1016/j.genhosppsych.2015.12.005.
-
6.
Mak KK, Ho CS, Chua V, Ho RC. Ethnic differences in suicide behavior in Singapore. Transcult Psychiatry. 2015;52(1):3-17. [PubMed ID: 25062745]. https://doi.org/10.1177/1363461514543545.
-
7.
Horwitz AG, Czyz EK, King CA. Predicting Future Suicide Attempts Among Adolescent and Emerging Adult Psychiatric Emergency Patients. J Clin Child Adolesc Psychol. 2015;44(5):751-61. [PubMed ID: 24871489]. https://doi.org/10.1080/15374416.2014.910789.
-
8.
Pompili M, Forte A, Lester D, Erbuto D, Rovedi F, Innamorati M, et al. Suicide risk in type 1 diabetes mellitus: A systematic review. J Psychosom Res. 2014;76(5):352-60. [PubMed ID: 24745775]. https://doi.org/10.1016/j.jpsychores.2014.02.009.
-
9.
Victor SE, Klonsky ED. Correlates of suicide attempts among self-injurers: a meta-analysis. Clin Psychol Rev. 2014;34(4):282-97. [PubMed ID: 24742496]. https://doi.org/10.1016/j.cpr.2014.03.005.
-
10.
Liu RT, Miller I. Life events and suicidal ideation and behavior: a systematic review. Clin Psychol Rev. 2014;34(3):181-92. [PubMed ID: 24534642]. https://doi.org/10.1016/j.cpr.2014.01.006.
-
11.
Ballard ED, Tingey L, Lee A, Suttle R, Barlow A, Cwik M. Emergency department utilization among American Indian adolescents who made a suicide attempt: a screening opportunity. J Adolesc Health. 2014;54(3):357-9. [PubMed ID: 24560037]. https://doi.org/10.1016/j.jadohealth.2013.11.015.
-
12.
Carra G, Bartoli F, Crocamo C, Brady KT, Clerici M. Attempted suicide in people with co-occurring bipolar and substance use disorders: systematic review and meta-analysis. J Affect Disord. 2014;167:125-35. [PubMed ID: 24955564]. https://doi.org/10.1016/j.jad.2014.05.066.
-
13.
Mars B, Burrows S, Hjelmeland H, Gunnell D. Suicidal behaviour across the African continent: a review of the literature. BMC Public Health. 2014;14:606. [PubMed ID: 24927746]. https://doi.org/10.1186/1471-2458-14-606.
-
14.
Mirhashemi S, Motamedi MHK, Mirhashemi AH, Taghipour H, Danial Z. Suicide in Iran. Lancet. 2016;387(10013):29. https://doi.org/10.1016/s0140-6736(15)01296-9.
-
15.
Shirazi HR, Hosseini M, Zoladl M, Malekzadeh M, Momeninejad M, Noorian K, et al. Suicide in the Islamic Republic of Iran: an integrated analysis from 1981 to 2007. East Mediterr Health J. 2012;18(6):607-13. [PubMed ID: 22888617].
-
16.
Moqaddasi Amiri M, Ahmadi Livani A, Moosazadeh M, Mirzajani M, Dehghan A. Seasonal Pattern in Suicide in Iran. Iran J Psychiatry Behav Sci. 2015;9(3):842. [PubMed ID: 26576177]. https://doi.org/10.17795/ijpbs-842.
-
17.
Nazarzadeh M, Bidel Z, Ayubi E, Soori H, Sayehmiri K. Factors related to suicide attempt in Iran, A systematic review and meta analysis. Hakim Res J. 2013;15(4):352-63.
-
18.
Choi SB, Lee W, Yoon JH, Won JU, Kim DW. Risk factors of suicide attempt among people with suicidal ideation in South Korea: a cross-sectional study. BMC Public Health. 2017;17(1):579. [PubMed ID: 28619107]. https://doi.org/10.1186/s12889-017-4491-5.
-
19.
Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet. 2016;387(10024):1227-39. [PubMed ID: 26385066]. https://doi.org/10.1016/S0140-6736(15)00234-2.
-
20.
Vijayakumar L, Pirkis J, Huong TT, Yip P, Seneviratne RA, Hendin H. Socio economic, cultural and religious factors affecting suicide prevention in Asia. Suicide and suicide prevention in Asia. Geneva, Switzerland: World Health Organization; 2008. p. 19-29.
-
21.
Kaplan H, Sadocks B. Comprehensive textbook of psychiatry. 8 ed. United States: Lippincott Williams and Wilkins; 2015.
-
22.
Bridge JA, Horowitz LM, Fontanella CA, Grupp-Phelan J, Campo JV. Prioritizing research to reduce youth suicide and suicidal behavior. Am J Prev Med. 2014;47(3 Suppl 2):229-34. [PubMed ID: 25145744]. https://doi.org/10.1016/j.amepre.2014.06.001.
-
23.
Daniel SS, Goldston DB. Interventions for suicidal youth: a review of the literature and developmental considerations. Suicide Life Threat Behav. 2009;39(3):252-68. [PubMed ID: 19606918]. https://doi.org/10.1521/suli.2009.39.3.252.
-
24.
Schwartz-Lifshitz M, Zalsman G, Giner L, Oquendo MA. Can we really prevent suicide? Curr Psychiatry Rep. 2012;14(6):624-33. [PubMed ID: 22996297]. https://doi.org/10.1007/s11920-012-0318-3.
-
25.
Ganz D, Braquehais MD, Sher L. Secondary prevention of suicide. PLoS Med. 2010;7(6):1000271. [PubMed ID: 20532240]. https://doi.org/10.1371/journal.pmed.1000271.
-
26.
Welton RS. The management of suicidality: assessment and intervention. Psychiatry (Edgmont). 2007;4(5):24-34. [PubMed ID: 20806027].
-
27.
Sareen J, Isaak C, Katz LY, Bolton J, Enns MW, Stein MB. Promising strategies for advancement in knowledge of suicide risk factors and prevention. Am J Prev Med. 2014;47(3 Suppl 2):257-63. [PubMed ID: 25145748]. https://doi.org/10.1016/j.amepre.2014.05.041.
-
28.
Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192(2):98-105. [PubMed ID: 18245022]. https://doi.org/10.1192/bjp.bp.107.040113.
-
29.
Chioqueta AP, Stiles TC. Psychometric properties of the Beck Scale for Suicide Ideation: a Norwegian study with university students. Nord J Psychiatry. 2006;60(5):400-4. [PubMed ID: 17050298]. https://doi.org/10.1080/08039480600937645.
-
30.
Healy DJ, Barry K, Blow F, Welsh D, Milner KK. Routine use of the Beck Scale for Suicide Ideation in a psychiatric emergency department. Gen Hosp Psychiatry. 2006;28(4):323-9. [PubMed ID: 16814632]. https://doi.org/10.1016/j.genhosppsych.2006.04.003.
-
31.
Esfahani M, Hashemi Y, Alavi K. Psychometric assessment of beck scale for suicidal ideation (BSSI) in general population in Tehran. Med J Islam Repub Iran. 2015;29:268. [PubMed ID: 26793659].
-
32.
Utah Department of Health. Interpreting the SF 12, Utah department of health. Utah: Utah Department of Health; 2001. Available from: http://health.utah.gov/opha/publications/2001hss/sf12/SF12_Interpreting.pdf.
-
33.
Melville MR, Lari MA, Brown N, Young T, Gray D. Quality of life assessment using the short form 12 questionnaire is as reliable and sensitive as the short form 36 in distinguishing symptom severity in myocardial infarction survivors. Heart. 2003;89(12):1445-6. [PubMed ID: 14617561].
-
34.
Gandek B, Sinclair SJ, Kosinski M, Ware JJ. Psychometric evaluation of the SF-36 health survey in Medicare managed care. Health Care Financ Rev. 2004;25(4):5-25. [PubMed ID: 15493441].
-
35.
Ardakani A, Seghatoleslam T, Habil H, Jameei F, Rashid R, Zahirodin A, et al. Construct Validity of Symptom Checklist-90-Revised (SCL-90-R) and General Health Questionnaire-28 (GHQ-28) in Patients with Drug Addiction and Diabetes, and Normal Population. Iran J Public Health. 2016;45(4):451-9. [PubMed ID: 27252914].
-
36.
Wongpakaran T, Wongpakaran N, Boripuntakul T. Symptom checklist-90 (SCL-90) in a Thai sample. J Med Assoc Thai. 2011;94(9):1141-9. [PubMed ID: 21970206].
-
37.
Ransom D, Ashton K, Windover A, Heinberg L. Internal consistency and validity assessment of SCL-90-R for bariatric surgery candidates. Surg Obes Relat Dis. 2010;6(6):622-7. [PubMed ID: 20627709]. https://doi.org/10.1016/j.soard.2010.02.039.
-
38.
Michal M, Adler J, Wiltink J, Reiner I, Tschan R, Wolfling K, et al. A case series of 223 patients with depersonalization-derealization syndrome. BMC Psychiatry. 2016;16:203. [PubMed ID: 27349226]. https://doi.org/10.1186/s12888-016-0908-4.
-
39.
Chakravarthy B, Frumin E, Lotfipour S. Increasing suicide rates among middle-age persons and interventions to manage patients with psychiatric complaints. West J Emerg Med. 2014;15(1):11-3. [PubMed ID: 24578763]. https://doi.org/10.5811/westjem.2013.12.19513.
-
40.
Phillips JA, Robin AV, Nugent CN, Idler EL. Understanding recent changes in suicide rates among the middle-aged: period or cohort effects? Public Health Rep. 2010;125(5):680-8. [PubMed ID: 20873284]. https://doi.org/10.1177/003335491012500510.
-
41.
Rezaeian M. Suicide among young Middle Eastern Muslim females. Crisis. 2010;31(1):36-42. [PubMed ID: 20197256]. https://doi.org/10.1027/0227-5910/a000005.
-
42.
Janghorbani M, Sharifirad G. Completed and attempted suicide in Ilam, Iran, (1995-2002), incidence and associated factors. Arch Iran Med. 2005;8(2):119-26.
-
43.
Rajaie A, Yasami M, Layeghi H, Bager Yazdi S. The integration primary prevention program of suicide within primary health care system. Tehran: Psychiatric Institution Publication; 2005.
-
44.
Tsirigotis K, Gruszczynski W, Tsirigotis M. Gender differentiation in methods of suicide attempts. Med Sci Monit. 2011;17(8):65-70. [PubMed ID: 21804473].
-
45.
Vijayakumar L. Suicide in women. Indian J Psychiatry. 2015;57(Suppl 2):233-8. [PubMed ID: 26330640]. https://doi.org/10.4103/0019-5545.161484.
-
46.
Sein Anand J, Chodorowski Z, Ciechanowicz R, Wisniewski M, Pankiewicz P. The relationship between suicidal attempts and menstrual cycle in women. Przegl Lek. 2005;62(6):431-3. [PubMed ID: 16225087].
-
47.
Hendin H, Phillips MR, Vijayakumar L, Pirkis J, Wang H, Yip P, et al. Suicide and suicide prevention in Asia. Geneva, Switzerland: World Health Organization; 2008.
-
48.
Chen YY, Wu KC, Yousuf S, Yip PS. Suicide in Asia: opportunities and challenges. Epidemiol Rev. 2012;34:129-44. [PubMed ID: 22158651]. https://doi.org/10.1093/epirev/mxr025.
-
49.
Bolhari J, Malakouti SK, Hakim Shooshtari M, Nojomi M, Poshtmashadi M, Asgharzadeh Amin S, et al. The prevalence of suicide attempt in proportion of referrals to emergency departments in Karaj. Hakim Res J. 2007;10(1):50-5.
-
50.
Dragisic T, Dickov A, Dickov V, Mijatovic V. Drug Addiction as Risk for Suicide Attempts. Mater Sociomed. 2015;27(3):188-91. [PubMed ID: 26236166]. https://doi.org/10.5455/msm.2015.27.188-191.
-
51.
Yasamy MT, Sabahi A, Mirhashemi M, Seifi S, Azar Keyvan P, Taheri MH. Epidemiological survey of suicide through the forensic medical center in the province of Kerman. Iran J Psychiatry Clin Psychol. 2002;7(4):4-12.
-
52.
Menon V, Sarkar S, Kattimani S, Mathan K. Do Personality Traits Such as Impulsivity and Hostility-Aggressiveness Predict Severity of Intent in Attempted Suicide? Findings From a Record Based Study in South India. Indian J Psychol Med. 2015;37(4):393-8. [PubMed ID: 26702169]. https://doi.org/10.4103/0253-7176.168563.
-
53.
Werth JJ. The relationships among clinical depression, suicide, and other actions that may hasten death. Behav Sci Law. 2004;22(5):627-49. [PubMed ID: 15378592]. https://doi.org/10.1002/bsl.616.
-
54.
Cotrena C, Branco LD, Kochhann R, Shansis FM, Fonseca RP. Quality of life, functioning and cognition in bipolar disorder and major depression: A latent profile analysis. Psychiatry Res. 2016;241:289-96. [PubMed ID: 27209359]. https://doi.org/10.1016/j.psychres.2016.04.102.
-
55.
Xiang YT, Weng YZ, Leung CM, Tang WK, Ungvari GS. Socio-demographic and clinical correlates of lifetime suicide attempts and their impact on quality of life in Chinese schizophrenia patients. J Psychiatr Res. 2008;42(6):495-502. [PubMed ID: 17663994]. https://doi.org/10.1016/j.jpsychires.2007.06.001.