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��ࡱ�>��	su����r�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[�)��0�lbjbj����	:pΐΐ�J������������������89D}$!=f�������.B�|<~<~<~<~<~<~<$�>�)AR�<9�������<������<   ������`; �|<  V�%@x&�������%�F�t^�%L;�<0!=&x{A�:{Ax&{A�x&��� ������<�< ���!=������������������������������������������������������������������������{A����������	�:	)Gender Differences of Suicide Attempt among Iranian Patients with Psychiatric Disorders
Abstract
Background: The prevalence of suicide in Iran is higher than Middle East countries. The aims of this study were to determine the prevalence of suicide attempt in psychiatric patients; associations of it with clinical and socio-demographic factors; and, gender differences with regard to these factors.
Methods: Participants in this descriptive-analytic study were all patients who were hospitalized for at least two days in Razi Center in Tehran during 2010. Multiple logistic regression was used to analyze the factors related to suicide.
Results: Almost 23.4% of participants had a history of suicide attempt. Suicide attempt in divorced, separated, and widowed women was much higher than single women (P=0.032). Also, women who were drug abusers more often attempted suicide relative to who were not (P=0.047). Suicide attempt was more in young men (P<0.001). In addition, bipolar disorder (P=0.011), depression (P=0.27), drug abuse (P<0.001), and alcohol abuse (P=0.017) were risk factors of suicide attempt among men. Interactions between gender and marital status (P=0.002) and between gender and the type of psychiatric disorder (P=0.004) were statistically significant. 
Conclusion: There were significant differences in suicide attempt risk factors between men and women with psychiatric disorders; these differences could not be related to different exposures to the known risk factors in the two genders.
 Key words Suicide attempt, Gender, Risk Factors, Psychiatric disorders
Introduction
Suicide is one of the preventable public health problems. On The National Survey on Drug Use and Health (NSDUH) report in 2011 about 1 million adults in the United States (0.5% of the U.S. adult population) make a suicide attempt annually [1]. Although in comparison with most countries, especially Western communities, the prevalence of suicide is lower in Iran, it is higher than Middle East countries [2]. Ghafarian Shirazi et al. (2012) reported the overall suicide attempt rate of 26.5 and the completed suicide rate of 6.7 per 100,000 in general population in Iran [3] but another  recent study (2012) showed lower rate of it in other Middle East countries especially Muslim-majority countries such as Bahrain and Kuwait which have had the completed suicide rate of 3.8 and 1.8 per 100,000 population respectively [4].
Patients with a history of suicide attempt are likely to try it again [5]. Most of them have psychiatric disorders and these disorders have the strongest relationship with attempting suicide [6]. These disorders include schizophrenia, depression, bipolar disorders, and drug and alcohol abuse [7-9]. Mohammadi et al. showed that 45.3% of the participants who had attempted suicide reported at least one psychiatric disorder during their lifetime [10]. Also a prevalence of 10.81% for psychiatric disorders in Iran is reported [11]. 
The effects of psychiatric disorders differ in the two genders [12]. Most studies have reported a significant relationship between gender, as a demographic characteristic, and suicide. These studies have reported different results about suicide attempt and suicide mortality in both genders [5,6,13,14]. Also, suicide attempt differs between men and women with psychiatric disorders [15].
It is not clear whether differences in exposure to known social, cultural, or other gender-related risk factors cause behavioral differences in men and women regarding suicide [16]. Need-based healthcare services require determination of differences in risk factors of suicide attempt in the two genders [17]. Therefore, this study was conducted to determine the prevalence of past suicide attempt in men and women with psychiatric disorders; associations of it with clinical and socio-demographic factors; and, gender differences with regard to these factors in a cross-sectional study in Razi Training, Therapeutic, and Psychiatric Center (one of the largest training, therapeutic, and psychiatric centers in Iran). 
Materials & Methods
Participants in this descriptive-analytic study were all patients who were hospitalized for various reasons for at least two days in Razi Training, Therapeutic, and Psychiatric Center in Tehran during 2010. Out of 984 patients, 950 had the ability to communicate with the interviewers and were included in this study. Among them, 941 answered the suicide-related questions (response rate=95.6%) and therefore analyses were performed based on their information. The majority of the participants were male (73.4 %) with the average (mean�SD) age of 45.3�1.4. The value of the questionnaires filled by patients� expression depended on their insight. Patients in the denial phase of insight were excluded from our study. Insight was described as the ability of a patient to identify his/her illness. Stages of insight are from complete denial of illness to true emotional insight  [18]. A written consent was obtained from each eligible individual prior to entry to this study. Data collection was done through interview and a validated questionnaire in patients with psychiatric disorders in Iran [19]. The questionnaire contained demographic characteristics, tobacco use, history and current status of the disease, current drug use status, besides items related to the past suicide attempt, it's frequency, time, methods, etc.
The prevalence of suicide attempt was calculated for the whole study population and for each gender group. Men and women were compared regarding some selected variables using independent-samples t test and Chi-square test. Factors related to suicide were analyzed separately for men and women using multiple logistic regressions. Odds ratios with 95% confidence intervals were calculated and comparison between the categories of each independent variable with the reference group was done using the Wald method. The outcome variable was previous suicide attempt and the independent variables those socio-demographic and clinical variables which significantly associated with the outcome variable in univariate logistic regressions. The variables of age, level of education, marital status, accommodation status, employment status, type of psychiatric disorder, cigarette smoking, alcohol and drug abuse were entered to the final model (separately for men and women). Eventually, interactions between gender and other variables with a statistically significant effect in multiple logistic regression were analyzed using a full regression model to see if it could be explained by differential men and women's exposure to risk factors. If there is no significant relation between sex and risk factor it means that sex could explain different exposure to that factor and vice versa [20]. A P-value<0.05 was considered significant and analyses were done using SPSS software version 17.
The protocol of our study was approved by the Ethics Committee of Tobacco Prevention and Control Research Center of Iran.
Results
The history of suicide attempt was positive in 220 (23.4%) patients. The prevalence of suicide attempt in male and female patients was 25.8% and 16.8% respectively. The men/women ratio for suicide attempt was 178/42. Most individuals had a history of one suicide attempt (46.6%) at night (30.7%) with no difference between the two genders. Also the most prevalent (36.7%) method of suicide attempt was self- cutting with no significant difference between men and women. Men and women had statistically significant differences in almost all of the selected variables. Most of the men (77.2%) and women (87.1%) had education less than high school and 69.6% and 45.8% were single, respectively. In addition, 57.3% were cigarette smokers and 23.1% were drug abusers (Table 1).
Univariate analysis showed that female participants who had attempted suicide tended to be more often at high school level of education, divorced, separated or widowed, in private or rented accommodations, unemployed, cigarette smoker, drug or alcohol abuser and less often in schizophrenia and bipolar disorders. Also male participants who had attempted suicide tended to be more often at university level of education, married, in private or rented accommodations, unemployed, cigarette smoker, and drug or alcohol abuser. Age was associated with suicide attempt in both genders (Table 2).
Multiple logistic regression revealed that after adjusting of these variables, suicide attempt was much higher in divorced, separated, and widowed women as compared to single women (OR=5.09, 95% CI;1.15-22.58, P=0.032). Also, women who were drug abusers were at higher risk of suicide attempt as compared to those who were not (OR=7.28, 95% CI;1.02-51.61, P=0.047). Among men, bipolar disorders (OR=2.35, 95% CI;1.22-4.54, P=0.011), depression (OR=2.22, 95% CI;1.09-4.50, P=0.27), drug abuse (OR=2.38, 95% CI;1.47-3.86, P<0.001), and alcohol abuse (OR=1.87, 95% CI;1.11-3.15, P=0.017) were risk factors of the suicide attempt  and also suicide attempt decreased in the older men (P<0.001) (Table 3). The last column in Table 3 shows P-values obtained from the interactions between the gender, as the main effect, and the other variables in regression model. Interactions between the gender and the marital status (P = 0.002) and between the gender and the type of psychiatric disorder (P = 0.004) were statistically significant.
Discussion
Findings of this study showed that suicide attempt risk factors differed in the two genders. While marital status was associated with suicide attempt in women, suffering from bipolar disorder, depression, and alcohol abuse were risk factors of suicide in men. Drug abuse was a risk factor for attempting suicide in both genders. 
Since women employ less rough methods to attempt suicide, they are accounted as �suicide survivors� [21]. In this study, men and women did not differ in methods of attempting suicide. Perhaps the reason is that participants of our study were hospitalized because of psychiatric problems whereas studies which compare suicide methods in the two genders usually consider completed suicides [22].
Our findings about the effect of drug abuse on suicide attempt in the two genders agree with most studies [7,23,20]. Besides drug abuse, age and alcohol abuse also correlated with suicide attempt in men after adjusting the effect of other variables in the regression model while no such correlation was found in women.  Men are more sensitive to social and economical changes as compared to women. Our findings are in agreement with the results of most studies [20,24].
Marriage is a protective factor against suicide [12]. In this study, divorced, separated and widowed women attempted suicide more than singles. Moradi et al (Tehran, 2009) showed that the probability of attempting suicide was higher among students with family conflicts and rupture [25]. Based on our study, it seems that this effect is greater in women. 
In this study, the prevalence of suicide attempt was higher in men as compared to women. Also, men with depression and bipolar disorders attempted suicide more than others. Among individuals who attempt suicide, the prevalence of psychiatric disorders is higher in men as compared to women [17]. Although the prevalence of depression is higher in women, suicide attempt is observed more in depressed men. The reasons may be more severe signs of the disease, more being ashamed of disease, or various reactions of men to psychiatric disorders than women [15].  
Risk factors were more closely related to sex rather than different exposures in the two genders which can explain the reason for the difference in the prevalence of suicide attempt between men and women with psychiatric disorders. This finding is consistent with Qin et al. study which indicated that adjustment for risk factors does not eliminate gender differences in suicide risk [24]. In 2005, Zhang et al in the United States showed that, the nature of suicide differed in the two genders. More research is needed to study the neurologic and genetic risk factors of suicide. In fact, differences between the two genders regarding the majority of the effective factors and their differences regarding the suicide risk factors reveal biologic diversities and interactions of biologic and non-biologic differences of men and women [20].
Although completed suicide rates seem to be lower in Muslim countries but rates of attempted suicide, don't appear to be lower than other countries [26]. There is a general agreement among researchers that to date statistics have underestimated the extent of the suicide attempt in developing and countries such as Iran as the result of ineffective civil registration systems and disparities in coroners practices. Moreover in Muslim countries attempted suicide is considered a sinful act that strongly banned by Islamic religion so family and friends may try to hide the cause of death because of social stigma, religious sanctions, and legal issues associated with suicide [27,28]. 
One of the limitations of our study was that some patients were excluded due to their low level of insight. Despite the fact that researchers had to exclude these patients for ethical reasons, the prevalence of suicide attempt might be even higher in these patients. Moreover, our study had a cross-sectional design and therefore could not evaluate the effect of changes in variables on the incidence of suicide attempt over time.
Improvement of psychiatric health requires the employment of preventive interventional measures and facilities. Mental health needs should not be considered as second-hand needs after physical health needs. Integration of mental health and public health, despite being useful, does not seem enough [12]. The findings of our study suggest that mental health care will be more effective if performed with paying attention to the person�s gender [17].
Acknowledgement
This study was performed with financial support from National Research Institute of Tuberculosis and Lung Diseases (NRITLD).









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