REVIEW ARTÍCULO DE REVISIÓN
Revisión sistemática de los factores de riesgo de suicidio e intento de suicidio entre los pacientes psiquiátricos de América Latina y el Caribe
Germán L. TetiI; Federico RebokII; Sasha M. RojasIII; Leandro GrendasII; Federico M. DarayII
IHospital Braulio A. Moyano, Buenos Aires, Argentina
II3ra Cátedra de Farmacología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina. Send correspondence to: Federico M. Daray, email@example.com
IIIDepartment of Psychological Science, University of Arkansas, Fayetteville, Arkansas, United States of America
OBJECTIVE: To analyze published evidence from the Latin America and Caribbean (LAC) region pertaining to risk factors for completed suicide and suicide attempts among psychiatric populations.
METHODS: Potential studies were identified through systematic electronic searches in MEDLINE and LILACS. Included studies were cohort, case-control, and cross-sectional designed investigations of psychiatric samples in which suicide or a suicide attempt was reported as an outcome and evaluated with some measure of impact (odds ratio, risk ratio, or hazard ratio). Methodological quality was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations.
RESULTS: Of the 2 987 identified studies, a total of 17 studies were reviewed to determine potential suicidal risk factors. Eleven studies used a case-control design, five used a cross-sectional design, and only one study used a prospective-cohort design. The main risk factors for suicide attempts in LAC included major depressive disorder (MDD), family dysfunction, and prior suicide attempt, while the main risk factors for completed suicide were male gender and MDD. The methodological quality of most of the studies was low.
CONCLUSIONS: This review provides evidence that the majority of relevant risk factors for suicide and suicide attempts in the LAC region are similar to those observed in Western societies but different from those reported in Eastern societies. Studies of higher methodological quality from the region are needed to support these results.
Key words: Suicide; suicide, attempted; risk factors; Latin America; Caribbean region.
OBJETIVO: Analizar los datos probatorios publicados de la región de América Latina y el Caribe (ALC) que fueran pertinentes a los factores de riesgo de suicidio consumado e intentos de suicidio entre las poblaciones psiquiátricas.
MÉTODOS: Se seleccionaron los posibles estudios mediante búsquedas electrónicas sistemáticas en MEDLINE y LILACS. Se incluyeron estudios cuyos diseños de investigación fueran de cohortes, de casos y controles, o transversales de muestras psiquiátricas, y en los que el suicidio o un intento de suicidio se notificaran como un resultado, y se evaluaran mediante alguna medida de la repercusión (razón de posibilidades, razón de riesgos o razón de riesgos instantáneos). Se evaluó la calidad metodológica mediante el uso de las recomendaciones de la iniciativa de Fortalecimiento de la Notificación de los Estudios Observacionales en Epidemiología (STROBE, por sus siglas en inglés).
RESULTADOS: Se analizaron 17 de los 2 987 estudios seleccionados con objeto de determinar los posibles factores de riesgo de suicidio. Once estudios usaron un diseño de casos y controles, cinco usaron un diseño transversal, y un único estudio usó un diseño de cohortes prospectivo. Los principales factores de riesgo de intento de suicidio en ALC fueron el trastorno depresivo mayor (TDM), la disfunción familiar y el intento de suicidio previo, mientras que los principales factores de riesgo de suicidio consumado fueron el sexo masculino y el TDM. La mayor parte de los estudios mostraron una mala calidad metodológica.
CONCLUSIONES: Esta revisión aporta datos probatorios de que la mayor parte de los factores de riesgo pertinentes al suicidio y los intentos de suicidio en la región de ALC son similares a los observados en las sociedades occidentales pero diferentes a los notificados en las sociedades orientales. Se necesitan estudios regionales de mayor calidad metodológica para apoyar estos resultados.
Palabras clave: Suicidio; intento de suicidio; factores de riesgo; América Latina; región del Caribe.
Suicide and suicide attempts are critical issues among the general population and are classified among the leading causes of death and injuries worldwide. Approximately 1 million individuals die by suicide each year (1). Estimations suggest that by the year 2020 the number of deaths by suicide will increase by 50%, reaching an annual rate of 1.53 million individuals (2). In the last 45 years, suicide rates have increased by 60% worldwide (2). Suicidal behavior is a more frequent problem than completed suicide. For every completed suicide there are 10 - 20 times more individuals who attempt suicide (3).
Across Latin America and the Caribbean (LAC), reported incidences of suicide occur at variable rates (4). In the Caribbean region, the rates range between 0.1 per 100 000 inhabitants (in Jamaica) and 23.1 per 100 000 inhabitants (in Guyana) (4). In South America, the highest incidences of suicide are observed in Uruguay and Cuba, with values that range between 17 and 18 per 100 000 inhabitants. The lowest rates of completed suicide are found in Peru and Bolivia (1.9 and 2.3 per 100 000 inhabitants respectively). Other countries, including Argentina, Brazil, Chile, Colombia, Ecuador, and Venezuela, show intermediate incidence (2, 4).
Various strategies are available to significantly reduce the likelihood of death by suicide. Attention to the study of suicidal risk factors is a fundamental step in understanding and preventing suicide (5, 6). A risk factor for suicide is defined as any detectable characteristic of an individual or group of people proved to be associated with an increased probability of suicide (5, 7). This is particularly relevant because risk factors are identifiable and can serve as warning signs before the suicidal act, allowing for time to anticipate and apply appropriate intervention to prevent suicidal behavior (6). Risk factors for suicide and suicide attempt may not be universal. For this reason, culturally informed preventive strategies that enable improved assessment of risk factors across diverse populations are needed.
While suicide is a serious problem in high-income countries, 84% of all suicides worldwide occur in low- and middle-income countries. Unfortunately, current evidence for the latter group of countries is scarce and of poor quality (8). As mentioned above, risk factors for suicide may not be universal. To increase understanding of different suicidal risk factors across different cultures, evidence must be generated locally, worldwide. The aim of this study was to analyze published evidence from the LAC region on risk factors for completed suicide and suicide attempts among psychiatric populations.
MATERIALS AND METHODS
A systematic literature search for evidence published between January 1966 and August 2012 was completed using the MEDLINE (PubMed) and LILACS (Latin American and Caribbean Health Sciences) databases. The search of the MEDLINE database used the following terms: (Suicide [Mesh] OR suicide* [Tiab] OR Suicide Attempt [Mesh] OR Suicide atte* [Tiab]) AND (Risk Factors [Mesh] OR risk* [Tiab]) AND (Follow-Up Studies [Mesh] OR Follow-up stud* OR Prospective Studies [Mesh] OR Prospective stud* OR Cohort Studies [Mesh] Cohort Stud* [Tiab] OR Case-Control Studies [Mesh] OR Case-Control Stud* [Tiab]). The search of the LILACS database used the following combination of terms: "Suicide" or "suicide attempt" AND "risk factors" AND NOT "suicidal ideation." The reference lists of each retrieved article were also scanned to identify any additional papers of relevance. All research that met the inclusion criteria, in any language, were considered. The inclusion criteria were: 1) study is an original work; 2) included analysis of suicide attempts, defined as a potentially self-injurious act with a nonfatal outcome and evidence that the person intended at some level to kill himself/herself (9); 3) included analysis of completed suicide, defined as a death from injury, poisoning, or suffocation where there was evidence that the injury was self-inflicted and that the decedent intended to kill himself/herself (9); 4) included some measure of impact (odds ratio (OR), risk ratio (RR), or hazard ratio (HR)); 5) used a case-control, cross-sectional, or cohort study design; 6) was conducted with patients from the LAC region; and 7) included only clinical patients in the study sample. Exclusion criteria were: 1) study is a review; 2) examined only suicidal ideation as an outcome variable; 3) had no measures of impact (i.e., did not include ORs, RRs, or HRs); 4) was a case report or used a case series study design; and/or 5) was conducted with patients outside the LAC region.
Each team member worked independently and extracted selected studies by using a data extraction sheet. Data were collected for the following variables: author name(s); year of publication; country of study; study design; study outcome (suicide or suicide attempt); evaluated risk factors; and ORs, RRs, or HRs with the corresponding 95% confidence intervals (CIs) and P values.
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations were used to assess the methodological quality of the evaluated studies. The STROBE recommendations include a checklist of 22 items (criteria) designed to evaluate the quality of scientific articles. The 22-criteria checklist evaluates three main study designs for analytical epidemiology: cohort, case-control, and cross-sectional (10). Two reviewers independently assessed the quality of the articles by calculating the percentage of the STROBE criteria met by each article ("STROBE score"), and any disagreement was resolved by consensus. Selected articles were listed in descending order by the STROBE score. The criteria used to determine the overall quality assessment (on a scale of A - D) has been used in previous reviews (e.g., (11)). Three categories of quality assessment were established: 1) the study fulfilled more than 80% of STROBE criteria, 2) the study met between 50 - 80% of STROBE criteria, and 3) the study met less than 50% of STROBE criteria.
The primary literature search yielded a total of 2 987 studies. After initial review of each of the study abstracts, 2 905 studies were eliminated for not meeting the inclusion criteria described above, leaving a total of 82 articles to be read in greater detail. After applying the inclusion criteria to the full text, a total of 17 articles were included in the final review (Figure 1).
Table 1 describes the 17 studies selected for the literature review, including details about the control and case groups. Eleven of the studies used a case-control design, five used a cross-sectional design, and one had a prospective-cohort design. The majority of studies had a relatively low sample size; only five had a sample size with 200 or more patients. Almost all studies had a sample population of adult clinical patients; only five evaluated adolescent populations. All 17 studies evaluated risk factors associated with suicide attempts but only three evaluated risk factors associated with completed suicide. The studies included in the review were conducted in six different countries: five study samples were from Brazil, four from Cuba, three from Chile, two from Mexico, two from Colombia, and one from Argentina.
Table 2 provides a summary of all risk factors associated with completed suicide and suicide attempts. Risk factors that appeared in more than one of the included studies are described below by type of variable.
Demographic variables. Female gender, a predetermined factor, was associated with a greater frequency of suicide attempts in three of the four studies that evaluated gender as a risk factor (12 - 15). In contrast, all studies evaluating the gender ratio for completed suicide indicated the frequency was greater among males than females (13, 16).
Physical and mental health. All seven studies that evaluated major depressive disorder (MDD) as a risk factor found an association with suicide attempts (6, 12, 14 - 18). Two of the studies (12, 15) obtained results from patients experiencing substance dependence or substance abuse. In addition, Torres et al. (17) found an association between suicide attempts and MDD among patients diagnosed with obsessive-compulsive disorder (OCD). All studies that examined MDD as a risk factor for completed suicide (7, 16) found an association for that variable.
Sixty percent of the studies that evaluated anxiety disorder as a risk factor found an association with suicide attempts (15 - 19). Post-traumatic stress disorder (PTSD) was also associated with suicide attempts in the two studies that evaluated this diagnosis (17, 20), but both studies were conducted among patients with comorbid OCD (17) or comorbid bipolar disorder (20). Impulse control disorder was also found to be associated with suicide attempts in the two studies that evaluated it as a risk factor (6, 17). In addition, two-thirds of the studies that examined substance abuse as a risk factor for suicide attempts found a positive association (16, 19, 21). Alcohol intoxication prior to a suicide attempt was associated with an increased likelihood of a suicide attempt in the study that evaluated it as a risk factor (21). Finally, a prior suicide attempt was significantly associated with an increased risk of a new suicide attempt in each study that evaluated this variable as a risk factor (6, 13, 22).
Family variables. Each study that evaluated different forms of family dysfunction found a positive association for suicide attempts (18, 23 - 25). Two of these studies were obtained from an adolescent patient sample (24, 25). Family structure and lack of social support were risk factors for suicide attempts in all studies that evaluated these variables (6, 18, 23, 26).
Table 3 lists the studies included in the literature review in descending order by STROBE score. All 17 studies had a STROBE score between 23% and 86%. Only two studies (12%) had a STROBE score considered to be of high quality (above 80%).
Suicide has been linked to multiple risk factors, including mental health factors, social factors, and biological factors (5). For the purposes of suicide prevention, it is fundamental to understand the factors associated with an increased likelihood of suicide and suicide attempts. To the best of the authors' knowledge, this study is the first systematic review of risk factors for suicide and suicide attempts among psychiatric patients in the LAC region. A total of 17 articles were systematically examined to search for relevant risk factors associated with completed suicide or suicide attempts among patients from LAC. This study did not identify significant differences in risk factors for suicide and suicide attempts in the LAC region compared to those for the general population of Western countries. The LAC risk factors for suicide and suicide attempt did differ, in some respects, from those seen in Eastern countries. While the literature review for this study indicated a total of 23 prominent risk factors, only 10 were examined in more than one study. Taken collectively, the 10 prevalent risk factors indicate that male gender and MDD are significantly associated with completed suicide. Risk factors for suicide attempts included female gender, MDD, anxiety disorder, PTSD, previous suicide attempt, and family dysfunction.
Consistent with studies based on community and clinical samples from Western societies (27 - 29), the current study found that women had a greater likelihood of attempting suicide whereas men had a higher rate of completed suicide. This finding differs from those reported in China and India (8, 30 - 32). Substantial research suggests a prior suicide attempt is the greatest predictor of a future suicide attempt or completed suicide (33 - 37). A meta-analysis based on psychological autopsy found suicide attempts and deliberated self-harm to be the most significant risk factors associated with suicidal behavior (OR = 16.33; 95% CI = 7.51 - 35.52) (34). Similarly, findings from this review suggest a prior suicide attempt to be a prominent risk factor for suicide and suicide attempts among psychiatric patients in LAC.
The evidence suggests that individuals suffering from affective disorders are at an increased likelihood for suicide (35, 38 - 40). Among the observed research from the LAC region, all studies found MDD to be a risk factor for suicide and suicide attempts. The relationship between anxiety disorders and suicide attempts has been a subject of great debate in previous literature (41, 42). Specifically, research reports that patients suffering from anxiety disorders are at an even higher risk for suicide than previously assumed (43, 44). In the LAC region, three of five studies indicated a significant relation between anxiety disorder and suicide attempts. However, it was unclear which type of anxiety disorder was more associated with suicide attempts. In the current study, all research that evaluated PTSD as a risk factor found a positive association with suicide attempts. Several studies indicate substance use disorder is related to suicidal behavior among clinical populations (45 - 47). For example, in the systematic review by Hawton et al. (47), substance misuse (alcohol and/or drug) was a variable associated with risk for suicide in individuals with depression. In the current study, only two-thirds of the reviewed works identified substance abuse as a risk factor for suicide attempts. However, alcohol intoxication prior to suicide attempt was a risk factor in the one study that evaluated it as a risk factor (21). Based on these results, future research in the LAC region may benefit by examining suicidal risk factors specific to these disorders separately and among comorbid relationships.
Family dysfunction is considered a critical factor for suicidal behavior among individuals from Western societies (48, 49). The current study found a variety of family factors associated with suicide attempts. Specifically, four of the reviewed studies suggest increases the likelihood of suicide attempts among patients. In addition, a poor family structure was found to be positively associated with suicide attempts. Therefore, it seems important to gain further understanding of family risk factors among patients in LAC. However, future research is needed to quantify the operational definition of family dysfunction in the LAC region. In this study, the articles that evaluated family dysfunction as a risk factor used different instruments to assess this construct. It is important to consider the social context when evaluating risk factors for suicidal behaviors. Results from community samples and patients from high-income countries indicate limited social connectedness is associated with suicidal behaviors (50). However, social disconnection may differ across different cultures. For example, widowed, divorced, or separated women from India and China report a reduced risk of suicide versus other causes of death, compared to married women, whereas women and men from the United States who have separated from their spouses are at higher risk for suicidal behaviors compared to married individuals (30). In the current study, the lack of social support was associated with suicide attempts in the two studies that evaluated this risk factor, similar to findings from high-income countries.
In the general population of LAC, specifically among adolescents, suicide rates have been rising in almost all Latin American countries. Nicaragua reports the highest rates of completed suicide among adolescents in Latin America (51). To date, family or personal history of suicide attempt, intra-family violence, physical and sexual abuse, poor communication between family members, frequent moves of the family nucleus, rigid family environment, authoritarianism or loss of authority between parents, identification and idealization of figures (icons) of other adolescents who committed suicide, and crowding and living together in small and closed space are thought to be risk factors for suicidal behavior among adolescents in LAC (51). Suicide rates among the elderly are also increasing, especially in Argentina, Chile, Cuba, Puerto Rico, and Uruguay. Specific risk factors among this population include loneliness and estrangement, social isolation, and income reduction accompanied by changes in the economic situation (50). Studies among community samples from this region would help to further identify unique risk factors for suicidal behavior among individuals in the LAC region.
This study includes an evaluation of quality for each study included in the literature review. Only 12% of the studies were of high quality (STROBE score of 80% or greater), indicating the need for work of higher quality from this region. Initially, the authors planned to complete a meta-analysis of all of the studies included in the review. However, due to the low quality of the studies found in the review, the meta-analysis was eliminated. The validity of the results from a meta-analysis depends on the quality of the individual studies, and analysis of a combination of biased studies can further boost the bias. Thus, carrying out more high-quality scientific studies in areas in the LAC region will help generate public health policies based on valid data.
This study had some limitations. As noted, the majority of the studies found in the literature review were of poor quality based on their STROBE score. Furthermore, only one of the 17 studies used a prospective study design, the design that produces the most accurate results when evaluating risk factors. Data from five of the included studies were cross-sectional, limiting the authors' ability to infer causal relationships between the studied risk factors and outcome variables (suicide attempts and completed suicide). Despite the limitations related to the study designs, studies were included in the review to help identify possible associations between exposure variables and an event at a given time. Future work pertinent to the study of risk factors for suicidal behavior within this region would benefit from using prospective study designs. Notwithstanding the limitations described above, the current study provides a detailed evaluation of empirical evidence on risk factors for suicide and suicide attempts observed among clinical patients from the LAC region. The results suggest that the majority of relevant risk factors for suicide attempts and completed suicide found in the LAC region are similar to those observed in Western societies but differ from those reported in Eastern societies. Future research of higher quality is needed, including studies with robust designs and larger samples, to better understand the risk factors for suicide attempts and completed suicide in the LAC region.
Based on this study, the main risk factors for suicide attempts include MDD, family dysfunction, and prior suicide attempt, and the main risk factors for completed suicide include male gender and MDD. The methodological quality of the majority of studies on suicide attempts and completed suicide in the LAC region conducted between 1966 and 2012 was of low quality. The risk factors for both suicide attempts and completed suicide in the LAC region are similar to those observed in Western societies but different than those reported in Eastern societies.
Acknowledgments. Germán L. Teti is a recipient of a research fellowship from the Ministry of Health of the City of Buenos Aires. Federico Rebok is a recipient of a Ramón Carrillo-Arturo Oñativa research fellowship from the Ministry of Health of Argentina, and a researcher for the Ministry of Health of the City of Buenos Aires. Federico Manuel Daray is a researcher for the National Scientific and Technical Research Council (Consejo Nacional de Investigaciones Científicas y Técnicas, CONICET).
Conflicts of interest. None.
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Manuscript received on 28 February 2014
Revised version accepted for publication on 14 June 2014