Suicide risk and suicide risk factors among immigrants in Italy: A bi-center matched sample study

Abstract

Italy has the third-largest immigrant population of European Union countries, but only a few research papers have examined suicide risk in immigrant psychiatric patients in Italy. The main aim of this paper was to compare suicidal ideation and suicide attempts in a sample of 304 psychiatric patients. We included 152 immigrant patients matched with 152 Italian patients admitted to the same wards during the same time period by age, gender, and diagnosis. We also investigated sociodemographic and clinical characteristics of the two samples including psychiatric diagnosis, age of illness onset, duration of illness, previous hospitalizations, length of hospitalization, previous suicide attempts, and substance and alcohol abuse. There were no differences between immigrant and Italian patients in either suicidal ideation (previous or current) or suicide attempts (previous or current). Immigrant patients were more likely to have a shorter duration of illness than the Italian patients and Italian patients were more likely to report substance abuse than were immigrant patients. Despite similar suicide rates between immigrants and Italian psychiatric inpatients, appropriate assessment of suicide risk in these patients is essential in implementing therapeutic suicide prevention strategies.

Keywords

Suicidal ideation suicide attempt immigrants psychiatric disorders

Introduction

Immigration is a risk factor for a range of mental disorders, including psychotic disorders, major mood disorders, and post-traumatic stress disorder (Cantor-Graae & Pedersen, 2013; Swinnen & Selten, 2007; Turrini et al., 2017). In addition, although some research has demonstrated that immigration increases suicide risk (Sundaram et al., 2006; Westman et al., 2006), other research has reported a lower risk of suicide in immigrants than in native-born citizens (Crawford et al., 2005; Malenfant, 2004; Mullen & Smyth, 2004).

Suicide is a multifactorial phenomenon characterized by several biological, psychological, clinical, social, cultural, and environmental risk factors (Pompili, 2019). The presence of a psychiatric disorder is considered a risk factor for suicidal ideation among immigrants (Kwon & Han, 2019). Overall, several factors influence suicide risk in immigrants, including poor living conditions after migration, ethnic discrimination by the host population, acculturation stress, physical and emotional trauma and torture before and during migration, language difficulties, health service access barriers, and fears about immigration (Fossion et al., 2004; Garcia & Saewyc, 2007). Furthermore, ethno-cultural identity and acculturation, specific cultural and religious norms, stigma, shame linked to mental illness, and religious or spiritual beliefs and traditions, including beliefs about suicide, also influence suicide risk in immigrants (Walker et al., 2005). The role of family and community relationships may be particularly relevant in young migrant groups due to the cultural importance of family and community relationships (Renzaho et al., 2011). Furthermore, broader community connections and support, including support from religious communities, can protect against suicidal behaviors, while isolation and a lack of connection and support can contribute to suicide risk (Lai et al., 2017). One study suggested that suicide risk in immigrants also depends on the country of migration and on migratory processes (Ide et al., 2012).

Like other European countries, Italy had a very large and rapid wave of immigration during the 2000s. The percentage of immigrants in the population more than tripled, growing from 2.4% in 2002 to 7.6% in 2010 (Italian National Statistical Institute – ISTAT, demographic portal). High growth rates were recorded in both northern and central Italy and, in 2010, the provinces of Milan (north) and Rome (center) combined contained 18% of all immigrants in the country (Bratti & Conti, 2018). Although Italy has the third-largest immigrant population of European Union countries, only a few papers have examined suicide risk in immigrants (Iliceto et al., 2013; Kõlves et al., 2011; Marchi et al., 2020) and in immigrant psychiatric patients in Italy.

The main aim of this paper was to compare suicide risk (current suicidal ideation and suicide attempts) in a sample of immigrants compared to age-, gender-, and psychiatric diagnosis-matched ethnic Italian patients admitted to the psychiatric intensive care unit of two university hospitals in Rome (Sant’Andrea Hospital and Policlinico Umberto I Hospital). We also investigated sociodemographic and clinical characteristics of the sample (psychiatric diagnosis, age of illness onset, duration of illness, previous hospitalizations, length of hospitalization, previous suicide attempts, and substance and alcohol abuse).

Methods

In this cross-sectional bi-center matched sample study, investigators collected sociodemographic and clinical data from two matched samples, immigrants and Italians consecutively admitted to two psychiatric units from January 2013 to March 2021. The total sample consisted of 304 patients (170 women and 134 men): 194 from Sant’Andrea hospital and 110 from Policlinico Umberto I hospital and (both located in Rome and with a broad metropolitan catchment area). The former sample was also investigated in a previous study (Tarsitani et al., 2021). A total of 152 immigrant patients were matched with 152 Italian patients admitted to the same wards during the same time period for age, gender, and diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (American Psychiatric Association [APA], 2013) or fourth edition text revision (DSM-IV-TR) (APA, 2000) criteria. All the immigrants included in the present study demonstrated a good knowledge of the Italian language and were able to respond to all items successfully.

The mean age of the total sample was 37.16 years (SD = 12.6). Since this was a matched sample study, there were no significant differences between the two samples in sociodemographic variables. Inclusion criteria were adult inpatients aged ⩾18 years admitted to the psychiatric unit and a psychiatric diagnosis based on DSM-5 (APA, 2013). Exclusion criteria included the presence of degenerative neurological disease or cognitive deficits. Patients with incomplete clinical records were excluded from the study. With the term migrant (or immigrant), in the present paper we refer to the definition of the International Organization for Migration (IOM). Most experts and researchers agree with IOM, which describes a migrant as any person who is moving or has moved across an international border or within a state away from his/her habitual place of residence regardless of: the person’s legal status; whether the movement is voluntary or involuntary; what the causes for the movements are and what the length of the stay is (Forte et al., 2018).

Two psychiatrists collected the data from clinical records, and an ad hoc checklist was developed for the variables included in the study. Sociodemographic data (age, sex), diagnosis (bipolar disorder, depressive disorder, schizophrenia or other psychoses, personality disorders, other disorders), duration of illness, previous hospitalizations or suicide attempts, current suicidal ideation and suicide attempts, length of hospitalization, type of admission (involuntary or voluntary), and substance or alcohol abuse were all collected using the checklist. Psychiatric diagnosis was made during the first days of hospitalization. Trained psychiatrists assessed suicide ideation and suicide attempts when the patient arrived at the emergency department and on admission to the psychiatric ward. According to the definition adopted by Posner et al. (2007) in the Columbia–Suicide Severity Rating Scale (C-SSRS), suicide ideation included thoughts about a wish to be dead or active thoughts of wanting to end one’s life. Furthermore, a suicide attempt was defined as a nonfatal self-directed, potentially injurious behavior with an intent to die that may or may not have resulted in injury (Silverman et al., 2007a, 2007b).

All participants received a comprehensive explanation of the study procedures and goals, consistent with the Declaration of Helsinki, and all patients voluntarily participated in this study after signing a written informed consent form. As the assessment of psychiatric patients with particular attention to suicide attempts is part of several investigations approved by the local ethics review board, the present study was derived during previously approved recruitment of suicide attempters.

Statistical analysis

All statistical analyses were performed with Statistical Package for Social Sciences (SPSS 25.0). McNemar test was used for paired categorical variables. Paired sample t-tests were used to evaluate the differences between-groups and, in the case of non-parametrical distributions, the Wilcoxon test was used. All tests were considered statistically significant with a p-value <.05.

Results

One hundred and fifty-two immigrant patients were matched by age, gender, and diagnosis with 152 Italian patients. Most of the immigrants came from Europe (40.1%), Africa (25.7%), South America (17.8%), and Asia (16.4%) see Table 1. Sociodemographic and clinical characteristics of the study sample are shown in Table 2.

Table 1.

Origin of the immigrant group (N = 152).

Continent of origin	N (%)
Europe	61 (40.1%)
Africa	39 (25.7%)
Asia	27 (17.8%)
South America	25 (16.4%)

Table 2.

Sociodemographic and clinical characteristics of participants.

	Immigrants (N = 152)	Italians (N = 152)	Whole sample (N = 304)	Statistics	p
Sex (females)			55.9%		—
Age (years) M ± SD			37.16 ± 12.6		—
Diagnosis					—
Bipolar disorder			13.2%
Depressive disorder			13.2%
Schizophrenia or other psychoses			48.7%
Personality disorder			10.5%
Other			14.5%
Duration of illness M ± SD	8.52 ± 9.9	13.60 ± 10.1	11.06 ± 10.3	t = −4.95	<.001
Previous hospitalization	47.4%	56.6%	52.0%		.125
Previous suicide attempt	13.2%	19.7%	16.4%		.121
Current suicidal ideation	25.7%	26.3%	26.0%		.999
Current suicide attempt	12.5%	10.5%	11.5%		.736
Involuntary hospitalization	16.4%	20.4%	18.4%		.471
Substance abuse	10.5%	29.6%	20.1%		<.001
Alcohol abuse	9.9%	13.8%	11.8%		.286
Length of hospitalization (days) M ± SD	11.28 ± 12.5	11.14 ± 8.3	11.21 ± 10.6	Z = −.741	.459

No significant differences were found between the Italian and immigrant patients in terms of either suicidal ideation (previous or current) or suicide attempts (previous or current). The two groups differed according to the duration of illness. Immigrant patients were more likely to have a shorter duration of illness than the Italian patients (M = 8.52 ± 9.8; M = 13.60 ± 10.1; t = −4.95, p < .001, respectively). Moreover, the Italian patients were more likely to report substance abuse than were immigrant patients (29.6% vs. 10.5%, p < .001). The two groups did not differ in terms of previous hospitalization, involuntary hospitalization, or alcohol abuse (Table 2). Finally, no significant differences were found between the Italian and immigrant patients in terms of suicidality (ideation + attempt).

Discussion

The aim of the research was to evaluate possible differences in suicide risk (current suicidal ideation and suicide attempts) and suicide risk factors in immigrant and Italian psychiatric patients admitted to two university hospitals in Rome.

The first result of this study was that there were no differences between immigrant and Italian patients in terms of either suicidal ideation (previous or current) or suicide attempts (previous or current). Only a few papers have addressed suicidal ideation and suicide attempts in immigrants in Italy (Iliceto et al., 2013; Marchi et al., 2020). A multicenter study on 237 non-clinical Italians and 234 immigrants did not find differences in suicide risk or psychopathology between the two groups (Iliceto et al., 2013). Kõlves et al. (2011) investigated changes in non-fatal suicidal behavior rates and characteristics by comparing patients admitted to a hospital in Padua during two study periods (1992–1996 and 2002–2006). The authors demonstrated a significant increase in suicide risk during the second study period and changes in the characteristics of the suicide attempters, including age and gender (Kõlves et al., 2011). Overall, the results of the present study are in line with the results of previous papers that investigated Italian populations and with studies in other countries that did not find differences in suicidal ideation, suicide attempts, or suicide mortality between migrant and native populations (Amin et al., 2021; Shoval et al., 2007). Immigration does not seem to play a key role in suicide risk, confirming the importance of other psychological and psychiatric features independent of the migration process in determining suicide risk (Berardelli et al., 2019; Park et al., 2020; Turecki et al., 2019).

The second aim of this study was to assess possible differences in suicide risk factors between immigrant patients versus Italian patients. The suicide risk factors investigated in this paper included sociodemographic and clinical characteristics of immigrant and Italian psychiatric inpatients. The results showed that the two groups differed according to duration of illness. Immigrant patients had a later a shorter duration of illness than Italian patients. One possible explanation for the later age of onset may be the result of a delay in accessing healthcare services resulting from linguistic, cultural, and socioeconomic difficulties (Ngwakongnwi et al., 2012). On the other hand, the shorter length of illness could be related from delays in recognizing psychiatric disorders and the need for psychiatric services. Yet, it is also possible that immigration as a significant stressor might lead to the onset of mental disorders which would not otherwise have developed (Cantor-Graae & Pedersen, 2013; Swinnen & Selten, 2007; Turrini et al., 2017).

The results of our study demonstrated that immigrant patients were less likely to report substance abuse than Italian patients, confirming the so called ‘immigrant paradox’, with a lower use of licit and illicit substances in immigrants (Salas-Wright et al., 2014). Possible explanations for this include the hypothesis that immigrants are highly capable, self-disciplined individuals (Rubalcava et al., 2008) with cultural norms and practices (e.g. anti–drug use norms and a tendency to congregate around other immigrants) (Charles, 2006). A third possibility is that immigrants may abstain from high-risk or illegal activities because of fears of deportation or legal consequences (Hacker et al., 2011).

This study had several limitations. First, we did not assess the exact age at immigration or the presence of physical or emotional trauma or torture before or during immigration. We also did not assess other factors that could be involved in suicide risk, such as separation from the family, loss of status, loss of social networks, or other psychological factors. Furthermore, we did not investigate the main reasons that the immigrant patients left their country of origin. We did not use psychometric tools to assess psychological or psychiatric dimensions. Although this was a bi-center study, the samples may be representative of only the city of Rome. Future research is needed to confirm our findings in other samples of immigrants in high income countries.

In conclusion, suicide is a serious problem for immigrants as for psychiatric patients not immigrants, with implications for the wellbeing of individuals, their families, and the broader immigrant community. However, the migration process does not increase suicidal risk of patients, suggesting the importance of investigation in depth other psychological constructs and psychopathological dimensions involved in suicidal risk. Furthermore, appropriate assessment of suicide risk in these patients is essential in implementing of therapeutic suicide prevention strategies.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Isabella Berardelli

Lorenzo Tarsitani

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