Psychiatric pathology is growing in adolescents and young adults around the world(1). Most pathologies develop in youth, although they are diagnosed much later and are closely related to cultural values, religion, education, achievements, substance abuse, but also to interpersonal relationships(2).
The period of adolescence, but also of young adulthood, is a critical period for emotional and social development. The transition from adolescent to adult is a difficult period, with changes in academic, social and emotional levels(3). The young adult is influenced by environmental, cultural and social factors, but also by his/her personality structure(4). They face new challenges by trying to identify their own identity, to develop self-esteem, to be independent and to take responsibility for their actions. Often, those around them have high expectations which lead to a feeling of helplessness, insecurity, stress, but also to feeling of losing control(5). The most common pathology described is depression, with a prevalence of 11.3% in adolescents between 12 and 17 years old, and 9.6% in the population aged 18 to 25 years old, increasing in prevalence from 8.7% in 2005 for the age group between 12 and 17 years old and 8.8% in the age group 18-25 years old(6). Depression during this critical period can increase substance abuse, alcohol and psychoactive substances negatively affecting the subsequent personal development(7).
Depression, suicidal ideation but also suicide among adolescents and young adults are much more common, because often the pathology cannot be recognized by the parents, so that the adolescent receive the necessary help(8). Suicide is the second leading cause of death among young people aged 15 to 18 years old, after road accidents, and half of young people with autolytic attempts are diagnosed with severe depression with autolytic ideation(9). There are also significant differences between the sexes, men commiting suicide more often than women and women being diagnosed more frequently with a depressive episode with autolytic ideation but they do not commit suicide(10), with a frequency of 4/1 in Europe and America(11). Suicide affects all age groups, increasing with age, with a prevalence among men over the age of 80 of 60.1/100,000 and 27.8/100,000 among women. In young people between 15 and 19 years old, the frequency of suicide is 15.3/100,000 among men and 11.2/100,000 among women(12).
Several factors have been identified as predisposing factors for depressive pathology and for suicide: genetic factors, predisposing environmental factors represented by low socioeconomic status, large families with limited resources, the absence of one or both parents, abuses of different nature in childhood, but also independent, structural factors related to personality(13,14).
People with a deficient social support network are more likely to engage in unhealthy behaviors, such as smoking, sedentary lifestyle, alcoholism, unhealthy diet and sleep disorders, which become risk factors for depressive symptoms(15).
Regarding suicide, the depressive pathology is incriminated in 50-65% of cases, being more common in women than in men. Several studies confirm the genetic predisposition to suicide, but there are also biological predisposing factors represented by high levels of cortisol in young people(16), low levels of hydroxy-indolacetic acid(17), thyroid hormones(18) and cholesterol(19). Alcohol abuse is associated with an increased risk of suicide in men. In terms of personality structure, borderline and antisocial personalities are associated with an increased risk for suicide. Several studies have shown that there is a higher frequency of suicide among those who had multiple autolytic attempts, but also in people whose parents had a history of autolytic attempt like learned behaviors(20). The personal history of sexual abuse in childhood and poor family relationships, with conflicts, parental divorce or the death of one or both parents, increase the personal vulnerability and are implicit factors associated with an increased risk of suicide(21). Another incriminating aspect lately is represented by the influence of the internet and television through the advertising attributed to this subject by news but also of the multiple documentaries, movies and video games(22).
The protective factors in autolytic attempts are represented by: family in terms of support and responsibility, fear of death, fear of being judged by others for their action, cultural and religious values, personal beliefs, increased self-esteem and personal goals related to life(23).
There are several types of suicide: rational or high-risk suicide, in which the person in question considers the act of suicide as the only solution being made in order to avoid suffering in case of disabling diseases; nonpathological suicide is carried out following one’s own decision, conscious but also motivated, regarding the cessation of life due to limit situations in which the person finds himself and does not find a way out, although there are other solutions(24). The pathological suicide is committed outside conscious or voluntary control(25). Suicide from psychotic disorders such as depression or schizophrenia is the most common pathological suicide(26). The suicidal acts in hysterical pathology are often performed for demonstration purposes, in order to impress the entourage. Suicide committed under the effect of alcohol or psychedelic substances is committed accidentally or in order to impress the entourage(27). Another alternative of pathological suicide is represented by suicide committed in case of personality disorders, the most common personality disorders associated with an increased risk of suicide being represented by borderline personality but also by antisocial personality due to low capacity for self-control(28).
The aim of the paper is to identify the risk factors responsible for performing the suicidal act in young patients diagnosed with depressive pathology.
The present study is retrospective, performed by analyzing the clinical observation sheets of patients admitted to the Psychiatry Clinic II from Mureş County Hospital, Romania, between January 2011 and December 2016. The sample consisted of a number of 103 subjects.
All patients aged between 18 and 25 years old who were diagnosed with depressive disorder of different intensities were included in the study.
The sample of 103 subjects was divided into two groups: a group of patients diagnosed with depressive disorder and an autolytic attempt before hospitalization, and a group of patients diagnosed with a depressive disorder without suicide attempts.
Based on the data from the patient file, the created database included the following parameters: sex, age, place of origin, hospitalization type, length of hospitalization, main diagnosis, secondary diagnoses, use of psychoactive substances, alcohol and tobacco, social support network, autolytic attempts, the trigger of the current episode and the family history.
The statistical data processing was performed using the GraphPad Prism 8 program and the Microsoft Excel 2010 spreadsheet program. The results obtained by analyzing the patient file were centralized in the form of contingency tables and then compared by the Chi-square Test and the Fisher Test. The significance value was set at 0.05, with a 95% confidence interval.
The average age of the group of patients with autolytic attempt before hospitalization was 21.16 years old, and the average age of the group of patients without autolytic attempt was 21.66 years old.
The average number of hospitalization days for patients in the group with autolytic attempt was 12.16, and for those in the group without autolytic attempt, the average number was 10.52.
The group of patients with autolytic attempt is formed in a proportion of 64% of women and 36% men, and the group of patients without autolytic attempt is formed in a proportion of 58% of women and 42% men. There is no statistically significant difference between women and men as regards committing a suicide attempt in the studied group (p=0.34).
The patients in the group of those with autolytic attempt came in a proportion of 45% from the urban area, while 55% came from the rural area, and those from the group without autolytic attempt came in a proportion of 75% from the urban area and 25% from the rural area. Patients from rural areas are more likely to commit suicide than those from urban areas (p=0.04).
Patients with a deficient support network are more likely to commit suicide than those with an appropriate social support network (p=0.015). Multiple intrafamily conflicts increase the autolytic potential (p=0.000051).
The subjects diagnosed with borderline personality disorder had a higher risk of developing autolytic behavior, compared to other patients without personality disorders or traits (p=0.04).
The subjects diagnosed with a severe depressive disorder had a higher risk of having an autolytic attempt than those diagnosed with moderate or mild depressive episode (p=0.02).
In the studied group there were no statistically significant differences in terms of alcohol consumption (p=0.31) and smoking (p=0.16) between the two groups.
In our study, there are no statistically significant differences between the groups studied regarding sex, although the literature indicates that the risk of a man committing suicide is 2-4 times higher, but a woman is 3-9 times more likely to commit an autolytic attempt(29,30). These differences can be explained by the fact that men have more aggressive suicidal behavior in order to achieve the goal, being more impulsive and determined(31).
Regarding the area of origin, the subjects form rural areas are more prone to commit autolytic attempts, being demonstrated by the literature that male subjects from rural areas commit suicide attempts more frequently than those from urban areas(32,33), which can be explained by the fact that not all autolytic attempts in the urban areas are diagnosed.
Our study showed that subjects with a deficient support network and also with intrafamily conflicts have a higher risk of having an autolytic attempt, as confirmed by the literature which claims that patients who do not have family support or attention of the both parents are more prone to commit suicide(34).
Our study and the literature indicate that borderline personality disorder is associated with increased suicide risk(35). This can be explained by the fact that these people are emotionally unstable, impulsive and incapable of self-control. The literature indicates that antisocial personality disorder is also associated with an increased risk(36).
In our study, the patients diagnosed with a severe depressive disorder are more likely to have an autolytic attempt compared to patients diagnosed with a mild or moderate depressive episode. Literature data support the association between severe depressive disorder and suicide attempts(37).
Alcohol abuse is associated with increased suicide risk in the literature(37). In our study, in the studied group there was no statistically significant link between alcohol consumption and autolytic attempts.
There are many associations between the multiple risk factors and the autolytic attempt. By knowing these risk factors, strategies can be developed to achieve the prevention of attempts, especially by educating the population about the signs and symptoms of depression. The factors identified by us as favorable in committing an autolytic attempt are: depressive pathology, subjects who live in rural areas, subjects who have a deficient support network and multiple intrafamily conflicts, but also borderline personality traits.
The limitations of the study are represented by the small number of subjects, which is why the existence of potential risk factors was not taken into account.