Suicidal patients in a psychiatric emergency unit : clinical characteristics and aggression profile

OBJECTIVE
To explore and describe a profile of patients admitted to a psychiatric emergency facility, comparing patients with and without a recent suicide attempt in terms of their clinical characteristics and aggression.


METHODS
This was an exploratory comparative study where patients were assessed using the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Scale (OAS). Participants with a suicide attempt in the last 24 hours (SA) were compared to participants with a prior history of suicide attempt but no recent attempt (PHSA).


RESULTS
63 individuals (SA: 26; PHSA: 37) were selected. Both groups had similar demographic and clinical characteristics. The most prevalent diagnoses were mood (57.1%) and personality (50.8%) disorders. The majority of patients in both groups had a history of aggression episodes. Physical aggression in the week prior to admission was more prevalent in the PHSA group (51.4 vs. 19.2%, p = 0.017). The PHSA group also presented higher activation scores (p = 0.025), while the SA group presented higher affect scores on BPRS dimensions (p = 0.002).


CONCLUSION
The majority of individuals with a history of suicide attempt also presented a history of aggression. Inpatients with recent suicide attempt were hospitalized mainly due to the risk of suicide, while those with no recent suicide attempt were hospitalized mainly due to the risk of hetero-aggression. These findings support the hypothesis of an aggressive profile in suicidal patients and may open up a path for future research.


Introduction
Suicide is a global issue and a serious public health problem. 1 According to the World Health Organization (WHO), approximately one million people commit suicide each year worldwide.It is the second leading cause of death among people aged 15 to 29 years. 1 The Brazilian Mortality Information System (Sistema de Informação sobre Mortalidade [SIM-2013]) reports that the suicide rate in Rio Grande do Sul is the highest in Brazil (10.18 per 100,000 inhabitants). 2The mesoregion of east-central Rio Grande do Sul ranks first (15.96),and the center-west sits in fifth place (10.04).Both easily surpass the national mean of 5.01 per 100,000 inhabitants. 2There has been a rise in the mortality rate by suicide among the youth in recent years, although it is still more frequent in the elderly. 3uicide attempts are common and constitute a serious problem for public health, thus it is very important to evaluate risk factors for suicidal behavior, in order to plan strategies for its monitoring and prevention, as well as intervention strategies.Previous self-harm is considered a major risk factor, while mental disorder severity, aggression, impulsivity, and hopelessness seem to predispose to suicide. 4 The relationship between suicide, aggression and impulsivity was investigated in a postmortem study that showed that impulsive-aggressive traits play a greater role in suicide, particularly in younger individuals. 5Other studies have shown that aggression, impulsivity, and suicidality can be understood as interrelated personality facets. 6,7us, the objective of the present study was to describe a profile of the patients admitted to a psychiatric emergency facility, comparing patients with a recent suicide attempt vs. patients with a previous history of suicide attempt but not a recent attempt.This comparison will focus on their clinical characteristics and history of aggression, as aggression is one of the risk factors for suicide attempt.

Method
This was an exploratory comparative study without a control group.This work is part of a larger study that investigated aggressive behavior in psychiatric hospitalization.The methodology employed is fully described elsewhere. 8is was a cross-sectional study that included psychiatric inpatients aged between 18 and 65 years.
Subjects with a diagnosis of delirium were excluded.
Individuals subjected to clinical hospitalization due to suicide attempts were transferred to the Psychiatric Unit after initial clinical management.For the present study, we selected all participants who had attempted suicide in the 24 hours prior to admission (SA) and those who had a prior history of suicide attempt but no recent attempt (PHSA).

Instruments
These instruments were applied at the time of patient admission.
The OAS was used to record the episodes of aggression that occurred in the hospital.The instrument divides episodes into four types: verbal aggression, physical aggression against objects, physical aggression against self, physical aggression against other people. 14he instrument was applied daily throughout the patient's stay.History of aggression was assessed using the same criteria adopted for the OAS.

Statistical analysis
Analyses

Results
Of the 152 general psychiatric admissions registered during the period of the study and meeting the inclusion criteria, 139 patients were available to be interviewed by the researchers (13 left the hospital before the interview because they were subjected to a short period of observation only).Another two patients were excluded because they had a diagnosis of delirium.Of the 137 patients interviewed in the prior study, 63 were selected to the present analysis.There were 28 cases of suicide attempts in the 24 hours prior to admission (SA group).Two subjects were admitted twice due to suicide attempts over the time of the study, but only one admission was considered.Table 1 presents the general characteristics of the sample.
In the SA group, five participants (7.9%) had no prior history of suicide attempt.The mean number of suicide attempts was 3.1 (±3.0), with no statistically significant differences between the groups.Figure 1 illustrates the frequencies and methods of suicide attempts in the 24 hours prior to admission as well as those that occurred previously among participants.The two groups (SA and PHSA) were comparable regarding methods used in past suicide attempts (no significant difference).Violent methods for suicide attempts within 24 hours of admission (hanging, self-cutting, jumping from height, and vehicular impact) were used in 68% of the cases, and non-violent methods were used in 32%.
Participants had, on average, an income of R$ 1,654.85±1,330.38per month, and their disorders had begun at 25.4±12.5 years of age.There was no significant difference between the groups regarding these variables.Age at the beginning of psychiatric treatment was lower in the PHSA group (x = 32±13 vs. x = 25±12; p = 0.043), and the SA group had been on psychiatric treatment for less time (x = 5.5±7.4 years vs. x = 11.6±10.4years; p = 0.002).
There were differences between genders in the SA group in some variables.The majority of men were not followed by a mental health professional (81.8%), and this was the first visit to HUSM for many of them (72.7%).

14.3%
).There were no significant differences between the groups regarding these variables.
The majority of individuals were using some psychopharmaceutical at the time of admission (71.4%); however, 63.5% used it irregularly.Figure 2 shows the types of medications in use.A statistically significant difference was found only for the use of lithium.
A statistically significant association was found for reason for admission.In the SA group, suicide risk was cited most often (88.5 vs. 24.3%;p < 0 .001),while in the PHSA group, the risk of hetero-aggression was most commonly cited (48.6 vs. 19.2%;p = 0.020).
Table 2 presents the frequency of aggression and its relationship to recent suicide attempt.OAS scores presented no differences between the groups.

Discussion
This study aimed to describe the profile of patients with a history of suicide attempt subjected to psychiatric hospitalization at a tertiary reference hospital serving the central micro-region of the state of Rio Grande do Sul, southern Brazil.Aggression was present in the majority of individuals with suicidal behaviors.][16][17][18] The profile of the patients who were admitted to the psychiatric ward of HUSM after a suicide attempt was mainly of young adults with low education, living with partners or families, employed, without previous psychiatric hospitalization, irregularly using psychopharmaceuticals, and with prior suicide attempt.
The majority of the participants presented a history of aggression in the past and in the previous week.Twofifths remained aggressive during their hospitalization.
Participants as a whole had received previous emergency psychiatric treatment at the hospital, had used one or more psychopharmaceuticals (usually irregularly), and had a history of prior suicide attempt(s).
The methods of suicide attempt were mainly drug overdose (with prescription drugs), jumping from height, and self-cutting.Previous studies have also found that suicide attempters were adults in their thirties, with low education and cohabiting. 19,20he main difference between the two groups analyzed in the present study was that the PHSA participants showed an increased risk of heteroaggression.They more commonly had a history of physical aggression in the week before admission.In the same way, they had more activation symptoms, but fewer depressive symptoms.
In the PHSA group, more patients were followed by a mental health professional, and they were receiving psychiatric treatment for more time.The PHSA group also had a higher number of previous psychiatric hospitalization and used more lithium. 21The literature points out that lithium is a medication that may reduce suicide attempts independently of its mood stabilizing effects. 22,23  of aggression and depression have been seen as motivation-forming factors for suicide attempt. 24,25e relationship between aggression, impulsiveness and suicidal behavior has been well established in the literature over the course of decades. 15A postmortem study found an association of impulsiveness and aggression with suicide in youths and a negative correlation with age. 16In a study developed in China with university students, impulsiveness was revealed to be a characteristic that could increase the likelihood of acting against one's own life, because it might facilitate the transition from suicidal thoughts to suicidal acts/ behavior.The literature also points out that students with higher aggression ratings are more likely to commit suicide. 15A study that compared individuals with non-suicidal self-aggression, without self-aggression and suicidal individuals found a higher prevalence of aggression among the first and third groups compared to the second, as well as a history of physical and/ or sexual abuse in childhood, anxiety disorder, and substance use disorder. 17he most prevalent diagnoses in our sample were precisely mood disorders, personality disorders, and substance use disorders.Impulsiveness and aggression are traits present in various disorders (mood disorders, substance abuse, personality disorders -primarily those in Cluster B).Impulsive-aggressive traits lead to increased suicide risk. 16The literature also suggests that impulsiveness and aggression can be seen as part of the same construct. 15One study reported that individuals with depression and bipolar disorder presented greater impulsiveness and aggression than controls. 26Impulsiveness may therefore be a marker for suicide risk, strongly correlated with aggression in individuals with mood disorders.Aggressive and suicidal behaviors also share psychological and biological correlates. 15In the same way, there is evidence supporting the role of emotion dysregulation and personality and behavior alterations in the occurrence of suicidal behavior among individuals with those psychiatric disorders.Special attention should be given to individuals with these diagnoses, because they are more likely to complete suicide. 27Furthermore, the methods chosen to attempt suicide may also have been related to impulsiveness and aggression among our participants.We found that violent methods were used to attempt suicide in the last 24 hours before admission in the majority of the SA group.Individuals who attempted suicide using violent methods presented higher impulsiveness and aggression than those who used methods considered nonviolent (poison, drowning, drug overdose, etc.). 18In Brazil, the methods most commonly employed for suicide are hanging and firearms (violent methods). 28Suicide attempts leading to hospitalization are more common in the presence of intoxication (alcohol, medication and poisoning). 29mpleted suicide was most commonly observed in men, single individuals, and those using hanging, whereas nonlethal attempts predominated among women, with overdose of prescription drugs being the preferred method. 30Despite that, non-violent methods leading to hospitalization accounted for the minority of cases in our study.
Repeated suicide attempts were very common among participants.A literature review concluded that the main risk factor for repeated suicide attempts is having a history of a prior attempt and that the strongest suicide predictors are history of suicide attempt, advanced age, and/or high suicide ideation. 31 the same way, a recent study showed that after a first suicide attempt, the main risk factors for complete suicide are advanced age and hospitalization after the first attempt. 32The greatest risk of death by suicide is in the first year after an attempt, even for repeaters. 33 to 90% of deaths by suicide occur over the first 24 months after an attempt. 30ter discharge, there is a greater risk of suicide in the first week, primarily in individuals who live alone.
A population-based cohort study conducted in Denmark reported that suicide attempts and suicides occurred more often in the first week after discharge from the emergency service. 34In the same study, the authors reported that 87% of the people who died by suicide had consulted an emergency department due to a suicide attempt only once -i.e., the next attempt was fatal.
Uribe et al. found that suicide occurred most probably on the first or second attempt. 34These data emphasize the need for suicide prevention strategies targeted at people receiving care for suicide attempts, since it is well-known that suicide attempt is the main risk factor for completed suicide, as shown by a metanalysis of 24 studies of psychological autopsies. 35Brazilian study showed that only one-third of the people who attempted suicide sought treatment at an emergency service. 36In this sense, aggression and impulsiveness could serve as markers for future suicide attempt, and the individuals presenting these traits should be referred to a mental health service for evaluation.
Future research shall seek to investigate this.
Our study has some limitations.We did not assess all clinical factors that are related to suicide attempts (e.g., acute and chronic stress exposure and life adversities).In addition, sample size did not allow for the calculation of predictive values of measures or for the inclusion, in our analyses, of clinical factors that could also be associated with a recent suicide attempt (e.g., drug and alcohol dose).There is also the possibility of confounding effects of the psychiatric medications.In the same way, we do not know the length of time elapsed since the most recent suicide attempt for participants who attempted suicide in their lifetime but not in the previous week (PHSA group).As well, the study did not have a control group, and this is because of its naturalistic design.Thus, even though the methodology employed here does not allow assessing risk factors for suicide attempt, it does allow raising considerations about this particular profile of patients, and helps improve our understanding of the problem.
In addition, due to the exploratory nature of our study, we did not adjust for multiple comparisons.Despite the fact that this paper used appropriate statistical tests, generalization of the results is not possible, and no further assumptions can be made.Notwithstanding, exploratory and comparative designs are useful to provide means for generating hypotheses to be tested in future studies.
The association between aggression and suicide is well supported in the literature.If not every suicide attempt is motivated by impulsiveness and aggression, our study shows that the phenomena may be observed jointly in a significant portion of the patients hospitalized for suicidal behavior.Our exploratory comparative design showed differences between the groups in terms of reason for hospital admission, use of lithium, and duration of psychiatric treatment before hospital admission.The differences found in terms of the presence of an aggressive episode in the week prior to admission may provide soil for future research.It is suggested, as a public health strategy, that individuals hospitalized for suicide attempt and/or with a history of aggression be properly followed for preventing suicide.

Figure 1 -
Figure 1 -Frequency of methods of suicide attempts in the last 24 hours prior to admission, compared to previous suicide attempts, in both groups.PHSA = patients with a prior history of suicide attempt but no recent attempt; SA = patients who attempted suicide within 24 hours of admission.

Figure 2 -
Figure 2 -Use of psychopharmaceutical at the time of admission.PHSA = patients with a prior history of suicide attempt but no recent attempt; SA = patients who attempted suicide within 24 hours of admission.

Table 1 -
Comparison of demographic variables of individuals in the two groups PHSA = patients with a prior history of suicide attempt but no recent attempt; SA = patients who attempted suicide within 24 hours of admission; SD = standard deviation.* College or vocational/technical schools.† Living arrangement had one missing value.

Table 2 -
Relationship between suicide attempt and aggression PHSA = patients with a prior history of suicide attempt but no recent attempt; SA = patients who attempted suicide within 24 hours of admission.