Abstract
Objectives:
This study had two purposes: to explore the main socio-demographic and medical characteristics of the psychiatric patients with a history of suicidal behavior, and to identify the main risk factors underlying the suicidal ideation and acts among psychiatric patients, in the light of two recent theories of suicidal behavior.
Methods:
The study is based on a mixed methodological design. During 2019 to 2021, 65 hospitalized psychiatric patients, who committed at least one non-lethal suicide attempt, were investigated using a questionnaire a scales for data collection. Medical records were used to gather data about certain socio-demographic characteristics and the health status of the respondents. Patients also participated in a narrative interview aimed at disclosing their subjective experiences about their past suicidal behavior.
Results:
The typical psychiatric patient with a history of suicidal behavior, as highlighted by the quantitative analysis, portraits a young old male from an urban environment, childless, educated, having experienced employment problems, being involved in religious activities. The clinical picture of the patient with suicidal antecedents included a moderate or severe level of depression, the presence of socio-emotional loneliness, the manifestation of frequent and long episodes of suicidal ideation, and the intention of committing suicide in order to stop the pain, whose acts resulted in minor injuries. Findings from the qualitative data revealed four major risk factors for the non-lethal suicidal attempts: family disruptions and social problems; economic burdens; a mixture of psychiatric pathologies; and, to a lesser extent, somatic pathologies.
Conclusion:
This study is the first to explore the triggers of suicide acts conducted in a clinical environment in the Balkan region. Implications of the pandemic are also discussed. The findings are useful for designing prevention strategies based on individual psychotherapy and therapeutic or support groups, addressing the main risk factors behind the suicidal ideation and gestures.
Keywords
Introduction
Suicide is one of the leading causes of preventable death worldwide, having been declared a public health problem by the World Health Organization (WHO, 2014). Thus, worldwide efforts are constantly being made to reduce the number of suicides by implementing prevention programs at national level. These strategies address a number of risk or resilience factors from a medical point of view, also taking into account education, employment, social welfare, or legislation aspects (WHO, 2018). Although the need for these programs is well documented, many countries, including Romania (Dumitru et al., 2019), do not fully benefit from these solutions.
There are a number of theories about the origin of suicidal ideation and its conversion into suicidal gestures. The newest ones – the Interpersonal Theory proposed by Joiner and the subsequent Three-Step Theory proposed by Klonsky – provide a useful framework for identifying the risk factors prevalent in the Romanian culture, thus charting a possible course of action for prevention strategies (Klonsky & May, 2015; Van Orden et al., 2010).
According to Joiner et al. (2002), thwarted belongingness and perceived burdensomeness are sufficient causes for a passive suicidal ideation to be formed. The thwarted belongingness element reflects social disconnectedness (including loss of a spouse, incomplete family) and lack of support (including domestic violence, family conflicts). Perceived burdensomeness generally develops in contexts of ‘liability’ (e.g. homelessness, unemployment, and physical illness). Ones’ conviction that they are a burden to their families is often accompanied by self-blame and low self-esteem. If prolonged, such passive ideation may in time turn into active ideation (wish of death), but Joiner introduces the notion of acquired capability as a necessary ingredient for converting it into action. This refers to the diminishing of the fear of death (overcoming of the self-preservation instinct) through several means – past attempted suicides, pain tolerance and habituation, painful or provocative experiences, etc. (Van Orden et al., 2010).
Several authors further contributed to the idea of capability and defined two distinct types: dispositional – that refers to genetic factors such as pain sensitivity, and practical – knowledge and access to lethal means. Klonsky built on Joiner’s theory and added pain as a precursor of suicidal ideation that is augmented by Joiner’s thwarted belongingness and perceived burdensomeness. The author avoided specifying its nature as both psychological and physical pain can induce suicidal ideation. Alongside pain, hopelessness plays an important role as it creates the perception that a certain situation cannot be improved (Klonsky & May, 2015).
It is known that cultural as well as socio-economic factors play an important role in the development of risk factors and subsequent suicidal ideation (Stack, 2000). As most research is carried out in developed countries with various cultural norms, prevention strategies based on such results may not be effective in other countries. For example, in traditional societies such as pre-90’s Romania (especially among the middle-aged population) the male partner was expected to financially support his family to a greater extent than in Western European countries or the USA, thus being faced with extra pressure (David, 2015).
In order to develop effective strategies at national level it is important to identify the risk factors involved in the growth of suicidal ideation and its evolution in certain national socio-cultural contexts and to design prevention schemes tailored to the profile of the inhabitants of the concerned countries. WHO (2022) documented that the COVID-19 pandemic generated significant increases in the prevalence of anxiety and depression worldwide, and that young people were at greater risk of suicidal and self-harming behaviors due to mental health problems induced by social isolation. As a result, numerous countries included mental health and psychosocial support measures in their pandemic contingency plans (WHO, 2022). As part of the COMET-G cross-sectional study, a national level investigation involving 1,446 Romanian subjects also associated the suicidality risk with increased depression and anxiety within the younger population during the first year of COVID-19 pandemic (Panfil, 2022).
Given that in Romania data on the risk factors involved in the generation of suicidal ideation and suicidal act are scarce, in this study we proposed to obtain answers to the following questions: ‘What socio-demographic and clinical features characterize the psychiatric patients with a history of suicidal behavior?’ and ‘Which are the main risk factors that precipitate the apparition and maintain the manifestation of a suicidal behavior among these patients?’
Method
Study design
This study is based on a mixed research design. Several methods were used for data gathering. A battery of questionnaires and tests was administered in order to collect socio-demographic and clinical data from the respondents. The main instruments applied in this process included an omnibus sociological questionnaire, the Beck Depression Inventory BDI-II (Ward, 2006), the short Scales for emotional and social loneliness (De Jong Gierveld & Van Tilburg, 2010) and the Columbia-Suicide Severity Rating Scale (C-SSRS Screening; Posner et al., 2008). Medical documents provided information about some socio-demographic characteristics of the respondents (gender, date of birth, residency, civil status, education, and occupation) and their health status (psychiatric diagnosis and data from the psychological evaluation). According to the principle of triangulation in the mixed methods research, the quantitative stage of the research was followed by a qualitative inquiry. Thus, the patients who responded at the questionnaires and tests were invited to participate, voluntarily, to a narrative interview in order to share their subjective experiences related to their past suicide behavior. The interview was focused on three main open-ended questions: ‘What determined you to attempt to commit suicide?’, ‘What actually happened?’, and ‘How do you feel about this action now?’
Procedure and data analysis
The research was conducted during a period of 3 years, between 2019 and 2021. The interviews were recorded and the transcripts were completed with information from the subjects’ medical records, the quantitative data being then organized and analyzed using the SPSS Program. Frequency distributions and indicators of central tendency were applied to analyze the quantitative data, while qualitative data were explored using thematic analysis.
Participants
Sixty-five adult patients of over 18 years of age with a history of nonlethal suicidal behavior admited to the Psychiatry Clinic III of the Emergency County Clinical Hospital in Cluj-Napoca between 2019 and 2021 voluntary accepted to participate in the research. Interviews were conducted in the hospital, during the first week of the patient’s admission.
Ethical issues
Interviewees were informed about the procedures involved and provided written consent to participate in the study. For reasons of confidentiality, no personal data that could lead to theidentification of thepatients were recorded. Offers of psychological counseling after the interview were considered but no patient actually benefited from this opportunity. All study protocols and procedures involving human subjects were approved by the Ethics Committee of the Iuliu Hațieganu University of Medicine and Pharmacy in Cluj-Napoca (No. 270/ 30.07.2019).
Results
The social and clinic profile of the studied patients
Table 1 depicts the socio-demographic characteristics of the participants in this research. The gender and age distribution illustrate that more than two thirds of the participants were males and over three quarters were up to 54 years old. A large majority of the respondents lived in a big city. Only a third of the participants were involved in a marital or consentual relationship. Still, half of the respondents declared they had children. 1 More than half have never been married, while the rest were either divorced/separated or widowed. Half of the participants completed secondary or higher education. However, a weight of 60% of the investigated subjects had been confronted with job instability, as they reported between 3 and 12 jobs until the moment of inquiry. It is worth mentioning that three quarters of the interviewed patients were more or less involved in religious activities.
Socio-demographic characteristics of participants.
Table 2 captures the main clinic characteristics of the investigated group, as depicted after the application of the two standardized tests, namely BDI-II and the Scale for emotional and social loneliness. The scores obtained for the Beck Depression Inventory (BDI-II) highlighted, as expected, that over three quarters of the participants suffered from moderate or severe depression. The scores for the scale of socio-emotional loneliness vary from 0 to 6, values of 0 and 1 indicating the absence of loneliness and the others reflecting a more or less accentuated perceived loneliness. Lack of loneliness was indicated by only five of the investigated patients.
Clinical characteristics of the participants.
Several manifestations of suicide risk behavior included in Table 2 were depicted from the application of the Columbia-Suicide Severity Rating Scale. They revealed that 75% of participants experienced an active suicidal ideation with specific plan and intention; almost half (45%) had experienced suicidal ideation more than once a week; for 51% of the patients the duration of the suicidal ideation was longer than a few minutes. Regarding the reasons provided for suicidal ideation, half of respondents invoked stoppage of the pain, while one third mentioned attracting the attention of other persons as their main reason.
A weight of 40% patients survived a number of two to eight suicide attempts, for 17% of them the resulting injuries being at least moderate, if not severe.
Main risk factors for developing a suicidal behavior
The investigation of risk factors for developing a suicidal behavior proved that it is very difficult to distinguish a singular cause which could explain why an individual is trying to commit suicide. In most cases, as shown in Table 3, the patients reported a mixture of risk factors that led them to certain suicidal gestures. By far, the most proeminent factor that exposed the patients to a suicidal behavior was the existence of a psychiatric patology (26 out of 65 patients). Familial reasons were its leading cause, frequently in combination with other factors such as social problems, economic burdens, and psychiatric pathology (33 out of 65 patients). Somatic patologies alone or combined with psychiatric pathologies had a much lesser contribution in the explanation of the suicidal behavior.
The risk factors of the suicidal behavior.
Results of the qualitative data inquiry
Out of the 65 patients, 9 gave brief details about the reasons behind their suicide acts, so their situation was superficially captured in the analysis.
Using thematic analysis, four recurrent themes revealing the main factors leading to suicidal behavior were derived from the patients’ interviews: family and social problems, economic problems, psychiatric pathology, and chronic somatic pathology.
Family and social problems
During the interviews, most patients reported a problem in this category as the main reason for their suicide attempt. Males frequently invoked the existence of intra-family conflicts, most often with the spouse. A small number of participants mentioned the death of a family member as the reason for their suicidal act.
I argued with my wife, I told her I will kill myself; she didn’t believe me. I drank one litre of antifreeze, she still didn’t believe me. (male, 47 years old, rural environment, married, four children, secondary education, employed) I took a knife and wanted to stick it into my body. My partner stopped me. I wanted to scare her after an argument. (male, 58 years old, urban environment, consensual relationship, one child, secondary education, employed) After I broke up with my 31 years old boyfriend, I felt abandoned and I needed to draw attention. (female, urban environment, unmarried, no children, living alone, employed, substance abuse)
Two participants invoked social problems as motivation for their suicidal act. They had experienced difficulties in social and professional integration due to their addiction to psychoactive substances.
Some patients confronted with an excessive alcohol consumption have declared that they had attempted to suicide mostly in the context of alcohol intoxication.
Economic issues
The economic problems exposed by the participants were primarily related to unemployment, work conflicts, or debts, with adirect or indirect impact on supporting their families.
I thought I had no purpose in life. I can’t give my mother what she needs. I don’t have a job. (male, 45 years old, urban environment, divorced, secondary education, one adult child, lives with his mother, unemployed) There is no place for me in this life. It’s hard for me to be supported by my wife. I couldn’t find a job. . . I went to the market, bought a bottle of brandy and drank 40 tablets. I sent an e-mail to my doctor, who sent my wife home. (male, 56 years old, urban environment, married, 2 children, secondary education, unemployed)
Psychiatric pathologies
An important risk factor which can help understanding one’s history of suicidal actions is the presence of a psychiatric pathology. A large variety of psychiatric disorders was observed among the investigated patients. Thus, 28 participants had manifested symptoms of depression, 32 had experienced a certain kind of addiction (alcohol, drug, or gambling), and 10 persons were schizophrenic. Also, 30 patients were diagnosed with a type of personality disorder, 9 of them being characterized by an impulsive emotionally unstable personality disorder. A common trait of the investigated lot was the association of two or more psychiatric diagnostics. Only one participant had not been diagnosed with a psychiatric disorder, while another one had a singular diagnostic, namely mixed dementia.
This factor increases the risk of engaging in suicidal ideation and gestures especially through delusions or hallucinations. A total of eight patients explained that their suicidal gesture was triggered by hallucinations or delusions caused by aprimary psychiatric pathology – schizophrenia or major depression disorder with psychotic elements or bipolar affective disorder. In five patients, the determinant symptomatology consisted in imperative auditory hallucinations leading them toward suicide. Three patients presented delusions with paranoid themes that generated significant stress, prompting them to commit suicide.
I stood on the window sill thinking whether or not to jump. Some voices told me to jump and I did. I previously didn’t sleep three nights in a row. The thought of death was there but I wasn’t really contemplating suicide. Ever since Istarted the new treatment, I have had thoughts of death. (female, 33 years old, urban environment, single, no children, higher education, lives with her parents, no occupation) I heard the voice of the devil, as if in a dream, telling me to kill myself. I’m sorry I could have done better things in my life and didn’t. [. . .] I wanted to kill myself because I was ashamed of what was happening. I wanted to shame myself and my family. (male, 58 years old, rural environment, unmarried, no children, secondary education, lives alone, unemployed) I couldn’t do anything well; I didn’t want to be a burden to anyone so I took the prescribed medication for depression together with alcohol, with the intention of dying. (female, 45 years old, rural environment, unmarried, one daughter, vocational school, living alone, sickness invalidity pension)
Depressive symptoms were also invoked as the basis for their suicidal action by 12 patients who did not have a psychiatric diagnosis prior to their admission.
Somatic pathologies
Three patients mentioned that their suicidal gesture was related to somatic pathology, indicating that they suffered from a chronic disease or had dialysis-generated difficulties in chronic renal failure cases. The consequences of these pre-existing pathologies worsened their economic situation, resulting in difficulties of supporting themselves or their family. This, in turn, triggered a depressive pathology, all these patients having been diagnosed with major depressive disorder.
I thought life was meaningless. Like a bolt of lightning the thought came and I took my medication - I thought I’ll take my life. I couldn’t stand it anymore because of the dialysis. (female, 56 years old, urban environment, divorced, two children, professional school, lives with a daughter, retired, chronic renal failure)
Discussion
This study depicted the profile of Romanian psychiatric patients which adopted a non-lethal suicidal behavior, being hospitalized in a major psychiatric hospital in Cluj-Napoca between 2019 and 2021. The typical patient experiencing suicidal ideation or actions was a 25 to 34 years old male from a big city, unmarried, childless, educated, experiencing employment problems, involved in certain activities of a religious nature. The clinical picture of the patients with a history of suicidal behavior shows that most of those who participated in the research suffered from moderate or severe depression, perceived a high level of socio-emotional loneliness, had frequent and long episodes of suicidal ideation with specific plans and intentions, and had unsuccessfully attempted to comit suicide in order to aleviate their pain, their suicide attempts resulting in minor injuries.
This study aimed to identify the risk factors that, on their own account, led the psychiatric patients toward a suicide behavior. The results indicate a multitude of factors that act as triggers for the suicidal acts. They generally are of a chronic nature, the patients being confronted with these risk factors for a long period of time prior to the suicidal actions.
Although suicide rates in Romania have been slowly declining over the last 20 years, figures are still high. In 2019, the last year for which data is available, the suicide rate was 9.7 per 100,000 population. An increase in the suicide rates in males were registered between 2009 and 2012, during the economic recession. Romanian female suicide rates are five times lower than male rates and remained constant throughout the period 2000 to 2019 (World Bank, 2022). Another study found no increase in the suicide rates during 2020, as well as a shift from the traditional solution of hanging toward precipitation or the use of sharp objects as a mean ‘to end all problems’, perhaps due to the extended presence of family members during the COVID-19 lockdown. However, a greater number of suicide attempts were recorded as a result of disregarding psychiatric patients discarded as non-emergency cases (Vuscan et al., 2022).
In spite of this reality, there is no national program dedicated to suicide prevention, but there are several direct (telephone lines, support groups) and indirect (limited access to firearms, compulsory involuntary hospitalization in case of suicide attempts, and free psychiatric medication) prevention means, which address a small part of the existing risk factors and do not target the general population. Also, most of the available options are aimed at secondary prevention and not the primary prevention of suicidal ideation, which should be the desired goal of such programs (Cozman, 2009).
Family and social problems are the reasons provided by most of the participants in the study. The potential repercussions of familial conflicts are a decreased level of communication and trust between members, especially if they persist for a long period of time, and that can lead to divorce (Rada, 2020). Such disfunctionalities which can also extend to encompass the economic sphere (e.g. a decrease in job performance, possibly leading to dismissal) play an important role in the development of depression and subsequent suicidal ideation (Inder et al., 2014; Lundin & Hemmingsson, 2009).
Conflicts in general can act as a trigger for alcohol consumption in the general population and psychiatric patients in particular (Murphy et al., 2005). Impulsivity is closely linked to suicide and self-harm behaviors, more so in the context of acute alcohol use (Hufford, 2001). Chronic alcohol consumption is frequently associated with an increased rate of domestic violence, thus generating or intensifying intra-family conflicts (Murphy et al., 2001). The disinhibitory effect of alcohol also plays a role in the transition to action, often potentiating pre-existing impulsivity (Edwards et al., 2020; Boenisch et al., 2010).
Within the sphere of conflicts, a significant role in generating suicidal ideation is played by workplace conflicts. Given the economic nature of the professional role and the precarious or borderline financial situation of the patients who reported this problem (Beghi et al., 2021), changing jobs was not a realistic option for them, therefore they found themselves confined in a hostile environment (Claassen et al., 2010; Schneider et al., 2011).
The motivation for suicide attempts also varies according to gender. This variability may be due to the different roles that society imposes on men compared to women. Although the gender gap has decreased lately, a degree of traditionalism persists in the Romanian society, the male members being designated to financially support their family. Loosing this ability results in loss of self-esteem and family recognition of their status. The observation is supported by the fact that no female participant in the study cited economic problems (David, 2015). Distress induced by the fear of infection during the COVID-19 pandemic, along with economic and work-related pressures, was also documented by a previous study conducted in Romania (Vuscan et al., 2022).
The results of this study are consistent with modern theories of suicide. Klonsky, in the Three Step Theory (Klonsky & May, 2015), claims that suicidal ideation begins in the presence of pain (whatever its nature) and hopelessness. These elements were noticed in the interviews of participants, suicidal ideation occurring in the context of physical pain, major conflicts, or stressful situations, equivalent to the psychological pain mentioned by Klonsky, on the background of a constant hopelessness regarding the future.
Another element identified among the participants that supports Klonsky’s theory and plays an important role in the transition from ideation to action is the lack of connection with the socio-professional context. The participants in our study reported various social problems – single-parent families, long-lasting intra-family conflicts, a lack of or a deficient social support network, but also problems related to professional life – loss of job, conflicts with colleagues and superiors, as well as mental or somatic illnesses that prevented their integration in the work field.
In the study group, elements of self-harm capability were also identified – pain habituation in the case of patients with chronic diseases, and access to means – medication in the case of those with pathologies under treatment. The influence of these factors on the transition to action as proposed by Joiner and confirmed in other studies on suicide (Van Orden et al., 2010) was also identified in our study.
Although somatic patologies are not frequently cited as reasons for suicidality, a recent Romanian study found a positive association between the lipid profile and suicidal actions among patients diagnosed with bipolar disorder (Roșca et al., 2018).
The study has several merits. It brings insights on the determinants of suicidal attempts from the patients’ perspective immediately after an episode of suicidal act. As far as we know, it is the first study discussing the triggers of suicide acts conducted in a clinical environment in the Balkan region. Although these findings may not be attributable to the whole category of Romanian psychiatric patients, our study can provide a starting point in deepening the knowledge about the precursor factors of suicide attempts. Another merit of the study is that it offers a more complex image on the profile of suicide attempters by using a mix of methods for data collection in the clinical environment.
The curent study has some limitations. First of all, due to the sensitivity of the investigated topic and the fact that the narative interviews were conducted in the hospital immediately after a suicide attempt, most of the participants in the research offered schematic answers, poor in details. Partially, the precarity of their answers could be explained by the reservedness of speaking about an event perceived as shameful and/or by the unwillingness of some patients to rememorize the painful event. Secondly, the investigated group was disproportioned in terms of gender, hence allowing but a cautious analysis and a reserved verdict about the hierarchy and intensity of suicidality determinants among men and women. Thirdly, we are aware that the thematic analysis provided in this study has mainly a descriptive role, and that a more sophisticated analysis applied on a larger sample could capture the complex interlink between the identified reasons, as some of them act as mediators between a precursor factor and the suicidal act per se.
Conclusions
Suicide prevention is an important global target, many countries adopting national strategies to prevent suicide. Mainly due to the lack of resources, Romania does not benefit from a prevention strategy, although suicide is reflected in a significant number of deaths. Although the suicide rate has slightly decreased in Romania, it is a phenomenon with a significant impact.
The downward trend observed in the suicide rate in Romania, especially among men, is encouraging. However, most of the time, prevention strategies target already existing suicidal ideation or suicidal acts through crisis interventions. However, as the results of this study confirmed, suicide and suicidal ideation are complex problems that often have their roots inlong-term pre-existing causes and these should be the primary targets of prevention strategies.
One of the most common reasons provided for a suicide attempt is a familial conflict, combined or not with alcohol consumption, often on the background of an impulsive personality. A prevention strategy addressing these risk factors could significantly reduce the number of suicides by targeting a large sector of the population given the increased rate of alcohol consumption 2 and intra-family conflicts as can be deduced from the divorce rate.
Individual psychotherapy and therapeutic or support groups might be useful intervention means for addressing these situations but difficult access to psychotherapy services, especially in rural areas, and their high cost are serious barriers against their effectiveness. With the introduction and popularization of telemedicine, access to psychotherapy services via the Internet could help to standardize accessibility, but the problem remains of costs, which, although covered by compulsory insurance, the number of beneficiaries is insignificant.
Footnotes
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Iuliu Haţieganu University of Medicine and Pharmacy Cluj-Napoca through a Doctoral Research Project (PCD 2020-2021, no. 1033/78/2021).
