Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 166 Emergency (2014); 2 (4): 166-169 ORIGINAL RESEARCH Predictive Factors of Suicide Attempt and Non-Suicidal Self-Harm in Emergency Department Saad Salman1*, Jawaria Idrees2, Fahad Hassan3, Fariha Idrees4, Mashaal Arifullah5, Sareer Badshah6 1. Department of Psychiatry and Drug Detoxification Centre, Post Graduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan 2. Department of Zoology, Islamia College University, Peshawar, Pakistan 3. Islamia College University, Peshawar, Pakistan 4. Department of Chemistry, Islamia College University, Peshawar, Pakistan 5. Jinnah College for Women, Peshawar, Pakistan 6. Department of Statistics, Islamia College University, Peshawar, Pakistan Abstract Introduction: Suicide is the third cause of mortality in America, second leading cause of death in developed coun- tries, and one of the major health problems. Self-harm is self-inflicted damage to one’s self with or without suicid- al intent. In the present study, the predictive factors of suicide attempt and non-suicidal self-harm were evaluated in patients referred to emergency department (ED) with these problem. Methods: The total number of 45 pa- tients with suicide attempt or self-harm admitted to ED were included. Clinical symptoms, thoughts and behav- iors of suicidal, and non-suicidal self-harm in these patients were evaluated at baseline. Suicidality, suicidal intent and ideation, non-suicidal self-injury, social withdrawal, disruptive behavior, and poor family functions were evaluated at admission time. Brief clinical visits were scheduled for the twelfth weeks. In the twelfth week, pa- tients returned for their final visit to determine their maintenance treatment. Finally, data were analyzed using chi-squared and multiple logistic regression. Results: Forty-five patients were included in the study (56.1% fe- male). The mean age of patients was 23.3±10.2 years (range: 15-75; 33.3% married). Significant association of suicide and self-injury was presented at the baseline and in the month before attempting (p=0.001). The most important predictive factors of suicide and self-harm based on univariate analysis were depression (suicidal and non-suicidal items of Hamilton depression rating scale), anxiety, hopelessness, younger age, history of non- suicidal self-harm and female gender (p<0.05). The participants’ quality of life analysis showed a significant high- er quality in physical component summary (p=0.002), mental component summary (p=0.001), and general health (p=0.001) at follow up period. Conclusion: At the time of admission in ED, suicide attempt and non-suicidal self- harm are subsequent clinical markers for the patient attempting suicide again. The most independent predictive factors of suicide attempt and self-harm were poor family function, hopelessness, non-suicidality items of Hamil- ton depression rating scale, history of non-suicidal self-harm, and anxiety disorders. Key words: Suicide, attempted; self-injurious behavior; emergency services, psychiatric; mental disorders; pre- dictive value Cite this article as: Salman S, Idrees J, Hassan F, Idrees F, Arifullah M, Badshah S. Predictive factors of suicide attempt and non- suicidal self-harm in emergency department. Emergency. 2014;2(4):166-9. Introduction:1 uicide is the third cause of mortality in America, second leading cause of death in developed coun- tries, and one of the major health problems global- ly (1-4). Suicidality in adults have been remarkably rec- ognized as a factorial analysis of family perceptions, childhood abuse, social integration or neglect, and other social factors that can be a reason for the suicide at- tempt (5, 6). Anxiety disorders and depression increase *Corresponding Author: Saad Salman; Department of Psychiatry and Drug Detoxification Centre, Post Graduate Medical Institute, Lady Reading Hospital, Pakistan. Fax/Tel: 091-9222009; Email: saadirph@gmail.com Received: May 2014; Accepted: July 2014 the jeopardy for suicide and suicidal intent, ideation and behavior. It maybe increases the risk even more, if the depression, anxiety, and hopelessness left untreated (7, 8). The relationship between suicide attempts and other psychiatric disorders such as eating, anxiety, con- duct, and substance use disorders is very common. Non-suicidal self-harm (NSSH) is “self-inflicted damage to one’s self that lack evidence of suicidal intent” (9). On the other hand, self-harm can be defined as “attempt of harming one’s self with or without suicidal intent” (10, 11). Based on above-mentioned, the aim of the present study was to evaluate predictive factors of suicide at- tempt and non-suicidal self-harm in patients referring S mailto:saadirph@gmail.com This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 167 Salman et al to emergency department (ED). Methods: This prospective cohort study was conducted in ED of Lady Educational hospital, Post Graduate Medical Insti- tute Peshawar, Pakistan, during May to October 2012. The study protocol was approved by local ethic commit- tee and in accordance with Helsinki declaration. All re- spondents completed informed consent. The subjects were followed twelfth weeks after admission. Forty-five patients with suicidal attempt or self-harm, referred to the study protocol by their primary care provider immediately at the time of admission, were consequently entered to the study. The exclusion crite- ria were as follow: Subjects who were received antide- pressant-antipsychotic (alone or in combination during the preceding six months), co-morbid mania or bipolar disorder, psychotic symptoms, and substance use dis- order or dependence. Suicidality, suicidal intent and ideation, non-suicidal self-injury during the before month, social withdrawal, disruptive behavior, family functions, and quality of life were evaluated and submitted in data gathering files at the time of admission. McMaster Family Assessment Device 12-item was used to check the patient’s family and social condition (12). Hamilton Depression Rating Scale was applied to assess the depression in the partic- ipants (13). For checking the physical health of patients, General Functioning Scale was used (14). A clinical visit was scheduled for the twelfth weeks to regular psychiatric follow-ups. The clinical progress were evaluated during face-to-face encounter. In this context, suicide/self-harm attempt and quality of life (the SF-36 questionnaire) (15) during follow ups period were asked from subjects. Patients were divided to two groups included suicide or self-harm and those who lack of them during the follow up period. Demographic variables and other baseline values were compared between both groups. The t-test was performed for continuous data and chi-squared analysis conducted for categorical or dichotomous data. Potential differences were reported in terms of statisti- cal significance (p-value) as well as odds ratio (OR) whenever applicable. Statistical significant differences were defined as a p-value less than 0.05. SPSS version 20.0 was used for data analysis. Results: Forty-five patients were included in the study (56.1% female). The mean and standard deviation of patients’ age was 23.3±10.2 years (range: 15-75, 33.3% mar- ried). Table 1 summarizes the baseline demographics data of patients. Eight (17%) cases attempted suicide in the before month and 15 (33%) ones during the follow- up period. Significant association of suicide and self- harm was presented at the baseline and in the month before attempting (p=0.001). In addition, there was a remarkable relationship between suicidal intent and attempt at the time of admission and the last month (p=0.01). Social problems was significantly associated with self-harm which consequently prop up the patient to attempt suicide (odds ratio=1.8, p=0.055). The most important predictive factors of suicide and self-harm based on univariate analysis were depression (suicidal and non-suicidal items of Hamilton depression rating scale), anxiety, hopelessness, younger age, history of non-suicidal self-harm and female gender (p<0.05). Ta- ble 2 and 3 show the results of multivariate logistic re- gression analysis of independent predictive factors of suicide and self-harm, respectively. As it can be seen only family function (p=0.0001), hopelessness (p= 0.02) and higher levels of non-suicidality items of Hamilton scale (p=0.03) were independent predictors of suicidal attempt in follow up period. As well, independent pre- dictors of self-harms in fallow up period were history of non-suicidal self-harm (p<0.003), higher levels of non- suicidality items of Hamilton scale (p=0.023), hopeless- ness (p= 0.001), and anxiety (p=0.011). Table 4 shows the quality of life at baseline and follow up. The partici- pants’ quality of life analysis showed a significant high- er quality in physical component summary (p=0.002), mental component summary (p=0.001), and general health parameters (p=0.001) at follow up period. Discussion: The present study was based on evaluating the reasons of suicide attempt and non-suicidal self-harm. Based on the main findings of the present study the most im- portant predictive factors of suicide attempt and self- harm were as follow: family function, hopelessness, and non-suicidality items of Hamilton scale, history of non- suicidal self-harm, and anxiety. This investigation re- vealed that hopelessness plays an important role in Table 1: Baseline demographic characteristics of participants. Demographic parameters Number (%) Age (years) 23.3 (SD=10.2) Gender Female 25 (56.1) Male 20 (43.9) Marital status Married 15 (33.3) Single 30 (66.7) Educational level Graduate 10 (22.7) Under graduate 15 (33.0) Under diploma 20 (44.3) Occupational status Employed 6 (13.3) Unemployed 39 (86.7) This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Emergency (2014); 2 (4): 166-169 168 future suicides. Another important finding of this study was that depression did not clearly indicate if they- would commit suicide again or not. Hopelessness and self-harm were two independent variables. The quality of life of the patient was lower at baseline. Further- more, it indicated that the patient’s mental and physical conditions encouraged the subject to attempt suicide or at least injure, because of catch the attention or due to hopelessness. Quality of life scores were lower but for hopelessness greater at baseline. Self-harm was highly reflected the abysm of social mishaps and a greater lev- el of complexity among the young adolescents as well as adults (1, 9, 10). Hopelessness and anxiety disorders were correlated with self-injury but it was not apparent that the patient attempted suicide as well (16). One study revealed that depressed patients, who were hos- pitalized, were not prone to suicide. But the ratio of self-harm among the depressed adolescents was more than the healthy young participants (17, 18). The poten- tial risks of suicide at baseline and follow-up caused the patient to attempt subsequent suicide. The reason of the attempt(s) were severity of depression, anxiety, hopelessness, loss of a friend, unwanted sex, unwilling separation from a friend or partner, drug abuse, rape, parental problems, and problems with siblings (3, 18). Non-suicidal self-injury is a common practice among adolescents, thus the results cannot be only generalized to this fact that one or more attempt may not lead to the suicide. For further validation of the results, they should be checked on a larger population. Limitation During the course of study, several variables left “un- treated” including data collection for substance abuse, drug or alcohol addiction as well as prescriptive drug addiction, personality disorders, suicidal intent in the previous life history, and previous mental illnesses that Table 2: Independent predictors of suicide attempt based on multivariate logistic regression analysis. Variable Odds Ratio 95% Confidence interval P Suicidality item of Hamilton scale 3.20 0.82–5.25 0.51 History of non-suicidal self-harm 3.43 0.20–8.43 0.23 Non-suicidality items of Hamilton scale 2.53 1.55–2.90 0.03 Hopelessness 2.44 1.29–3.80 0.02 Family functioning 4.11 1.53–5.19 <0.001 Age 0.50 0.38–1.13 0.32 Female 1.34 0.34–1.66 0.41 Table 3: Independent predictors of suicidal self-harm during follow-up based on multivariate logistic regression analysis  Variable Odds Ratio 95% Confidence interval P Suicidality items of Hamilton scale 0.60 0.55–1.49 0.55 History of non-suicidal self-harm 23.2 5.87–60.1 0.003 Non-suicidality items of Hamilton scale 1.80 1.37–2.23 0.02 Hopelessness 2.94 1.49–8.71 0.001 Family functioning 1.15 0.42–1.68 0.34 Anxiety disorder 3.77 1.38–10.65 0.01 Table 4: Quality of life scores of the Patients at baseline and follow up period of the study  Items Baseline Mean (SD) follow up Mean (SD) P Mental component summary 41.3 (8.60) 68.3 (9.10) 0.001 Physical Functioning 38.1 (35.9) 39.0 (28.5) 0.56 Vitality 57.3 (23.9) 56.2 (21.2) 0.87 Physical role 51.2 (25.1) 51.0 (19.3) >0.99 Body Pains 47.9 (26.9) 64.5 (13.3) 0.003 Physical component summary 34.4 (4.10) 46.7 (5.70) 0.002 General Health 38.8 (29.9) 54.8 (25.5) 0.001 Social Functioning 53.2 (21.7) 69.8 (18.0) 0.77 Emotional role 57.0 (23.2) 52.4 (21.8) 0.86 Mental Health 65.6 (17.0) 78.3 (10.8) 0.001 This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 169 Salman et al lead to self-harm and suicide. Conclusion: At the time of admission in ED, suicide attempt and non-suicidal self-harm are subsequent clinical markers for the patient attempting suicide again. The most inde- pendent predictive factors of suicide attempt and self- harm were family function, hopelessness, non- suicidality items of Hamilton depression rating scale, history of non-suicidal self-harm, and anxiety disorders. Acknowledgments: The following individuals are acknowledged for their support, encouragement and guidance. Dr. Samiullah, Dr. Gohar Ali, Dr. Ismail, Ma’am Naila Riaz Awan and Ma’am Sehrish. Psychologists (interns): Mehreen, Sum- reen, Faiza for their help. Conflict of interest: None Funding support: None Authors’ contributions: The first two authors helped in idea inception, design- ing of the study and data interpretation. Third, fourth and fifth author participated in drafting the article and revised it critically, helped in data collection, analysis of the data and gave final approval of the version to be submitted. Sixth author helped in statistical analysis, acquisition and interpretation of data. References: 1. Andover MS, Morris BW, Wren A, Bruzzese ME. The co- occurrence of non-suicidal self-injury and attempted suicide among adolescents: distinguishing risk factors and psychosocial correlates. Child Adolesc Ment Health. 2012;6:11. 2. Wasserman D, Cheng Q, Jiang G-X. Global suicide rates among young people aged 15-19. World Psychiatry. 2005;4(2):114-20. 3. Chen Y-Y, Wu KC-C, Yousuf S, Yip PS. Suicide in Asia: opportunities and challenges. Epidemiol Rev. 2011;34(1):129-44. 4. Amini A, Munesan MR, Dolatabadi AA, et al. Quality of Life in Emergency Medicine Specialists of Teaching Hospitals. Emergency. 2014;2(3):[In press]. 5. Peltzer K, Pengpid S. Suicidal ideation and associated factors among school-going adolescents in Thailand. Int J Environ Res Public Health. 2012;9(2):462-73. 6. Amitai M, Apter A. Social aspects of suicidal behavior and prevention in early life: a review. Int J Environ Res Public Health. 2012;9(3):985-94. 7. Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299(8):901-13. 8. Asarnow JR, Emslie G, Clarke G, et al. Treatment of selective serotonin reuptake inhibitor—Resistant depression in adolescents: Predictors and moderators of treatment response. J Am Acad Child Adolesc Psychiatry. 2009;48(3):330-9. 9. Washburn JJ, Richardt SL, Styer DM, et al. Psychotherapeutic approaches to non-suicidal self-injury in adolescents. Child Adolesc Ment Health. 2012;6(1):1-8. 10. Wilkinson P, Kelvin R, Roberts C, Dubicka B, Goodyer I. Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). Am J Psychiatry. 2011;168(5):495-501. 11. Boxer P. Variations in risk and treatment factors among adolescents engaging in different types of deliberate self- harm in an inpatient sample. J Clin Child Adolesc Psychol. 2010;39(4):470-80. 12. Epstein NB, Baldwin LM, Bishop DS. The McMaster Family Assessment Device. J Marital Fam Ther. 1983;9(2):171-80. 13. Hamilton M. The Hamilton rating scale for depression. Assessment of depression: Springer; 1986. p. 143-52. 14. Haley SM, McHorney CA, Ware Jr JE. Evaluation of the MOS SF-36 physical functioning scale (PF-10): I. Unidimensionality and reproducibility of the Rasch item scale. J Clin Epidemiol. 1994;47(6):671-84. 15. Brazier J-, Harper R, Jones N, et al. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ. 1992;305(6846):160-4. 16. Guan K, Fox KR, Prinstein MJ. Nonsuicidal self-injury as a time-invariant predictor of adolescent suicide ideation and attempts in a diverse community sample. J Consult Clin Psychol. 2012;80(5):842-9. 17. Brezo J, Paris J, Turecki G. Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review. Acta Psychiatr Scand. 2006;113(3):180- 206. 18. Mork E, Walby FA, Harkavy-Friedman JM, et al. Clinical characteristics in schizophrenia patients with or without suicide attempts and non-suicidal self-harm-a cross-sectional study. BMC Psychiatry. 2013;13(1):1-8.