INTRODUCTION

The World Health Organization (WHO) concludes that mental health is an integral and essential component as part of our existence. It is an individual state that is influenced by various social, psychological, and biological factors¹. If being negatively altered it can trigger mental disorders, such as anxiety and depression, that could lead to suicidal ideations and culminate in the most dramatic scenario, suicide.

It is estimated that approximately 800,000 people commit suicide each year, and poverty is an essential social factor that increases the risk of suicide; more than a third of these deaths occur in low- and middle-income countries, it is even considered the third cause of death for young people between ages 15 and 19². The individual, family, and social factors that could intervene are considered the most frequent and the suicide attempt that is not consumed constitutes the most important individual risk factor. The spectrum as a whole is called suicidal behavior, which involves the idea of thinking about suicide, suicide planning, suicide attempt, and suicide execution itself³. This behavior can progress vertiginously if it is associated with depression without treatment or with inadequate treatment.

In 2018, the Ministerio de Salud (MINSA) reported 1,384 suicide attempts in all health institutions⁴. Suicide has become a public health problem in our country which occurs in all social strata, with various manifestations, starting with suicidal, passive, or active ideation, going through its entire spectrum, until it reaches consummate suicide.

The increasing incidence of suicide in the adult population and the frequency of patients with depression and suicidal behavior who complete, partially, or simply do not complete the indicated treatment. They underestimate the presence of suicidal ideation with progressive deterioration of mental health to a fatal outcome; therefore, the objective of this study is to determine the factors associated with suicidal ideation in these patients.

METHODS

RESULTS

Table 1shows the sociodemographic characteristics of the 201 patients who made up the sample, the female sex predominated 153 (76.1%), married or cohabiting marital status 137 (68.2%), more than half had Lima 103 (51.2%) as their place of birth, most had less than one year of psychiatric treatment 168 (83.6%). Regarding substance use, almost half of the patients reported consuming alcohol 93 (46.3%), a quarter tobacco 53 (26.4%), and only 18 (9.0%) drugs.

Of the 201 patients who made up the sample, 46 (22.9%) had suicidal ideation. The average age of these 46 patients was 32 years and the median 28 years, the standard deviation 15, and the age range 48. Of the patients with suicidal ideation, 13 patients were 18-19 years of age (28.3%), 18 patients between 18-23 years of age (39.1%), 7 patients were between 24 and 29 years of age (15.2%) and 21 patients were between 30 and 66 years of age (45.7%). The female sex was predominant 27 (58.7%), single marital status 27 (58.6%), and Lima as a place of birth 32 (69.7%).

InTabla 2, it is observed that the age, gender, marital status, place of birth, time of treatment a year or more, consumption of alcohol, tobacco, and drug use are associated factors, due to which its OR are more than the unit, in addition to the values of the confidence interval of the OR does not include the unit, therefore, we can say that suicidal ideation is associated to these variables with a level of significance less than 0.05.

Table 3shows the relationship between the dependent variable (suicidal ideation) and the independent variables associated in the bivariate analysis (young age, male sex, marital status single/divorced (without a partner), birthplace Lima, treatment time greater than one year, the consumption of alcohol, tobacco, and drug use), showing for each the adjusted OR and corresponding confidence interval and its level of significance. Only the variable "drug use " is shown as an associated factor for suicidal ideation since the adjusted OR is 11.31 and the confidence interval does not take the unit and the p-value is 0.005. No association was found with the other variables.

DISCUSSION

Suicidal ideation is a strong predictor of suicide, although this impact is still being analyzed in psychiatric and non-psychiatric environments⁶. The relevance of this study lies in discovering the factors associated with suicidal ideation based on a mental disorder very common in our current society, such as depression, and that, in the future, perhaps immediate, most of these patients can be identified timely preventing a fatal outcome.

Our results in the bivariate analysis were that being young, male, single, from Lima, having a treatment for depression for more than one year, consuming tobacco, alcohol, and drugs, are associated with suicidal ideation; however, only drug use remained significant in multivariate analysis.

Of the 201 depressive patients, approximately half of the young patients 25 (48%) had suicidal ideation and only one-seventh of the patients in the adult age group 21 (14.09%), and in the patients with depression and suicidal ideation also predominated the young age group 25 (54.3%) but discreetly compared to the adult age group 21(45.7%). This means that even though there are more depressive patients aged 30 years and older, they have less frequency of suicidal thoughts than the group of under 30 years. They may be influenced by the longer period of treatment that helps them use the tools that they need for improvement seeking medical help for their mental illness by going to an external office. Also, it was found that the young population is a factor associated with suicidal ideation, this result is consistent with the study by Dendup T. et al.⁷, as they are possibly more exposed to the use of legalized and non-legalized drugs⁸.

One-third of depressive patients (28.3%) who presented suicidal ideation were adolescents. Women were the largest population of patients with depression, such as those with suicidal ideation. According to WHO, women are more likely to make suicide attempts but are the least effective². However, in the bivariate analysis, being a male is significant as an associated factor, although it is not maintained in the multivariate, it may be due perhaps to interaction with other variables such as alcohol and tobacco consumption.

Many studies have found that parental support⁹is a protective factor against suicidal thoughts and attempts. Our family relationship variable was not significant, however, studies with a larger population can be expanded to see the effect of this relationship.

Lima, the capital of Peru, is an urbanized area with a higher percentage of the population with better sanitation services, but poverty rates persist. This region is affected by the migration of inhabitants of the coast, mountains, and jungle in search of better opportunities, however, it is difficult to achieve these goals. For this reason, many have worse conditions of poverty in which they are going to allocate their children. Apart from this, stress from traffic and work leads to thoughts of hopelessness. Our study concluded that being born in Lima is an associated factor for suicidal ideation, however, it differs from the study by Nie Y.et al.¹⁰which points out that coming from rural areas increases fatal thinking.

Lu l. et al.¹¹concludes that loneliness is an important factor in developing suicidal ideation, in our work, it was found that being single or divorced is an associated factor. Although this result is not maintained in the multivariate analysis, it does not exclude that this condition can worsen the state of depression, therefore generating more often negative thoughts, including that of suicidal ideation.

It has been shown that at the beginning of antidepressant treatment there is a lower adherence due to sociodemographic factors such as level of education, and other factors such as type of funding of pharmaceutical benefit and attendance at consultations¹². Our cutoff point for treatment time was one year, considered by the authors, to determine it as an associated factor. Time greater than one year was found as an associated factor in the bivariate analysis, however, it did not remain in the multivariate analysis. It may be due to the rejection of treatment because it shows temporary improvement, even, understanding that these drugs can be taken for life. The interaction of this variable with the others may have affected the outcome, so further studies are needed to determine its impact.

Unemployment is one of the leading causes of suicide in the world. Dendup T. et al.⁷concludes that being unemployed is a risk factor for suicidal ideation since economic instability generates mental instability so it is difficult for a patient to adequately control it, and can even worsen their psychiatric disorder and have severe complications with regression of improvement. However, in our study, it was not significant.

Both Dendup T.et al.⁷and Dutta R. et al.¹³agree that alcohol and drug use increases the risk of suicidal ideation. Although alcohol and tobacco consumption variables were not significant in the multivariate, this may be due to interaction with other factors. Like our study, Chávez-Hernández A. et al.¹⁴concluded that drug use associated with depression and impulsivity predicted suicidal ideation of high school students, even up to four times. Drugs alter the neurotransmitters of the brain so it limits the ability to control impulses and generates addiction, which in turn leads to acts against your life, from suicidal thoughts to suicide.¹⁵

There were some limitations to the study. The design of the present study is an analytical cross-sectional, so it is impossible to determine temporality relationships between the main variables analyzed, so causal relationships cannot be determined. Another failure of the study is that the results obtained from this study cannot be generalized to a different population than the study because of the non-probabilistic sample. Finally, there is a potential residual confusion bias due to the number of variables not obtained in the present study and that may act as confusing to the main variable under study.

CONCLUSION

In conclusion, drug use is associated with suicidal ideation in patients who attended an external clinic of the HMA psychiatric service.