Isr J Psychiatry Relat Sci Vol 46 No. 3 (2009) 189–194
Specific Characteristics of Suicide Attempts in Patients with Schizophrenia in Turkey Özcan Uzun, MD,1 Lut Tamam, MD,2 Tuncay Özcüler, MD,2 Ali Doruk, MD,1 and Mehmet Ünal, MD,2 1 Department of Psychiatry, Gulhane School of Medicine, Ankara, Turkey 2 Department of Psychiatry, Cukurova University Faculty of Medicine, Adana, Turkey Abstract: Background: Suicide attempt is a universally observed human behavior related to bio-psychological, social and cultural factors. While some studies have suggested that specific demographic/cultural and clinical variables are associated with suicide attempts in schizophrenia, these associations are often inconsistent. Objectives: The aim of this study was to investigate the possible association between socio-demographic and clinical variables and suicidal behavior in a sample of patients diagnosed as having schizophrenia in Turkey. Methods: Three hundred patients with a SCID-I diagnosis of schizophrenia were studied. The sample was subdivided into two groups based on the presence or absence of lifetime suicide attempts. The main demographic and clinical variables retrospectively collected were analyzed and compared between the two groups. Results: The results of present study revealed that the subjects who had and had not attempted suicide did not differ with respect to demographic variables. The suicide attempters tend to have younger age at onset of disorder, longer duration of psychosis, more hospitalizations, are more likely to have lifetime major depressive episodes, and a significantly higher rate of alcohol abuse or dependence than patients without a lifetime history of suicide attempts. Conclusions: Consistent with the results of previous studies, it has been found that demographic variables may be less valuable predictors of suicidal behavior than clinical variables. These results lead to the idea that socio-cultural variations may not be a critical determinant for suicide attempt among patients with schizophrenia.
Introduction Individuals with a diagnosis of schizophrenia have a shortened life expectancy (1). Compared with both the general population and persons with other mental disorders, these patients have increased mortality risk due to physical illness, accidents and other causes of violent death, especially suicide (1, 2). Researchers have found that suicidal behavior is more prevalent among people with schizophrenia compared to the general population (3, 4). A significant proportion of patients with schizophrenia also attempt suicide, with estimates of lifetime occurrence ranging from 18% to 55%. A high rate of suicide attempts (50–80%) does not result in death, but a history of suicide attempts is common in patients with schizophrenia who die by suicide (5). Compared with suicide attempts among persons without schizophrenia, attempts among those
with schizophrenia are more serious and typically require medical attention. The intent is generally strong, and the majority of those who attempt suicide have made multiple attempts. In addition, the methods used to attempt suicide are considered more lethal than those used by suicidal persons in the general population (6). Therefore, it is very important to examine the risk factors for suicidal behavior in patients with schizophrenia. Specific demographic and clinical variables have been suggested to be associated with suicide attempt in schizophrenia (7). More specifically, young age, male gender, high level of education, being unmarried and unemployed have been identified as demographic risk factors for suicide attempt in schizophrenia (4, 7). Researchers suggested that patients with schizophrenia who attempted suicide tend to have a relatively more chronic course of illness, with acute exacerbations
Address for Correspondence: Özcan Uzun, Department of Psychiatry, Gulhane School of Medicine, 06018 Etlik, Ankara, Turkey. E-mail:
[email protected],
[email protected]
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(8). Increased risk of suicide attempts is also associ- Assessments ated with having a history of depressive episodes A questionnaire form, prepared by authors, was and substance abuse (9). While some studies have used for the assessment of subjects’ basic sociodesuggested that specific demographic and clinical mographic variables (age, gender, marital status, variables are associated with suicide attempts in place of residence, educational level, and professchizophrenia, the associations are often inconsis- sional status). An additional questionnaire was tent (10). used for the assessment of subjects’ detailed hisOn the other hand, suicide attempt is a uni- tory of suicide attempt. Because data collection was versally observed human behavior related to bio- largely dependent on patient recall of historical inpsychological, social and cultural factors (11). For formation, all of the information was confirmed by example, Vijayakumar reported that demographic family members or significant others. If questions and socio-cultural risk factors for suicide in Asia arose, patients were recontacted for further clariare different from Western countries, but clini- fication. In almost all cases, suicide attempts were cal factors appear to be more similar than differ- also confirmed by review of medical records. The ent (12). Therefore, it may not be appropriate to 300 subjects included in the study were assigned generalize Western findings to all countries. In to one of two groups based on whether they had a this study, we aimed to identify the prevalence of lifetime history of a suicide attempt or not. suicide attempts in patients with schizophrenia To confirm the diagnosis of schizophrenia and and related sociodemographic and clinical features evaluate the influence of other specific psychiatric with suicide attempt in a sample of patients with comorbidities (major depressive disorder, subschizophrenia in Turkey, which has been under stance use disorder) the Structured Clinical Intercontinuous influences from both Asian and West- view for DSM-IV (SCID-I) (14), Turkish version ern cultural features. (15), was conducted by trained interviewers with each patient. The positive, negative, and depresMethod sive symptoms were assessed using the Scale for the Assessment of Positive Symptoms (SAPS) (16), Subjects the Scale for the Assessment of Negative Symptoms The study group consisted of 300 consecutive sub- (SANS) (17), and the Calgary Depression Scale for jects, who fulfilled the DSM-IV criteria for schizo- Schizophrenia (CDSS) (18), respectively. phrenia (13). Subjects were recruited from three centers in Turkey: Department of Psychiatry at Statistical analysis Faculty of Medicine, Cukurova University, Adana, The presence of suicide attempt in subjects with the Department of Psychiatry/ Gulhane Military schizophrenia was documented and descriptive Medical Academy, Ankara, and Adana State Men- statistics were used (frequencies, percentages, tal Health Hospital. The sample included subjects means, standard deviations). Selected sociodemoevaluated over the period from July 2003 to July graphic and clinical characteristics differences be2004. Patients were excluded if they had mental tween suicide attempter and nonattempter groups retardation or dementia. None had serious medi- were compared. To compare differences between cal or neurological illnesses. There were 195 men the groups, t test and χ2 tests (employing Fisher’s and 105 women in this study group. The mean age exact test when indicated) were performed. A p of the subjects was 36.7 ± 11.8 years. The average value of
