Suicidal behavior among drug addicts

ABSTRACT

Objective:

to describe the profile 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 conflict, important dates coinciding with the suicidal behavior and mothers with psychiatric history.

Key words:
Suicide; Suicide Attempt; Disorders Related to Substance Use; Risk Factors; Psychiatric Nursing

RESUMO

Objetivo:

descrever o perfil de dependentes químicos atendidos em um serviço de saúde mental, a frequência de comportamento suicida entre os participantes e as associações entre essas duas problemáticas.

Método:

estudo exploratório, retrospectivo e descritivo baseado em abordagem quantitativa, e dados coletados dos prontuários de pacientes com diagnósticos F10 a F19, segundo a CID10, atendidos no serviço no ano de 2013. Buscou-se identificar possível associação entre as variáveis independentes (história familiar, psiquiátrica e pessoal) e a variável dependente (comportamento suicida).

Resultados:

Maioria homens, solteiros, com baixa escolaridade, desempregados e idade entre 15 e 45 anos, 43,90% apresentaram registro de comportamento suicida.

Conclusão:

os dependentes químicos com comportamento suicida são jovens com idade inferior a 30 anos, que possuem alguma comorbidade psiquiátrica, transtornos de humor e/ou depressão, presença de conflito familiar, datas importantes coincidindo com o comportamento suicida e cujas mães têm história psiquiátrica.

Descritores:
Suicídio; Tentativa de suicídio; Transtornos Relacionados ao Uso de Substâncias; Fatores de Risco; Enfermagem Psiquiátrica

RESUMEN

Objetivo:

describir el perfil de dependientes químicos atendidos en servicio de salud mental, frecuencia de comportamiento suicida entre los participantes y asociaciones entre ambas problemáticas.

Método:

estudio exploratorio, retrospectivo, descriptivo; basado en abordaje cuantitativo. Datos extraídos de historias clínicas de pacientes con diagnósticos F10 a F19, según la CID10, atendidos en el servicio durante 2013. Se buscó identificar posible asociación entre las variables independientes (historia familiar, psiquiátrica y personal) y la variable dependiente (comportamiento suicida).

Resultados:

Mayoría de hombres, solteros, de baja escolarización, desempleados, edad entre 15 y 45 años. 43,90% cuenta con registros de comportamiento suicida.

Conclusión:

los dependientes químicos con comportamiento suicida son jóvenes de edad inferior a 30 años, que padecen 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

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 health¹.

The II Brazilian National Alcohol and Drug Survey² 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 use³.

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 population⁴.

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 problem⁵. 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 help⁴.

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 attempts⁶. 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 depression⁷.

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 families⁸.

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 service⁹. 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 method because it provides a better insight into the research problem and also generates hypotheses that can be evaluated by other forms of study¹⁰. 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 (χ²), 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).

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

Characteristics		n	(%)
Sex	Female	31	25.20
	Male	92	74.80
Marital Status	Married/Stable Union	24	19.51
	Single	56	45.53
	Separated	30	24.39
	Widower	4	3.25
	No information	9	7.32
Education	Illiterate	3	2.44
	Some Elementary or Middle School	91	73.98
	Elementary or Middle School	3	2.44
	Some High School	6	4.88
	High School	6	4.88
	Some College	2	1.62
	No information	12	9.76
Children	Yes	70	56.91
	No	53	43.09
Age	Under 15 years	5	4.06
	15 to 30 years	43	34.96
	31 to 45 years	49	39.84
	46 to 60 years	23	18.70
	61 to 75 years	3	2.44
Employment situation	Employed	19	15.45
	Unemployed	64	52.03
	Retired	9	7.32
	No information	31	25.20

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).

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

Behaviors		n	%
Suicidal behavior	Yes	54	43.90
	No	69	56.10
Suicidal ideation	Yes	37	30.08
	No	86	69.92
	Total ideation	82
	Mean ideation	0,66
Suicidal attempt	Yes	40	32.52
	No	83	67.48
	Total suicide attempts	72
	Mean suicide attempts	2
Perpetration methods (ICD-10)	(X60-X69) – Self-poisoning	36	32.73
	(X70) – Hanging, strangulation and suffocation	24	21.82
	(X71) – Drowning and submersion	2	1.82
	(X76) – Smoke, fire and flames	1	0.91
	(X78) – Sharp object	8	7.27
	(X80) – Jumping from a high place	4	3.64
	(X81) – Jumping or lying before moving object	7	6.36
	(X84) –Unspecified means	28	25.45

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 drug-addicted 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).

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

	Variables		Suicidal behavior		χ2	p value
			Yes %	No %
Psychiatric history	Hospitalization	Yes	54.35	45.65	3.26	0.053
		No	37.66	62.34
	Hospitalization in therapeutic community	Yes	43.59	56.41	0.00	0.560
		No	44.05	55.95
	Type of discharge	Medical discharge	46.15	53.85	0.02	0.533
		Discharge by Abandon-ment/Escape	44.44	55.56
	Treatment time	Less than or equal to 5years	40.70	59.30	1.19	0.186
		More than 5 years	51.35	48.65
	Age of admission	Up to 30 years	62.50	37.50	11.06	0.001
		31 years or over	32.00	68.00
	Began using drugs in childhood/adolescence	Yes	38.36	61.64	2.24	0.095
		No	52.00	48.00
	Began with legal drugs	Yes	30.23	69.77	4.63	0.25
		No	51.79	48.21
	Began with illegal drugs	Yes	66.67	33.33	1.54	0.207
		No	40.86	59.14
	Psychiatric comorbidity	Yes	57.89	42.11	8.44	0.003
		No	31.82	68.18
	F20-F29 – Schizophrenia, schizotypal and delusional disorders	Yes	60.00	40.00	1.12	0.212
		No	40.78	59.22
	F20 – Schizophrenia	Yes	57.14	42.86	1.12	0.219
		No	42.20	57.80
	F30-F39 – Mood (affective) disorders	Yes	63.89	36.11	8.26	0.004
		No	35.63	64.37
	F32-F33 – Depressive episode and Recurrent depressive disorder	Yes	68.75	31.25	10.84	0.001
		No	35.16	64.84
	(F40-F48) (F60-F69) (F70-F79) (G40-G45)	Yes	50.00	50.00	0.32	0.377
		No	42.86	57.14
Familyhistory	Family psychiatric history	Yes	45.56	54.44	0.682	0.344
		No	39.39	60.61
	Father	Yes	41.30	58.70	0.20	0.398
		No	45.45	54.55
	Mother	Yes	76.47	23.53	8.50	0.004
		No	38.68	61.32
	Father and Mother	Yes	48.08	51.92	0.64	0.269
		No	40.85	59.15
	Extended family	Yes	45.78	54.22	0.37	0.341
		No	40.00	60.00
	Previous nuclear family	Yes	44.87	55.13	0.08	0.462
		No	42.22	57.78
	Current nuclear family	Yes	50.00	50.00	0.16	0.466
		No	43.36	56.64
	Family history of ideation	Yes	0	100	0.79	0.561
		No	44.26	55.74
	History of consummated suicide	Yes	80	20	2.76	0.116
		No	42.37	57.63
	Family conflict	Yes	56.67	43.33	7.75	0.005
		No	31.75	68.25
Personal history	History of losses	Yes	41.67	58.33	0.03	0.560
		No	44.14	55.86
	Loss of parental figures in childhood	Yes	60.00	40.00	0.55	0.385
		No	43.22	56.78
	Important dates coinciding with the suicidal behavior	Yes	100	0	6.66	0.015
		No	41.53	58.47
	History of traumatic experiences	Yes	62.50	37.50	1.20	0.233
		No	42.61	57.39
	Criminal conduct	Yes	41.18	58.82	0.14	0.433
		No	44.94	55.06

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^13-15. 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^13-15, 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 addiction¹⁵.

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 out¹⁶.

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 unit¹⁴. 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 youth¹⁷. 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 individuals¹⁸. 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 poison¹⁹. Another study that investigated ideations, plans and attempts showed that most of them consisted of self-poisoning¹⁸.

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 generations²⁰.

WHO says that suicide is the second leading cause of death worldwide among young people from 15 to 29 years⁴. 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 substances²¹. 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 attempts².

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 disorders²². 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 suicide²³.

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 family²⁴.

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 services²⁵. 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.

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Publication Dates

• Publication in this collection
  Mar-Apr 2016

History

• Received
  04 Mar 2015
• Accepted
  14 Nov 2015