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Adolescent Psychiatry, 2013, 3, 102-113
Risk Factors for Suicidal Ideation Among High School Students in Istanbul Alican Dalkilic1, Hatice Burakgazi Yilmaz2*, Ali Unlu3, Ugur Evcin3, Parna Prajapati4 and Andres J. Pumariega4 1
Temple University School of Medicine, Philadelphia, PA and St. Elizabeth's Hospital, Washington, D.C.; Cooper University Hospital and Cooper Medical School of Rowan University, Camden, N.J.; 3 Narcotics Division, Governance of Istanbul, Istanbul, Turkey; 4Department of Psychiatry, Cooper School of Medicine at Rowan University, Camden, N.J. 2
Abstract: Objectives: Youth suicide is a major social and health problem world-wide. Over the last decade Turkey has become a regional power with growing regional aspirations with a young population and rapidly growing economy. The limited literature on Turkish youth suggests that suicidality is a growing challenge for Turkish youth. This study aims to examine the prevalence and risk factors of suicidal ideation amongst Turkish youth in Istanbul, its main metropolitan center. Methods: This study analyzed responses from 31,272 students, consisting of 20 percent of the total high school (HS) student population of Istanbul. The main survey instrument was a combination of the ESPAD 2007 survey and the Youth in Europe 2012 survey, examining risk factors commonly reported in the literature. Results: Our findings indicate a prevalence of one week suicidal ideation of 25.77 %, with depression, anxiety, selfesteem, anomie, irritability, "antisocial" behavior, peer influence, and illicit substances identified as associate risk factors. Other contextual factors were significant in different student sub-groups. Conclusions: To our knowledge this is the first study with results generalizable to all HS students of Istanbul and confirms findings of similar studies with other populations of Turkish youth as well as other nations.
Keywords: Youth suicide, Turkey, risk factors, epidemiology. INTRODUCTION Youth suicide is a major social and health problem worldwide. According to the World Health Organization, in 2004 the global mean rates of suicide in youth ages 15 to 19 years were estimated to be 7.4 per 100,000, with rates being higher for males (10.5) than females (4.1). The rates varied widely, from 46.5 per 100,000 in Sri Lanka to a reported 0.02 per 100,000 in Egypt, with 13 countries (including Russia, New Zealand, the Baltic States, Kazakhstan, Norway, and Canada and Slovenia) reporting suicide rates of 1.5 times the mean or more (Wasserman, Cheng, & Jiang, 2005). Suicide rates have significantly increased in many nations since the late 1960's. A rising trend of suicide rates in the 15-19 age group has been observed in males from both non-European and European countries, while the trend was fairly stable or declined slightly in females. Suicide rates among both young males and females were higher in non-European than in European countries during the 1965-1999 period (Wasserman, Cheng, & Jiang, 2005). *Address correspondence to this author at the Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ,; Tel: 301-442-8794; Fax: 888-878-1490; E-mail:
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In the United States (U.S.), suicide was the third leading cause of death for young people ages 10 to 24 in 2007, and suicide rates for youth ages 15 to 19 were 6.9 per 100,000 (Centers for Disease Control and Prevention, 2012; National Institute of Mental Health, 2012). A nation-wide survey of youth in grades 9–12 in public and private schools in the U.S. found that 16% of students reported seriously considering suicide, 13% reported creating a plan, and 8% reporting trying to take their own life in the 12 months preceding the survey. Each year, approximately 157,000 youth between the ages of 10 and 24 receive medical care for self-inflicted injuries at Emergency Departments across the U.S (Centers for Disease Control and Prevention, CDC, 2012). The latest (2011) CDC’s Youth Risk Behavior Survey (YRBS; Eaton et al., 2012), an annual survey of a representative sample of high school students in the U.S., indicated that 15.8 percent of youth seriously considered attempting suicide over the prior 12 months, 7.8 percent made a suicide attempt, and 2.4 percent survived a serious suicide attempt necessitating medical intervention. Risk factors that have been associated with suicide in the U.S. are depression and other mental disorders and substance-abuse disorders, with more than 90 percent of people dying by suicide having these risk factors. Other risk factors include prior suicide attempt, family history of mental disorder or substance abuse, family history of
© 2013 Bentham Science Publishers
Risk Factors for SI among Turkish Youth
suicide, family violence, including physical or sexual abuse, and firearms in the home, the method used in more than half of suicides (National Institute of Mental Health, 2012). Turkey has not been immune from this worldwide trend. In the WHO/EURO Multicenter study of suicidal behavior, the rates of completed suicides in people over 15 years old were reported for the Ankara/Istanbul catchment area, and the rates of completed suicides were reported to be 9.9 for males and 5.6 for females (Sayil, Demirci-Ozguven 2001). In Turkey, completed suicides were more common among teenagers and young adults (15-24 age group), while in European countries completed suicides were more common among 40 year olds and older. The most frequent reported method for attempted suicide in Turkey was overdose, and for completed suicide was hanging. Uzun and colleagues (2009) investigated general characteristics of suicide among children and adolescents in the province of Istanbul. During the years 2001 to 2005, they identified 176 suicides in youth aged 9–19 years. The overwhelming majority of the suicides (92%) were aged 15–19 years. More than half of the suicides (60%) were male. The most frequent means of suicide was hanging (55%) followed by firearms (20%) and jump or descent from height (15%). Turhan and colleagues (2011) examined the epidemiology of attempted suicides among 1,613 individual suicide attempters brought to emergency rooms in 8 state hospitals in Hatay, Turkey between January 2007 and December 2009. The mean annual rate of attempted suicides per 100,000 was 38.14 (16.11 in males, 60.42 in females). The rate of suicide decreased as age increased, with the highest rates being found in the 15-24 age group, in women, single individuals, and those with a high school education. The risk factors associated with repeated suicide attempts included psychiatric disease history in the family or the individual and suicide attempt history in the family. The most common precipitants reported were domestic conflicts, and the most common methods of suicide attempt were overdose and self-poisoning (Turhan, et al., 2011). Coskun, Zoroglu, and Ghaziuddin (2012) compared the suicide rates between Turkish and American youth and found that Turkish youth had a lower suicide rate than U.S. youth. In Turkey, suicide rates below age 15 years (per 100,000) were 0.28 for and 0.39 for females (in the U.S. 1.09 for males and 0.38 for females = 0.38); while for aged 15-24 years the rates in Turkey were 4.58 for males and 5.22 for females (in the U.S., 18.84 for males and 3.36 for females). However, there has been an increase in Turkey, while the rate in the US remained the same (Coskun, Zoroglu, and Ghaziuddin, 2012). When making these comparisons, we need to keep in mind that suicides might be under-reported amongst Turkish youth because of greater social and religious stigma compared to the U.S. Few studies on suicide amongst Turkish youth have examined risk factors for suicidal ideation, and particularly the relationship correlation between suicide and substance use. Toros, et al. (2005), investigated suicide attempts and risk factors among 4,143 Turkish youth ages 10 to 20 years. They concluded that having problems with parents, using illicit drugs, and presence of psychiatric problems in relatives are the best-predictors of suicide attempts in Turkish youth and
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children. However, the international literature suggests that suicidal ideation and attempts are significantly correlated with depression, substance abuse, and antisocial behaviors. For example, among Hispanic adolescents along the U.S.Mexican border, Pumariega et al. (2010) reported that, besides depression, factors such as substance use, generational status in the U.S., time spent with family, time spent in religious activities, and unsupervised time with peers were significantly correlated with rates of suicidal ideation and suicidal attempts. Hills, et al. (2005) investigated the relationship between lifetime suicide attempts and lifetime externalizing psychopathology (antisocial personality disorder, drug dependence, and alcohol dependence) in the U.S. National Comorbidity Survey data, and found a significant association between suicide attempts and externalizing disorder even in the absence of internalizing disorder (depression). Arria and colleagues studied suicidal ideation among 1,249 first year college students at the University of Maryland, College Park, and found that 6% of first year students had current suicidal ideations, with 40% of them having depression according to standard criteria. In the group with low levels of depressive symptoms, low social support and affective dysregulation were important predictors of suicide ideation, and alcohol abuse was independently associated with increased suicide ideation (Arria, et al., 2009). Pedersen (2009) investigated the relationship between cannabis use, depression, suicidal ideation and suicide attempt in a cohort study of 2,033 young Norwegians, and the participants were followed up over a 13-year period, from their early teens to late twenties. No correlation of suicidal behavior or depression with cannabis was observed in early adolescents, but there was a significant association with suicidal ideations and suicide attempts for those who had used cannabis 11+ times during the past 12 months. Over the last decade Turkey has become a regional power with growing regional aspirations with a young population, rapidly growing economy, and historical soft power reaching the Middle East, the Balkans, North Africa, the Caucuses, and many Muslims worldwide. Istanbul, with its 12 million residents, is the largest city in Turkey and also the major economic, cultural, and tourism center at the meeting point of Asia and Europe. At the same time, Turkey is dealing with many of the pressures of industrialization and globalization, with their resultant social, health, and mental health consequences. During the last two decades there has been a significant urbanization and Westernization of Turkish youth which might be factors contributing to increasing mental health risks. The study of significant youth morbidities such as suicidality and substance abuse and the development of risk factor models in Turkish youth based on available data are very important to address the future mental health needs of youth in Turkey, and possibly of Muslim youth globally. The results of the survey which we report on in this paper constitute an initial effort towards these goals. METHODS Participants The Istanbul Department of Education and Istanbul Police Department conducted a survey of Turkish high school
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students in the Istanbul region with the aim of developing models to understand risk factors for suicidal ideation and substance abuse. This has yielded a dataset of entries from 31,272 students, representing the total high school (HS) student population of Istanbul. The survey was conducted according to the procedures of Nuremberg Code and Declaration of Helsinki with permission from the Governance of Istanbul during the period of May to June 2010. The Institutional Review Board (IRB) of Cooper University Medical Center and the Ethics Committee of the Security Sciences Institute of the Turkish Police Academy both approved the use of the dataset for this study. Out of 39 provinces of Istanbul, 28 (inner cities) were selected for sampling. The schools were divided into three categories in each province as regular, occupational, and Anatolian high schools (HS) based on the regulations of the Ministry of Education and each school type has a special structure, focus, and curriculum. Data Sampling and Distribution In 2010 there were 232 regular, 242 occupational, and 88 Anatolian high schools (HS's) with a total of 562 schools in Istanbul. In each category the schools were listed alphabetically and every third school was selected from the list starting from A. The sampling design included 65 Regular, 62 Occupational and 27 Anatolian HS's into the study with the total of 154 HS's. The sample represents approximately 20% of the total school population. In general students in three types of HS represent a continuum of socioeconomic status (SES) backgrounds, as the Anatolian HS's are more college preparatory and accessed by higher SES populations via entrance examination, the Regular HS have more students from the middle class, and the occupational HS's are preferred more by students from lower SES, as their curriculum includes vocational skill training, as well. Since the unit of analysis of the study was individual adolescents, the majority of the population consisted of youth between the ages of 14 and 19 in Istanbul. Systematic sampling was used to select the allocated sample of classrooms. Every third classroom from each grade was included in the sampling. As the schools and classes were selected by stratified sampling method, the sample is representative of schools in their districts and the city of Istanbul. Ninth graders represent the largest student group, and student numbers decrease towards the higher grades among total number of students and in our sample. Survey Instrument The survey instrument used in the study was a combination of the European School Survey Project on Alcohol and Other Drugs (European School Survey Project, ESPAD, 2007) and Youth in Europe Survey (YIE, 2012). Both of these surveys were translated into Turkish and used in research previously (Ögel, et al., 2000; Ögel, et al., 2004; Altuner, et al., 2009). A total of 27 items were used from these surveys. A "trick" substance named “relevin” (used in the ESPAD survey; ESPAD, 2007) was included in the questionnaire, and the responses from students who endorsed its use were removed from analysis, as their responses were deemed not credible. They consisted 1.2%
Dalkilic et al.
(332) of the sample, pointing to an acceptable face validity ratio. Under “Recoding variables for analysis” below, we list the items and measures from the survey included in this study. Method of Collection Trained counselors and teachers who were assigned as pollsters distributed the survey, and its completion was anonymous and based on self-report, with full right of refusal. To improve validity, classroom teachers were not allowed to be present during the survey period. To maximize confidentiality, students were provided anonymous optical forms, and the booklets were collected in closed unmarked envelopes, with computers compiling responses. Data was entered into electronic spreadsheets and analyzed using SPSS software (version 18). Missing values ranged from 017% for independent variables and 9.5% for the dependent variable. Participants who answered at least one question were included in the data analysis. Recoding Variables for Analysis Variables were re-coded for analysis from the survey questionnaire as follows: (a) Dependent variable: Suicidal ideation in the past week was the main dependent variable. The item on suicide under the CES-D (Item: How often did you feel any of the following mental or physical discomforts in the past week, sub-item: I thought of committing suicide; Radloff & Lenore, 1977) was used. Any positive responses provided to that item by the responding students were coded as “yes”. (b) Independent variables: ‐ Age – This variable was re-coded from year of birth to give the actual age of the participant. It was re-categorized into young (13-17 years) and old (18-21 years) for Chi-square analysis. ‐ Parental education – The item values for mother’s education and father’s education were added to compute this variable. A higher total value reflects a higher combined parents education level combined. This value was recategorized into low, mid, and high education for Chi-square analysis. ‐ Immigration status – The values for internal immigration status of the participant and his/ her parents were added to compute this variable, accounting for any member of the immediate family (mother, father, or participant) being from Istanbul or from outside Istanbul. ‐ Perceived family affluence – Perception of family affluence, rated by the student as better than, similar to, or worse than others. ‐ Self-esteem scale (Rosenberg Self-esteem scale; Rosenberg, 1965) – All the answers to the subquestions were added to give a self-esteem scale ranging from 1-40; a higher value reflects lower self-esteem. ‐ Depression scale (short form of the Centers for Epidemiological Studies-Depression Scale- CES-
Risk Factors for SI among Turkish Youth
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D; Radloff & Lenore, 1977) – All responses to questions were added to give a total score ranging from 1-48; a higher value reflects worse depressive symptoms. Anxiety scale – All responses to sub-questions were added to give a score ranging from 1-12, a higher the value reflects worse anxiety. Anomie scale (Anomie Scale of Exteriority and Constraint; Bjarnason 1998) – All responses to the sub-questions were added to give an anomie score ranging from 1-37; a higher score reflects lower anomie. Antisocial behavior scale (Antisocial behavior scale; Bachman et al. 1997) – All responses to the sub-questions were added to give an antisocial personality score ranging from 1-42; a higher value reflects more antisocial behavior. Irritability or Anger scale – All responses to the sub-questions were added to give a score ranging from 1-20; a higher value reflects more irritability or anger. Time with peers – All the answers to the subquestions were added to give a score ranging from 1-28; a higher score reflects more time spent with peers. Parental involvement – All responses to the subquestions were added to give a score ranging from 1-60; a higher score reflects lower parental involvement. Family substance use – All responses to the subquestions for parents and siblings were added to give a score ranging from 0-18; a higher score reflects more substance use in the family. Peer influence – All responses to the subquestions were added to give a score ranging from 1-62; a higher score reflects less peer influence. Drug abuse was calculated by adding all responses to the sub-questions for the specific substances (over the counter sleeping pills, cannabis, amphetamines, LSD, ecstasy, cocaine, mushrooms, inhalants, anabolic steroids, and homemade brews). Drug abuse including alcohol variable was calculated after adding alcohol to the drug abuse score.
STATISTICAL ANALYSIS The data are tabulated as number (percent) for the dependent (suicidal ideation) and independent variables (age, gender, school type, family immigration, perceived family affluence, parental education, school grades, self esteem scale, faith scale, anomie scale, anxiety scale, depression scale, irritability/anger scale, antisocial personality, time with peers, time with family, parental involvement, family substance use, peer influence) and substance use independent variables (any drug abuse, and any drug abuse plus alcohol). Chi-square test statistic was used to analyze the difference between the groups. Binary logistic regression was used to analyze the regression models between dependent variable and independent variables (predictors). Level of significance was kept at
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