Jun 30, 2011 - Depression Inventory, BDI), recent life-event changes (Social Readjustment Rating Scale, SRRS), sociodemographic and other relevant.
L. F. Ch an et al.: Inpatients with Depressive Disorder Crisis©2011; 2011 in aVol. Malaysian Hogrefe 32(5):Publishing 283–287 Sample
Short Report
Suicide Attempts Among Depressed Inpatients with Depressive Disorder in a Malaysian Sample Psychosocial and Clinical Risk Factors L. F. Chan, T. Maniam, and A. S. Shamsul National University of Malaysia Medical Centre (UKMMC) Abstract. Background: Depressed inpatients constitute a high-risk population for suicide attempts. Aims: To describe the interactions of clinical and psychosocial risk factors influencing suicide attempts among a Malaysian sample of depressed inpatients. Methods: Seventyfive subjects were diagnosed with a depressive disorder according to the Structured Clinical Interview for DSM-IV Axis I DisordersClinical Version (SCID-CV). Data on suicide attempts, suicidal ideation (Scale for Suicidal Ideation, SSI), depression severity (Beck’s Depression Inventory, BDI), recent life-event changes (Social Readjustment Rating Scale, SRRS), sociodemographic and other relevant clinical factors were collected. Results: A third of the subjects presented after a current suicide attempt. Significant factors for a current suicide attempt were race, religion, recent life-event changes, suicidal ideation, and alcohol use disorder. Independent predictive risk factors for a current suicide attempt were Chinese race, recent marital separation, major mortgage or loans, and being newly diagnosed with depression. Any recent change in personal habits was shown to be a protective factor against current suicide attempt. Age and gender were nonsignificant factors. Conclusions: The findings are generally consistent with existing studies and highlight the role of psychosocial risk factors. Keywords: suicide attempt, psychosocial risk factors, Malaysia
The highest risk of suicide is found among inpatients with depressive disorders (Botswick & Pankratz, 2000). Lönnqvist (2000) found that depression was diagnosable in 29% to 88% of cases of suicide and psychological autopsy studies in Asia have shown similar rates ranging from 35% to 89% (Cheng, 1995; Phillips, Yang, Zhang, Wang Li, & Zhou, 2002; Vijayakumar & Rajkumar, 1999). Risk factors for suicidal behavior ranging from ideation to attempts and completed suicides have been studied extensively, albeit less so in developing nations (Bertolote, Fleischmann, De Leo, & Wasserman, 2003). Among patients with depressive disorders, risk factors for attempted suicide include previous suicide attempt, younger age, higher severity of depression and suicidal ideation, higher severity of life stressors, comorbid alcohol or other substance use disorder, childhood history of abuse, family history (first-degree relative) of attempted or completed suicide (Oquendo et al., 2004), lacking a partner (Sokero et al., 2005), and comorbid physical illness (Duggan, Sham, Lee, & Murray, 1991). From a psychosocial perspective, some South East Asian authors have alluded to the impact of interpersonal © 2011 Hogrefe Publishing
losses and conflicts as precipitants of attempted suicide especially among young female ethnic Indians (Maniam, 1988; Wai, Hong, & Heok, 1999). Currently, there is still a paucity of data on risk factors for suicide attempts among depressed inpatients in Asia, which incidentally, has about 60% of the world’s suicides (Beautrais & Mishara, 2008). This study aims to describe the interactions of clinical and psychosocial risk factors influencing suicide attempts among a culturally heterogeneous sample of Malaysian depressed inpatients.
Method Setting This study was conducted at the National University of Malaysia Medical Centre (UKMMC), a semigovernmental teaching hospital and a national tertiary referral center in Kuala Lumpur. This article presents cross-sectional data from a larger naturalistic prospective study of the predicCrisis 2011; Vol. 32(5): 283–287 DOI: 10.1027/0227-5910/a000088
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L. F. Chan et al.: Inpatients with Depressive Disorder in a Malaysian Sample
Table 1. Differences between depressed inpatients with and without suicide attempt Characteristic
Suicide attempt No
All patients
Total, n (%)
52 (69.3)
23(30.7)
75 (100)
Age (years), mean (SD)
44 (12.1)
43.4 (12.4)
43.8 (12.1)
Female
31 (59.6)
11 (47.8)
42 (56)
Malay
23 (44.2)
5 (21.7)
Chinese
14 (26.9)
16 (69.6)
Indian
15 (28.8)
2 (8.7)
17 (22.7)
23 (44.2)
4 (17.4)
27 (36)
Race
Buddhist-Taoist
ns 12.267 (2), p = .002
28 (37.3) 30 (40)
Religion Muslim
Significance, χ², (df), p
Yes
15.278 (4), p = .004 6 (11.5)
10 (62.5)
16 (21.3)
Hindu
12 (23.1)
1 (4.3)
13 (17.3)
Christian
10 (19.2)
7 (30.4)
17 (22.7)
1 (1.9)
1 (4.3)
2 (2.7)
33 (63.5)
17 (73.9)
50 (66.7)
ns
Others Married High educational level
45 (86.5)
21 (91.3)
66 (88)
ns
Unemployed
22 (42.3)
10 (43.5)
32 (42.7)
ns
Diagnosis
ns
Bipolar disorder
14 (26.9)
8 (34.8)
22 (29.3)
Major depressive disorder
30 (57.7)
12 (52.2)
42 (56.2)
Dysthymia
1 (1.9)
0 (0)
1 (1.3)
Adjustment disorder
4 (7.7)
1 (4.3)
5 (6.7)
Major depressive disorder superimposed on dysthymia
3 (5.8)
2 (8.7)
5 (6.7)
Psychotic features Current
13 (25)
9 (39.1)
22 (29.3)
ns
Lifetime
25 (48.1)
9 (39.1)
34 (45.3)
ns
29 (55.8)
11 (47.8)
40 (53.3)
ns
7 (13.5)
7 (30.4)
14 (18.7)
ns
24 (46.2)
12 (52.2)
36 (48)
ns
Melancholic features Newly diagnosed depression Previous psychiatric admission Medication noncompliance
26 (50)
11 (47.8)
37 (49.3)
ns
Past suicide attempt
20 (38.5)
12 (52.2)
32 (42.7)
ns
Suicidal ideation
33 (63.5)
23 (100)
56 (74.7)
11.255 (1), p = .001
15 (28.8)
10 (43.5)
25 (33.3)
ns
9 (17.3)
9 (39.1)
18 (24)
4.164 (1), p = .041
11 (21.2)
9 (39.1)
20 (26.7)
ns
4 (7.7)
2 (8.7)
Any substance
20 (38.5)
11 (47.8)
31 (41.3)
ns
Anxiety disorder
11 (21.2)
2 (8.7)
13 (17.3)
ns
Chronic medical condition
25 (48.1)
6 (26.1)
31 (41.3)
ns
Family history of suicide attempt
1 (1.9)
2 (8.7)
3 (4)
ns
Family history of completed suicide
2 (3.8)
1 (4.3)
3 (4)
ns
History of sexual abuse
11 (21.2)
3 (13)
BDI total mean score, (SD)
27.8 (12.9)
Substance abuse/dependence Nicotine Alcohol (current) Alcohol (past) Others (amphetamine, opiates, sedatives)
SSI total median score, (SD) SRRS total median score, (SD) Note. SD = standard deviation, ns = not significant. Crisis 2011; Vol. 32(5): 283–287
8 (7.9) 198 (184.4)
24.2 (14.5) 9 (7.9) 232.5 (256.9)
6 (8)
ns
14 (18.7)
ns
26.3 (13.1)
ns
8.0 (7.9)
ns
201.0 (200.6)
ns
© 2011 Hogrefe Publishing
L. F. Chan et al.: Inpatients with Depressive Disorder in a Malaysian Sample
tive risk factors for suicidal behavior among depressed inpatients.
Subjects Psychiatric inpatients between the ages of 18 to 76 years, who were being treated for a depressive disorder from May 2007 to October 2008, were eligible for inclusion in the study. A total of 75 consecutive inpatients with a DSM-IVTR depressive disorder according to the Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID – I/CV; First, Spitzer, Gibbon, & Williams, 1997) were recruited into the study. The following were excluded: 11 who did not give consent, 15 who could not comprehend English or Malay, 2 who were too ill to be interviewed, and 30 who were discharged before completing the assessment. Excluded patients did not differ significantly from the study subjects in terms of age (p = .675), gender (p = .052), and race (p = .221). This study received ethics approval from the Medical Research and Ethics Committee of UKMMC.
Instruments and Measures Axis I diagnoses including substance use disorders and anxiety disorders were assessed with the SCID – I/CV. Severity of depression was measured with the Beck Depression Inventory (BDI) that was translated into the national language (Malay) and backtranslated, and pretested on a separate sample of 10 psychiatric inpatients with depressive disorders. The internal reliability coefficient (Cronbach’s α) of this Malay version of the 21-item BDI was 0.956. A modified Malay version of the Social Readjustment Rating Scale (SRRS; Othman, 1986) was used to assess patients’ self-report of the magnitude of life event changes within the past 12 months. The severity of suicidal ideation was assessed using the Scale for Suicidal Ideation (Beck, Kovacs, & Weissman, 1979). A suicide attempt was defined as a nonfatal, self-inflicted destructive act with explicit or inferred intent to die. Occurrence within a month prior to baseline assessment
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was considered a current attempt; beyond that was considered a past attempt. Relevant data on sociodemographic and clinical factors were collected during the baseline clinical interview. Noncompliance to psychiatric medication was defined as the patient’s self-report of missing more than 30% of prescribed medication over a month (Scott, 2000).
Statistical Analysis The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 12.0. Bivariate tests included χ², independent t, Mann-Whitney, Kruskal-Wallis, Pearson, and Spearman’s rank correlation. Multivariate logistic regression models were conducted to estimate the independent predictive risk factors of suicide attempts for all variables with p ≤ .2.
Results The main methods of current suicide attempts were poisoning and cutting or stabbing (n = 6, 26.1% each). A third of the subjects (23/75) had made a current suicide attempt. Factors significantly associated with suicide attempts were race, religion, suicidal ideation, current alcohol abuse or dependence (Table 1), marital separation, major mortgage or loans, and change in personal habits in the past year (Table 2). From multiple logistic regression analysis (Table 3), the independent predictors of a current suicide attempt were Chinese race, being a newly diagnosed case of a depressive Table 2. Life event changes associated with suicide attempt Life event changes
Suicide attempt OR
95% CI
Marital separation
8.82
1.62–47.93
Major mortgage or loan
5.25
1.36–20.30
Change in personal habits 0.30 0.07–0.99 Note. OR = odds ratio, CI = confidence interval.
Table 3. Independent predictors of suicidal attempts from multivariate logistic regression Variables
B
S. E.
Wald, χ²
p
OR
95% CI Lower
Malay Chinese Indian
8.291 2.102
0.802
6.864
Upper
.016 .009
8.183
1.698
39.434
–0.008
1.077
