ÖZET
Çalışmamızda İstanbul Üniver-sitesi Cerrrahpaşa Tıp Fakülte-si Acil ServiFakülte-sine Şubat 1999-Ha-ziran 2001 tarihleri arasında in-tihar girişimi sonrasında baş-vuran ve çocuk psikiyatrisi kon-sültasyonu istenen 11-16 yaş-larındaki 40 çocuk incelen-miştir.Benlik saygısı, depres-yon ve anksiyete düzeyleri açı-sından psikometrik olarak de-ğerlendirilmiştir. Sonuçlar yaş ve cins bakımından deney
gru-buyla eşleştirilmiş ve geçmi-şinde psikiyatrik başvurusu ve intihar girişimine rastlanma-yan kontrol grubu ile karşılaş-tırılmıştır. Ayrıca tüm olgula-rın sosyo-demografik özellikleri belirlenmiştir.
Çalışmamızda ele alınan olgu-ların katılan olguolgu-ların erkek \ kız oranı 1\ 5.5 olduğu gö-rülmüş ve bunları çoğunlukla 15-16 yaş grubunda toplandık-ları tesbit edilmiştir.
Olguların tamamının intihar
girişim yöntemi olarak ilaç kullanımını tercih etmiş ol-dukları belirlenmiştir. Anılan popülasyonun yarısına yakını-nın daha önceden intihar gi-rişiminde bulundukları görül-müştür.
Bildirilen intihar girişim ne-denlerinden aile içi problemle-rin biproblemle-rinci sırada yer aldığı be-lirlenmiştir.
Anahtar kelimeler: İntihar gi-rişimi, Ergenlik, Depresyon, Anksiyete
> Burçin ALSANCAK, M.A1 > Neylan ZİYALAR, Ph.D2 > Levent KAYAALP, M.D1. 1İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi Çocuk Ruh Sağlığı ve Hastalıkları AD. İstanbul
2İstanbul Üniversitesi Adli Tıp Enstitüsü Cerrahpaşa Tıp Fakültesi Yerleşkesi. İstanbul
DEPRESYON VE ANKSİYETE
İNTİHAR GİRİŞİMİNDE BULUNMUŞ ERGENLERDE
İSTANBUL PİLOT ÇALIŞMASI
Stress events often precede adolescents’ suicides, including a loss of a romantic
relationship, disciplinary troubles in school or with the law, or academic or
family difficulties. (Omar & Hagedorn, 2001). As Garland et al. (1989) have
noted, there is a widespread and popular view of suicide attempt behaviour
which implies that youthful suicide attempts may occur in any young person
who is confronted. recognisable with recognisable life stresses and who makes
a suicide attempt as a means of coping with what appear, at the time, to be
insurmountable life stresses...
ABSTRACT
During the past three decades, many countries have repor-ted significant increases in ra-tes of suicide among young pe-ople. Researchers reported that the most important correlate for youth suicide is a previous
at-tempt. Attempted suicide pro-bably has a high prevalence in many countries including Tur-key.
In our study the assumption is that every suicide attempt is a sign that suicide can be carri-ed out. Under this assumpti-on, suicide attempts of a
gro-up aged 11 through16 have been
examined; the study made from the aspects of sex, age, reasons given, preferred methods and each case considered according to depression and anxiety .
Key words: Attempted
Suici-de, Adolescents, Depression, Anxiety
DEPRESSION AND ANXIETY AMONG ADOLESCENTS
A PILOT STUDY IN ISTANBUL
WHO ATTEMPT SUICIDE
INTRODUCTION
Schneidman defined suicide as “the human act of self inflicted, self intended cessation” and of-fered that this is a definition of suicidal behavior in adults that can also be applied to children (Schneidman, 1995).The term “at-tempted suicide” is an umbrel-la term that covers a number of different behaviors. Common to such behavior is that people inf-lict acute harm upon themselves, poison or injure themselves, or try to do so with a non-fatal out-come. Also common in such be-havior is the occurrence of condi-tions of emotional turmoil. Suici-de attempts are unSuici-dertaken with a view to, and expectation of acu-te self-harm or unconsciousness as a means of realizing changes through the actual or intended consequences (Kerkhof, 2000). Suicide attempts by adolescents are over 100 times more
frequ-ent than successful suicides (US Public Health Service). Suici-de attempts among youth have been shown to be associated with depression, substance use, loss of a family member or fri-end to suicide, and female gen-der. (Hollis, 1996; Crumley, 1990; Woods et al., 1997; Brent et al., 1993). Rates of both attempted suicides and completed suicides by adolescents have increased since the 1960s (Centers for Di-sease Control, 2000; Rosenberg et al., 1987; Wexler et al., 1978). Recent epidemiological studi-es suggstudi-est that the lifetime rate of suicide attempts among high school students ranges from 3% to 15% in US (Centers for Dise-ase Control, 2000; Lewinsohn et al., 1994; Shaffer and Hicks, 1992). Although the majority of these attempts are of low me-dical lethality (Lewinsohn et al., 1996), having made a past suici-de attempt is the strongest pre-dictor of both future suicide at-tempts and completions
(Haw-ton, 1992; Shaffer and Hicks, 1992).
Stress events often precede ado-lescents’ suicides, including a loss of a romantic relationship, discip-linary troubles in school or with the law, or academic or family difficulties. (Omar & Hagedorn, 2001).As Garland et al. (1989) have noted, there is a widespread and popular view of suicide attempt behaviour which implies that yo-uthful suicide attempts may oc-cur in any young person who is confronted with recognisable life stresses and who makes a suici-de attempt as a means of coping with what appear, at the time, to be insurmountable life stresses (Garland et al.,1989).It has been also determined that there exists a significant relationship betwe-en depression, anxiety and suici-dal behavior in children and ado-lescents (Pfeffer, 1986; Groholt et al., 2000; Beautroise, 1997; Stein et al., 1998; Wichstrom, 2000; La-dame et al., 1991).
Depressed youths often engage in suicidal behavior, and suicidal youths often meet criteria for af-fective disorders (Kovacs et al., 1993; Pfeffer et al., 1991). Simi-larly, evidence from both child-ren and adults has suggested a possible association between anxiety and the risk of attemp-ted suicide (Mattison, 1988; We-issman et al., 1989). Mood disor-ders, poor parent-child communi-cation, and a previous suicide at-tempt are also risk factors for su-icide in both boys and girls (Pfef-fer et al., 1991).
MATERIAL
AND METHOD
This study concerns all children and adolescents who were trea-ted at University of Istanbul Cer-rahpasa Medical Faculty’s Child Emergency Service in Febru-ary 1999- June 2001 as a result of suicide attempts. They were 40 in total comprised of 34 girls and 6 boys aged 11 through 16. The children were given a questionna-ire inquiring socio-demographic features, suicide attempt method, suicide attempt model, the rea-son for the attempt, how the sui-cide attempt was noticed and any information about previous at-tempts.
Subsequently, Child Depression Scale and State- Trait Anxiety In-ventory were applied to both sui-cidal and the control groups. The results have been evaluated by SPSS statistical analysis prog-ram.
RESULTS
As the age groups of the cases in our study were examined, it was seen that 5% of the cases were aged 11, 5% aged 12, 10% aged 13, 20% aged 14, 30% aged 15 and 30% aged 16.
As the gender groups in our cases were considered, the girls repre-sented 85% and the boys,15%. 62.5% of the cases came from a poor economic background, 37.5% had an average economic background, 90% belonged to a nuclear family while 10% belon-ged to a large family.
45% of the cases had previously attempted suicide while 55% had not. As suicide attempt histories were examined, 35% were found to have previously attempted sui-cide once, 5% twice and other 5% three times or more.
As the reasons for the suicide at-tempts were examined, following a suicide attempt model was fo-und in only 15% of the cases and this was the same for all the ca-ses of suicide attempts in which the model was ‘’a friend’’.
However, though drug overdo-se was identified as the method of suicide attempts for all of the cases studied, it should be no-ted that the study was conducno-ted on cases from child emergency services. Other attempts such as jumping from a high place or cut-ting an artery (slitcut-ting of wrists) would be taken to the orthopedic or surgery department.
There was a great difference bet-ween suicidal and control groups in consideration of alcohol use in the families. This situation was determined in the families (fat-hers) of 50% of the suicidal gro-up, but the same condition could not be found in the control gro-up. As the cases were examined according to chronic physical ill-ness in the families, this was fo-und in 7.5 % of the suicidal group and 5% of the control group. 90% of the suicide attempts were discovered as a result of inges-ting drug overdose (%65 parace-temol, %25 analgesics % 10 he-art medicine) in the presence of another person, or informing fri-ends or family members after the deed. The remaining 10% of the cases were found out through the discovery of empty drug contai-ners.
As the reasons given for suicide attempts were examined, at 55% family problems were found to be the primary motive, this fol-lowed by problems caused by the opposite sex, such as re-jection and splitting up, at 25%. The tertiary motive was identifi-ed as boridentifi-edom for unknown re-asons at 10% and the remaining motives as both a lack of har-mony in the social environment and/or school and any causative event that occurred in life with 5% each.
As the suicidal and the cont-rol groups were compared to each other by t-test according to Child Depression Scale and State- Trait Anxiety Inventory,
the following results were pro-duced: There was no meaning-ful difference from the statisti-cal viewpoint when the suicidal and control groups were compa-red on the basis of state anxiety (t=1.595, p>0.05), but there was an meaningful difference when they were compared on the ba-sis of trait anxiety (t=3.376, p<0.001). Considering depressi-on, statistically, there was a me-aningful difference between the groups (t=4.827, p<0.000).
DISCUSSION
In our study, it was found that in suicide attempts, frequency inc-reases with age. According to authors, it was stated that both the contemplation and threat of suicide were found in those un-der the age of 12, however inci-dence of suicide attempts increa-ses with respect to age from the age of 12 (Rosenthal and Rosent-hal,1984).
As the cases of suicide attempts were evaluated according to gen-der, the rate of attempts is higher in girls compared to that of boys. For suicide attempts, the com-parative rate of girls to boys
va-ries between 3/1 and 9/1 ( Haw-ton et al., 1982). In our study, this rate is identified as 5.5/1, agree-ing with authors. ( Joiner et al., 2000; Kohn et al., 1997; Apter et al., 1997; Negron et al., 1997; Groholt et al., 2000).
There are studies which prove that suicide attempts are related to the family socio-economic level ( Beautrois et al, 1997; ).Our study shows that attempted suicide ca-ses are mostly from low
socio-economic level families. More than half of the cases are from low-income families. All these re-sults are in concordance with li-terature. However Pfeffer states that suicide attempts have no re-lationship with features of social condition, age, gender, race or re-ligion. High socio-economic level families can prefer private hospi-tals or private surgeries and as a result those cases can be off re-cord. This probability supports Pfeffer’s theory (Pfeffer, 1986). Our study results show that 45% of cases have previously attemp-ted suicide. According to the aut-hors previously attempted suici-de cases occur between 14% and
50% (Hawton et al, 1982). As the number of suicide attempts inc-rease, future suicide attempt cri-ses can be heightened and more serious symptoms can occur as a result of more intense emotiona-lity. So it is obvious that a pre-vious suicide attempt is the most important risk factor for a futu-re attempt (Beck, 1997; Groholt et al, 2000; Stein et al, 1998; Wichs-trom, 2000; Joiner et al, 2000). Many authors have suggested
that imitation or copy cat beha-viour has a role in attempted su-icide.(Smith and Crawford,1986; Harkavy et al 1987;Hawton et al,1982).15% of the cases in our study reported that they know peers who have attempted sui-cide.
In half of the cases in our study, fathers are alcohol abusers, but in the control group neither fat-hers nor motfat-hers used alcohol. In Islamic religion poses strong sanctions against suicide and for-bids alcohol consumption
The rate of alcohol use in the adult population was reported as 0.9 % in a study considering 2000
Similarly, evidence from both children and adults has suggested
a possible association between anxiety and the risk of attempted
suicide (Mattison, 1988; Weissman et al., 1989). Mood disorders, poor
parent-child communication, and a previous suicide attempt are also
risk factors for suicide in both boys and girls (Pfeffer et al., 1991).
people, carried out in Turkey (Arı-kan et al, 1996). When this result was compared with both the ge-neral population and the control group, the difference was already statistically meaningful. In lite-rature, of the cases that have at-tempted suicide, 60% of the fat-hers and 30% of the motfat-hers used alcohol and harmful substances ( Jacobziner, 1965; Cohen-Sandler et al, 1982).
In our study cases, it was deter-mined that the mothers did not use alcohol. Even if the child be-haved as if rejecting the mother-father figures in the time du-ring their personality formati-on, the mother-father figures
re-mained the most important mo-dels of self-identification. See-ing the parents under the influen-ce of, or being controlled by al-cohol causes difficulty in this for-mation process. In such a case, the child is faced with an unreli-able model. Considering alcohol use, family violence can also be a current issue in the home. In one-to-one interviews with the child-ren, they stated that they were subject to some physical harm as a result of alcohol abuse by the-ir fathers. Most writers have
sta-ted that there is a relationship between physical mistreatment in the family and suicidal behavior in the child (Jacobziner, 1965; Gro-holt et al, 2000).
In some of the cases, one of the family members had a serio-us physical illness. According to some studies early and chronic life event stresses,particularly within the family context are as-sociated with suicidal behaviour in children and adolescents.(Haw-ton et al, 1982; Beautrois et al, 1997; Bergstrand and Otto, 1962, Pfeffer et al,1993). The illness of a family member can affect a child’s emotional needs, becau-se the person is probably
occu-pied with the illness, the child in stress cannot get the support he/ she needs. If one parent has the illness, the child feels that he/she is losing his love object. The child never again feels the same, men-tally or physically. Self respect decreases, lack of confidence grows, the child gets emotionally hurt and angry very easily (Gro-holt et al, 2000; Cohen-Sandler et al, 1982,Pfeffer et al,1994). All of the cases in our study in-gest drug overdose in the
suici-de attempt (%65 paracetemol, %25 analgesics, %10 heart medi-cine). In most of researches con-cerning attempted suicide, this is considered to be the most prefer-red method ( Hawton et al, 1982; Groholt et al, 2000; Bergstrand and Otto,1962).
It is also in accord with our study cases that mostly girls are sub-ject to suicide attempts and they prefer more soft methods than boys (Bergstrand and Otto, 1962). In suicide attempts, as impulsive and reactive, committing the ac-tion is highly related to the ava-ilability of the means. Drugs are preferred because they are al-ways at hand and easy to take
(Petzel and Cline, 1978; Hawton et al, 1982).
In our cases, 10% of suicide at-tempts were discovered beca-use the empty drug containers were found nearby, 90% were no-ticed because the child took the drugs near another person, or af-terwards informed other that they had attempted suicide. Howe-ver, the children stated that they had not deliberately arranged so-mething order to be noticed. For this situation it can be stated
There was no meaningful difference found between the state
anxiety scores of the suicidal and the control groups. State
anxiety is the anxiety felt in conditions that a person considers as
threatening. As this kind of anxiety is related to the condition of
the person, it is temporary.
that help is being called for. It is also possible that such suici-de attempts are not planned be-forehand, mostly done on impul-se, but the intention is being noti-ced by the others.
In 55% of our cases, it was stated that family problems were the re-ason for the suicide attempt. Most of the children and adolescents who attempted suicide had prob-lems within their families (Co-hen et al,1982; Bergstrand and Otto,1962, Beautrois et al,1997). There was no meaningful diffe-rence found between the sta-te anxiety scores of the suicidal and the control groups. State an-xiety is the anan-xiety felt in
condi-tions that a person considers as
threatening. As this kind of anxi-ety is related to the condition of the person, it is temporary. When com-pared with the control group, it’s seen that there was no difference in anxiety levels of the ones who had attempted suicide at the time that they filled the scale. Howe-ver there are meaningful differen-ces between two groups according to trait anxiety, which is not caused as a result of an external factor. It comes from within. The person thinks their personality values are under threat or they think that they are under stress and as a result feels anxious. A person who tra-itly feels anxious can cause himself harm. According to authors there is a relationship between trait
an-xiety and suicide attempts (Groholt et al, 2000; Beautrois et al, 1997; Stein et al, 1998).
As both of the groups were con-sidered according to depressi-on, there was already a meaning-ful difference. This identified that depression is an important factor in children’s suicide attempts .The studies are in agreement with the-se results ( Wichstrom, 2000; La-dame et al, 1991). Depressed young people often have lasting problems at school, difficulties in their peer relations and also difficulties with their parents. Impulsive behaviour and asocial behaviour are additio-nal risk factors for attempted su-icide among depressed young pe-ople.
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İletişim Adresi:
Neylan ZİYALAR, Ph.D.
İstanbul Üniversitesi Adli Tıp Enstitüsü Cerrahpaşa Tıp Fakültesi Yerleşkesi. Fatih/İstanbul
GSM: (0532)2616854 Tel: (0212)4143000/22804
