Suicidal behavior among drug addicts

Objective: to describe the profi le of drug addicts attended in a mental health service, the frequency of suicidal behavior among the participants and the associations between these two problems. Method: an exploratory, retrospective and descriptive study based on a quantitative approach, and data collected from medical records of patients with F10-F19 diagnoses according to the ICD-10 treated in this service in 2013. We expected to identify a possible association between independent variables (family, psychiatric and personal history) and the dependent variable (suicidal behavior). Results: Most of the individuals were men, single, with a low educational attainment, unemployed and aged between 15 and 45 years; 43.90% had a record of suicidal behavior. Conclusion: drug addicts with suicidal behavior are young people under the age of 30 presenting psychiatric comorbidity, mood disorders and/or depression, presence of family confl ict, important dates coinciding with the suicidal behavior and mothers with psychiatric history.


INTRODUCTION
Dependence and abuse of psychoactive substances characterize a serious public health problem in Brazil and in the world.In 2012, between 162 and 324 million people, i.e., from 3.50% to 7.00% of the world population between 15 and 64 years, consumed illicit drugs at least once.There are an estimated 16 to 39 million current drug users and 183 thousand deaths related to this harm to health (1) .
The II Brazilian National Alcohol and Drug Survey (2) showed that Brazil consumes 20% of the world's cocaine, being the biggest crack market.Regarding marijuana, estimates show that 3% of the adult population are frequent users, the equivalent of more than 3 million people; men use 3 times more marijuana than women and 1% of the male population is addicted.Other relevant data shows that nearly 67 million people consume alcohol regularly, of which 17%, i.e., approximately 11 million, present abusive use or dependency.
The problem of drug addiction reflects on individuals, bypassing their health issues and reverberating on their social, psychological and family demands.There are many possible influences of the family environment on the issue of the use and abuse of psychoactive substances, such as: parental support deficiency, overprotection of children, presence of an implicit culture of drug use, existence of conflicts and violence, misinformation and ignorance about drug use (3) .
Thus, this problem is inserted in several areas, with emphasis on the connection that it presents with suicidal behavior, being a risk factor for its occurrence.This is also a public health problem, presenting an estimated of 804 thousand deaths worldwide in 2012, representing a global rate of 11.60 deaths per 100 thousand population (4) .
Suicide arises from the interaction of psychological, social and cultural factors.Suicidal behavior must be analyzed in its different expressions, including suicidal ideation, planning and the completed attempt.Between 10 and 20 attempts are estimated for each suicide consummated, which shows the extent of the problem (5) .In addition, as risk characteristics for suicide, there are history of previous attempts, harmful use of alcohol, financial problems, chronic pain and family history of suicide.We also highlight the stigma associated with mental illness as a barrier for the individuals to seek help (4) .
The relationship between alcohol consumption, attempted suicide and depression was investigated in a study that presented harmful use of alcohol, history of attempted suicide, depression, use of psychiatric drugs and HIV seropositivity as risk factors associated with suicide attempts (6) .A literature review of publications from 1991 to 2009 about alcohol use and suicide points depression as a frequent forerunner of alcohol abuse and this consumption pattern as an aggravating factor for that disorder.Suicidal behavior was identified as a risk factor in situations in which there is an association between alcohol abuse and depression (7) .
Male users of alcohol and other drugs in treatment in Psychosocial Support Centers (CAPS) have reported drug use as motivation for suicidal behavior.They also mentioned hopelessness and family relationships made vulnerable by the dependence and the intention to end their own lives to stop family discomfort.By hurting themselves and losing their lives, they would no longer mistreat their own families (8) .
In that context, we emphasize the importance of health care for individuals involved with drugs.Nurses, because of their important role in promoting community health and for being professionals that deal directly with these demands in health services, have great responsibility in identifying risk situations, especially the ones related to drug addiction and abuse and to suicidal behavior, regardless of the level of health care, to avoid the anticipation the end of life.
Based on the extent of the issue of the problematic use of psychoactive substances and of suicide as well as the association between both situations, the objective of this research is to describe the profile of drug addicts treated in a mental health service, the frequency of suicidal behavior among participants and the associations between these two problems.

METHOD Ethical aspects
This research has met the ethical aspects provided by the National Health Council Resolution 466/2012, and received approval of the Human Research Ethics Committee of Universidad Federal de São João del-Rei.

Design, study location and period
An exploratory, retrospective and descriptive study, with a quantitative approach, carried out in a Psychosocial Support Center III (CAPS III), a mental health reference unit of the Midwest of Minas Gerais, Brazil.It is a municipal health service that offers daily treatment to people with serious and persistent mental disorders, with an operating capacity for municipalities of over 200,000 inhabitants, installed in 1997.The service offers 3 health care modes: urgency and emergency -which provides care for people with mental disorders experiencing crises-, outpatient treatment with scheduled appointments and a 1-day stay service (9)   .The study was conducted from August 2014 to February 2015, a period that involved data collection, registering and analysis.

Study protocol
Data were collected by documentary analysis of the service records filed in the unit.Documentary research is a relevant alguna comorbilidad psiquiátrica, trastornos de humor y/o depresión, presencia de conflicto familiar, fechas importantes coincidentes con comportamientos suicidas, y cuyas madres tienen historia psiquiátrica.Palabras clave: Suicidio; Intento de Suicidio; Trastornos Relacionados con Sustancias; Factores de Riesgo; Enfermería Psiquiátrica.method because it provides a better insight into the research problem and also generates hypotheses that can be evaluated by other forms of study (10) .For data collection we used a form built specially for this research, containing the following variables: sociodemographic characteristics (sex, marital status, educational attainment, children, age, employment situation); psychiatric history (treatment record, drug use, psychiatric comorbidity and type of discharge from CAPS); family history (suicidal behavior and psychiatric family history); personal history (recent losses, loss of parental figures in childhood, traumatic experiences, criminal conduct and important dates coinciding with the suicidal behavior) and history of suicidal behavior (suicidal ideation and suicide attempt).

Population or sample; inclusion and exclusion criteria
The population was composed of 144 medical records that met the following inclusion criteria: treatment in 2013, records of diagnosis between F10-F19 (Mental and Behavioural Disorders due to psychoactive substance use) in the International Classification of Diseases (ICD-10) (11) , with or without psychiatric comorbidity.To identify the medical records we used the service's monthly control journal, which contains the admissions and the diagnoses of patients.The sample was intentional since we selected all the medical records of patients present at the service in 2013 who fulfilled the inclusion criteria.We chose the year of 2013 because it was the last full year available before the data collection, since the Ethics Committee approved the project in 2014.Of this population, 21 medical records were excluded for not being found in the service; the remaining 123 constituted the final sample of the research and were analyzed.

Analysis of the results and statistics
Data were coded and typed into a previously programmed Microsoft Excel 2010 spreadsheet.They were subsequently transported to the statistical program SPSS 17.0 (Statistical Package for the Social Sciences) for descriptive and association among variables analyses.In the descriptive analysis, mean values and standard deviation were calculated for the quantitative variables, and absolute and relative frequency for the qualitative variables.To calculate the statistical significance of associations we used Pearson's Chi-square test (χ 2 ), with a significance level of 5% (p≤0.05) to identify a potential association between independent variables (family, psychiatric and personal history) and the dependent variable (suicidal behavior).

RESULTS
The sociodemographic variables characterized all 123 drug addicts with diagnoses between F10-F19, by ICD-10, treated in the service.The data were found in the admission sheets of patient record and show that most were male (74.80%), single (45.53%), with an educational attainment of only some elementary or middle school (73.98%), had children (56.91%), were aged 15 to 45 years (74.80%) and unemployed (52.03%) (Table 1).Of the 123 records analyzed, 43.90% had a history of suicidal behavior.We considered suicidal behavior as the presence of ideation and/or attempt in the record.In isolation, ideation appeared in 30.08% and attempt in 32.53% of the records consulted.Considering that the same patient may present more than one ideation or attempt, the total was 82 ideations and 72 attempts, resulting in a mean and standard deviation of 0.66 (1.59) ideations and 2.00 (1.22) attempts by individual.For the latter, perpetration methods were used 110 times, knowing that a single attempt can involve more than one; the most frequent one was self-intoxication (35%) (Table 2).
Analyzing the distribution of the variables related to psychiatric history, we noted that at admission the mean age and standard deviation of patients was 34.85 years (12.66 years).Most records (59.35%) mentioned beginning of drug use in childhood and adolescence, with a legal drug as the first one (58.90%),especially alcohol.We identified the presence of psychiatric comorbidity in 46.34% of the records.Since some individuals presented more than one comorbidity, they totaled 79.Diagnoses of mood disorders (F30-F39) were the most frequent, with 45.57% among the 6 groups of comorbidities found.
Regarding the story of treatment outside CAPS, 37.40% of the records showed a history of treatment in psychiatric hospitals and 31.71% in therapeutic communities or rehabilitation clinics.About the treatment discharges from CAPS III in the researched period, 21.95% were due to abandonment or escape.
We observed that the majority (73.17%) of dependents had psychiatric family history.The extended family (grandparents, father, mother, siblings, uncles, nephews and cousins) showed a 67.48% frequency, the previous nuclear family (father, mother and brothers), 63.41%, and the current nuclear family (spouse and children), 8.13%.About the family history of suicidal behavior, 5 records had reports of attempted suicide in the family.Family conflict was present in 48.78% of patients.
Regarding personal history, 4.07% of the records reported the loss of parental figures in childhood, and the exact same percentage showed important dates coinciding with the suicidal behavior, including the end of romantic relationships and death of family members.There was a total of 9.76% of losses around the time of admission, and 5.69% of drugaddicted patients reported traumatic experiences as a result of violence, including sexual and physical abuse as well as murder.We also found that 27.64% had a history of criminal conduct, meaning that they had been arrested.
Observing the results from the inference test, we verified that age was associated with suicidal behavior until 30 years (p<0.001).The presence of psychiatric comorbidity was associated with suicidal behavior (p<0.003).Mood disorders (p<0.004) and depressive disorders (p<0.001) were also associated.We also observed an association between suicidal behavior and the presence of maternal psychiatric history (p<0.004),familiar conflict (p<0.005) and important dates (p<0.0015).

DISCUSSION
Male prevalence among addicts corroborates the results of similar studies.A study describing the profile of Psychosocial Support Centers -Alcohol and Drugs patients found a male prevalence of 88.15% (12) .When sex was evaluated only among alcohol dependents, a male predominance of 89.9% (13) was also noted.
Low educational attainment showed a considerably higher frequency of some elementary or middle school (73.98%), while in other studies there was predominance of elementary school or middle school (13)(14)(15) .The most frequent employment situation was unemployment, which reveals the influence of the dependence pattern on the individual's social relations.By association, the low educational attainment can also contribute to this problem.Considering that in the sample studied most individuals started using drugs in childhood or adolescence, the need for treatment in a specialized service, in adulthood, can be evaluated.In this case, we can infer the influence of this use in the social context of these individuals.
As for marital status, research involving drug addicts usually shows a majority of single people (13)(14)(15) , which is in agreement with  this study.It is worth mentioning that this may result from the difficulty in relating to others because of the role of drugs in their life as well as the struggle to maintain relationships that can outlast the conflicts generated by the abuse of psychoactive substances.The study revealed that 80% of participants had had stable unions and that the separation was directly related with the drug addiction (15) .About having children, we obtained a positive response in most records of this study and, researching the literature we found the percentage of 66.2%.It should be noted that the problem of drug addiction takes over the issues regarding the individual, causing consequences for the family institution and reflecting on descendants.Emotional overload is common as a result of conflicts that arise, making the family feel helpless, invalid and worn out (16) .
The mean age at admission of 34.85 years (12.66 years) is corroborated in a study that also described the profile of drug addicts in a medical rehabilitation unit (14) .These data may characterize the dependency, given the need for treatment in a specialized service.The frequencies of hospitalization in psychiatric hospitals and in therapeutic communities, when observed, confirm the severity of the cases and, therefore, the need for specific and full-time health care of these patients.Treatment abandonment and escape had a significant percentage of 21.95%, worth investigating.
The early use of drugs during childhood occurred for the majority of individuals investigated; the most frequent one was alcohol.Neglect and abandonment, physical aggression, lack of family dialogue and, primarily, the culture of drug abuse in the family environment are identified as possible determinants for the initiation of drug use in youth (17) .Thus, the role of the family in this context must be supportive to prevent this matter, stressing the importance to pay attention to the identification of young people in complicated situations.
A population-based study found a prevalence of suicidal ideation in 17.1% and attempt in 2.8% of the investigated individuals (18) .Comparing with the frequency found in this study among drug addicts, we observed 30.08% and 32.52% for ideation and attempt, respectively.These data demonstrate a higher prevalence of suicide among drug addicts and how much the risk factors should be routinely investigated in the evaluation of a patient's suicide risk.
Self-intoxication and hanging were the most common suicide means.A study evaluating 80 suicide attempts in pre-hospital environment found that 55% were self-poisoning by medicine and 22.5% by poison (19) .Another study that investigated ideations, plans and attempts showed that most of them consisted of self-poisoning (18) .
The considerably high frequency of psychiatric family history and the maternal background association with suicidal behaviour provoke reflection on family influences, transgenerational pattern of chemical dependency and suicidal behavior.A study conducted in six CAPS of Minas Gerais identified, among crack users in treatment, a repeating pattern of intrafamily violence, conflicts or disruptions of relational intrafamily bonds and dependency throughout generations (20) .
WHO says that suicide is the second leading cause of death worldwide among young people from 15 to 29 years (4) .The data found in this investigation corroborates this statement, since they associate the age of 30 years or less with the suicidal behavior.The years of potential life lost with premature and avoidable death of these individuals are a fact to reflect upon.
The existence of psychiatric comorbidities in drug addicts was a risk factor for suicidal behavior.The diagnoses showed that mood disorders and depression can lead to suicidal behavior, a relation already shown in the literature.Mood disorders are the main psychiatric disorders associated with suicide, followed by the use and abuse of psychoactive substances (21) .National estimates show that more than two in every 10 suicide attempts were related with the use of alcohol.Therefore, this is a phenomenon strongly associated with depression, and combined they present a significant association with suicide attempts (2) .
A study conducted in a medical unit of a university hospital involving people with suicidal ideation showed significantly higher rates of moderate and severe depressive disorders (22) .A study on the prevalence of depression in the primary health care, associating it with abuse, alcohol addiction and suicide risk, found that people presenting suicide risk had a 2.5 higher chance of depression than those without risk of suicide (23) .
Family conflict is also in the literature as a decisive factor for suicidal behavior among drug addicts.A study regarding the social representations about drugs, developed by family members of drug addicts, identified feelings of vulnerability, helplessness and frustration concerning the treatment of the disease, perception of drugs as something that harms family relationships, being responsible for conflicts and disharmony in the family (24) .The end of romantic relationships and deaths of family members as influential causes of suicidal behavior, given the association observed, show the influence of personal history in this behavior.Thus, we highlight the relevance of this history in the lives of individuals, in their conduct and decisions, noting that the identification of risk situations is imperative, since dependency itself is a risk.
These data demonstrate the extent of the problem by identifying that it is not restricted to specialized mental health services, but present throughout the health care setting.A study that investigated the role of nurses of the family health strategy in addressing drug addicts found gaps in the academic training of these professionals regarding the topic, which limits their practice in the referrals to mental health services (25) .We reiterate, therefore, the importance of having trained professionals who can identify risks related to suicidal behavior in any health sector to prevent the premature death of drug addicts.

CONCLUSION
This study described the profile of addicts treated in a psychosocial support center, the frequency of suicidal behavior among these people and the associations that can lead to it.
We highlight the profile of addicts who show suicidal behavior in the institution.They are young people with psychiatric comorbidity, mood disorders and/or depression, presence of family conflict, important dates coinciding with the suicidal behavior, and whose mothers have psychiatric history.
The relevance of this investigation enabled the knowledge of these factors and provided constructing inferences important to understand the issue of suicide and its relationship with chemical dependency.The knowledge of characteristics on these themes, their relationships and repercussions, is important for nursing in all its activities in the health care area, knowing that the understanding of these factors improves the identification of both problems and, thus, enables effective interventions of prevention and assistance.
Given the results, this study may base the construction of political actions and programs focused on these problems, as well as the conduction of other studies that contribute to understanding suicidal behavior among drug addicts.
As limitations, there is the fact that this is an intentional sample, which did not allow the investigation of all the drug addicts that had already been treated in the service, and the statistical method that did not enable comparison among non-addicts.

Table 1 -
Distribution of sociodemographic variables and suicidal behavior among drug addicts in treatment at the Psychosocial Support Center III, 2013

Table 2 -
Distribution of suicidal behavior among drug addicts in treatment at the Psychosocial Support Center III, 2013

Table 3 -
Association between family, psychiatric and personal history among drug addicts with suicidal behavior