Abstract
Background
The objective of this study was to examine the relationship of mental health status between self-poisoning suicide patients and their family members, and it also sought to identify potential patient’s risk and parental factors for the prediction of suicide attempt, anxiety, and depression.
Methods
In this study, 151 poisoned patients were prospectively included, and they were matched 1:1 with 151 family members. We gathered information on patient’s and their matched family member’s demographics, lifestyle choices, mental health status, level of intimacy, and history of psychiatry disease. The relationship of patient’s and their family member’s mental health state was investigated using a correlation matrix. Multivariable analyses (multiple logistic regression) were conducted among patients and their matched family members, to identify potential risk factors for self-poisoning suicide, anxiety, and depression.
Results
Of the total patients, 67.55% (102/151) attempted self-poisoning suicide. Poisoned patients had more severe anxiety and depression symptoms than their matched family members, and this difference was even more pronounced among patients with self-poisoning suicide. Generalized anxiety disorder-7 (GAD-7) score for family members was significantly and favorably correlated with patient’s GAD-7 score after eliminating non-suicide patients and their matched family members. The patient health questionnaire-9 (PHQ-9) score showed a similar pattern, and the family member’s PHQ-9 score was strongly and favorably associated with patient’s PHQ-9 and Beck hopelessness scale-20 (BHS-20) score. Multivariable analysis showed that married marital status (P = 0.038), quitting smoking (P = 0.003), sedentary time of 1 to 6 h (P = 0.013), and participation in a sports more than five times per week (P = 0.046) were all significantly associated with a lower risk of suicide by self-poisoning, while a more serious anxiety state (P = 0.001) was significantly associated with a higher risk of self-poisoning suicide. Multivariable analysis demonstrated that, specifically among self-poisoning suicide patients, married marital status (P = 0.011) and no history of psychiatry disease (P < 0.001) were protective factors for anxiety, while divorced or widowed marital status (P = 0.004), a sedentary time of 1 to 3 h (P = 0.022), and a higher monthly income (P = 0.027) were significant contributors to anxiety. The propensity of additional family-matched characteristics to predict patient’s suicidality, anxiety, and depression was also examined.
Conclusions
Self-poisoning suicide patients have severe mental health issues. Patients who self-poison have a close connection to their family member’s mental health, particularly their levels of anxiety and depression. According to the findings, being married and adopting healthy lifestyle habits, such as quitting smoking and drinking, increasing their physical activity levels, and managing their idle time, are able to help patients with mental health concerns and even suicidal thoughts.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12888-023-04779-9.
Keywords: Self-poisoning suicide, Mental health, Anxiety, Depression, Family members, Matched-pair analysis
Background
Around the world, self-poisoning is a frequent method of ending one’s life, and poisoning can be caused by exposure to toxins chemicals, and drug overdoses [1]. It is a serious public health issue that contributes to global morbidity and mortality, particularly in low- and middle-income nations [1]. Self-poisoning is particularly prevalent in China, and a recent study pointed out that self-poisoning was responsible for roughly 60% of suicides [2]. In addition, both the prevalence and rate of suicide attempts using self-poisoning are dramatically rising among young people [3, 4].
Based on epidemiological and toxicological data, it was determined that national restrictions on harmful pesticides were an effective strategy for preventing suicide by pesticides intake [5, 6]. Even so, illicit drugs and medically prescribed drugs, such as psychotropic drugs, sedative-hypnotics, analgesics, and antidepressants [7], are still readily accessible and can be the most frequently misused drugs [8]. Identification of risk and protective factors is a crucial component of national suicide prevention since it helps to further understand the kind and type of preventive actions needed. Risk factors can occur on a variety of scales, including the individual, sociocultural, and situational, and numerous factors have been linked to increased self-poisoning, including borderline personality disorder or traits [9, 10], alcohol use disorder [9], depressive disorder [9], substance abuse [11, 12], asthma [11], fewer social connections [13], living in neighborhoods [13], being female [10, 14], and being young [13]. However, to the author’s best knowledge, there were few research that looked at the relationship between the mental health state of self-poisoning patients and their family members. It is important to stress that a thorough understanding of the risk factors for suicide behaviors in terms of patients and family members is necessary to carry out prevention activities, which highlights the need for a wider investigation.
In addition, during the Corona Virus Disease 2019 (COVID-19) pandemic, lockdowns and other public health measures had a significant impact on suicide [15]. Researchers noticed a decline in hospital admissions for self-poisoning suicide during the great pandemic, and, of note, this underlying trend actually reflected a decline in the number of patients receiving medical care for self-poisoning rather than a real decline in incidence. Thus, early professional healthcare seeking should be emphasized more, especially during the great pandemic. Identification of risk factors is an important step in guiding suicide prevention.
Therefore, the purpose of this study was to examine the relationship of mental health status between self-poisoning suicide patients and their family members, as well as to identify potential risk factors for predicting suicide attempt, anxiety, and depression using information from both the patients and their family members. In this study, it was expected that new risk factors for self-poisoning could be discovered from patients and their relatives. The study’s findings will be very helpful in directing the implementation of preventive interventions from the perspective of patients and their families.
Patients and methods
Patients
Between May 2021 and May 2022, this study prospectively enrolled 151 poisoned patients and 151 family members based on a matched rate of 1:1. We collected basic demographics, living habits, history of psychiatric diseases, and mental health status among patients and their counterpart family members. All included patients were admitted to our hospital for the treatment of poisoning. Patients were excluded for analysis if they (1) were unwilling to participate, (2) were unaware of self-identity, space, time, and expressing well-being, and (3) could not cooperate with medical workers or researchers for any other reasons. Family members were excluded if he or she (1) refused to take part in the study or (2) could not adequately articulate their well-being. The inclusive and exclusive criteria resulted in the collection of 237 patients and 236 family members. According to the matched rate of 1:1, 151 poisoned patients were matched with 151 family members in terms of patient’s admission ID. Figure 1 shows patient’s diagram. The study eliminated unmatched patients and family members from analysis. The Ethics Committee of the Fifth Medical Center of the Peoples Liberation Army (PLA) General Hospital approved the study protocol (No. KY-2021–12-34–1). All patients and family members provided written informed consent before the data were anonymously analyzed. The Helsinki Declaration was followed in this investigation.
Fig. 1.
Patient’s diagram and study design
Characteristics of patients and their family members
All clinical traits among patients were categorized into the following types: (1) The patient’s basic demographic (gender, age, marital status, education level, and habitation geographic area), (2) their lifestyles (bland diet, greasy food, smoking, drinking, sedentary time, sport frequency per week, and monthly income), (3) their mental health status (anxiety, depression, self-esteem, hopelessness status, and social support status), and (4) their history of psychiatric diseases (history of depression and history of psychiatry disease). Anxiety and depression were assessed using generalized anxiety disorder-7 (GAD-7) [16] and patient health questionnaire-9 (PHQ-9) [16], respectively. Patient’s self-esteem was evaluated using self-esteem scale-10 (SES-10) [17], hopelessness status was measured using Beck hopelessness scale-20 (BHS-20) [18], and social support status was assessed using social support questionnaire-10 (SSQ-10) [19]. All the above scales, score ranges, explanations, Cronbach’s α, and relevant references are summarized in Supplementary table 1. All aspects of the patient’s lifestyle were self-reported, and a face-to-face interview was used to evaluate patient’s mental health. Poisoning patients were divided into two categories: self-poisoning and accidental poisoning. Self-poisoning suicide and method of self-poisoning, such as medicinal overdose, pesticide, or toxic chemicals, was initially identified using patient’s admission medical record, and verbally reconfirmed through patient’s self-report and their family members.
Regarding patient’s family members, this study collected their demographics including family relationship with patients, gender, age, living arrangement, and level of education, living habits (including sedentary time per day, sport frequency per week, drinking, smoking, and monthly income), intimacy score with patients, and mental health including anxiety and depression. Intimacy score was reported by family members and it ranges from 0 to 100 with higher scores indicating higher levels of intimacy between patients and their family members, and the score was adopted based on previous studies [20, 21]. The GAD-7 and PHQ-9 scales were used, respectively, to assess anxiety and depression.
Statistical analysis
For categorical variables in the study, all data were summarized as the format of proportion, and for continuous variables, data were presented as mean and standard deviation (SD). Between non-suicide patients and suicide patients, as well as between their families, a comparison of characteristics was performed. The comparison of categorical variables was evaluated using the Chi-square test or continuous adjusted Chi-square test, while the comparison of continuous variables was examined using the t test or rank test. Correlation matrix was used to investigate the association of mental health status between patients and their family members, and specifically between suicide patients and their matched family members. In the correlation matrix, corresponding Pearson correlation coefficients, scatter diagrams, and histograms were all presented. To identify potential risk factors for self-poisoning suicide (no vs. yes), anxiety (none vs. mild vs. moderate vs. severe), and depression (none vs. mild vs. moderate vs. severe), multivariable analyses (multiple logistic regression) were performed in terms of patients and their family members, respectively. After adjusting for age and gender specifically among significant characteristics, this study performed a new analysis and verified their statistical significance. Finally, the study provided a summary of the risk factors for suicide, anxiety, and depression among patients and their families. Data were analyzed using R programming language (version 4.1.2). Statistical significance was established as a P-value of less than 0.05 with two-tailed sides.
Results
Characteristics of self-poisoning patients and their family members
To investigate the characteristics of suicide patients by self-poisoning, a comparison was performed between poisoned patients with and without suicide. When compared to poisoned patients who did not attempt suicide, self-poisoning patients were more likely to be female (66.7% vs. 42.9%, P = 0.009), younger (28.02 years old vs. 38.84 years old), and single (53.09% vs. 8.2%) (Table 1). Also, suicide patients did significantly less frequency of sports each week (P < 0.001) and had significantly lower monthly income (P = 0.013).
Table 1.
A comparison of characteristics according to the presence of self-poisoning suicide among patients
| Characteristics | Overall | Suicide | P | |
|---|---|---|---|---|
| No | Yes | |||
| n | 151 | 49 | 102 | |
| Gender (%) | 0.009 | |||
| Male | 62 (41.1) | 28 (57.1) | 34 (33.3) | |
| Female | 89 (58.9) | 21 (42.9) | 68 (66.7) | |
| Age (mean (SD), years) | 31.53 (14.72) | 38.84 (12.33) | 28.02 (14.53) | < 0.001 |
| Marital status (%) | < 0.001 | |||
| Single | 59 (39.1) | 4 (8.2) | 55 (53.9) | |
| Dating | 9 (6.0) | 3 (6.1) | 6 (5.9) | |
| Married | 76 (50.3) | 41 (83.7) | 35 (34.3) | |
| Divorced or widowed | 7 (4.6) | 1 (2.0) | 6 (5.9) | |
| Education level (%) | 0.976 | |||
| Primary | 52 (34.4) | 16 (32.7) | 36 (35.3) | |
| High school | 36 (23.8) | 12 (24.5) | 24 (23.5) | |
| University | 58 (38.4) | 19 (38.8) | 39 (38.2) | |
| Graduate | 5 (3.3) | 2 (4.1) | 3 (2.9) | |
| Habitation geographic area (%) | 0.181 | |||
| City | 102 (67.5) | 29 (59.2) | 73 (71.6) | |
| Countryside | 49 (32.5) | 20 (40.8) | 29 (28.4) | |
| Bland diet (%) | 0.370 | |||
| No | 68 (45.0) | 19 (38.8) | 49 (48.0) | |
| Yes | 83 (55.0) | 30 (61.2) | 53 (52.0) | |
| Greasy food (%) | 0.073 | |||
| No | 129 (85.4) | 46 (93.9) | 83 (81.4) | |
| Yes | 22 (14.6) | 3 (6.1) | 19 (18.6) | |
| Smoking (%) | 0.424 | |||
| Yes | 45 (29.8) | 12 (24.5) | 33 (32.4) | |
| No | 106 (70.2) | 37 (75.5) | 69 (67.6) | |
| Drinking (%) | 0.540 | |||
| Yes | 24 (15.9) | 6 (12.2) | 18 (17.6) | |
| No | 127 (84.1) | 43 (87.8) | 84 (82.4) | |
| Sedentary time (%, hours) | 0.169 | |||
| Less than 1 | 37 (24.5) | 9 (18.4) | 28 (27.5) | |
| 1 ~ 3 | 61 (40.4) | 25 (51.0) | 36 (35.3) | |
| 3 ~ 6 | 28 (18.5) | 10 (20.4) | 18 (17.6) | |
| Above 6 | 25 (16.6) | 5 (10.2) | 20 (19.6) | |
| Sport frequency per week (%) | < 0.001 | |||
| 0 | 33 (21.9) | 8 (16.3) | 25 (24.5) | |
| 1 ~ 2 | 63 (41.7) | 16 (32.7) | 47 (46.1) | |
| 3 ~ 5 | 35 (23.2) | 10 (20.4) | 25 (24.5) | |
| Above 5 | 20 (13.2) | 15 (30.6) | 5 (4.9) | |
| Monthly income (%, ￥) | 0.013 | |||
| Less than 3000 | 82 (54.3) | 21 (42.9) | 61 (59.8) | |
| 3000 ~ 6000 | 52 (34.4) | 19 (38.8) | 33 (32.4) | |
| 6000 ~ 9000 | 8 (5.3) | 2 (4.1) | 6 (5.9) | |
| Above 9000 | 9 (6.0) | 7 (14.3) | 2 (2.0) | |
| Severity of anxiety (GAD-7, %) a | < 0.001 | |||
| None | 48 (31.8) | 37 (75.5) | 11 (10.8) | |
| Mild | 33 (21.9) | 9 (18.4) | 24 (23.5) | |
| Moderate | 38 (25.2) | 1 (2.0) | 37 (36.3) | |
| Severe | 32 (21.2) | 2 (4.1) | 30 (29.4) | |
| Severity of depression (PHQ-9, %) a | < 0.001 | |||
| None | 47 (31.1) | 36 (73.5) | 11 (10.8) | |
| Mild | 17 (11.3) | 5 (10.2) | 12 (11.8) | |
| Moderate | 24 (15.9) | 4 (8.2) | 20 (19.6) | |
| Severe | 63 (41.7) | 4 (8.2) | 59 (57.8) | |
| SES-10 (mean (SD)) | 26.46 (6.16) | 30.33 (5.08) | 24.60 (5.77) | < 0.001 |
| BHS-20 (mean (SD)) | 9.63 (4.29) | 6.27 (3.17) | 11.25 (3.80) | < 0.001 |
| SSQ-10 (mean (SD)) | 36.21 (11.53) | 41.96 (12.69) | 33.44 (9.85) | < 0.001 |
| History of depression (%) | < 0.001 | |||
| Yes | 56 (37.1) | 5 (10.2) | 51 (50.0) | |
| No | 95 (62.9) | 44 (89.8) | 51 (50.0) | |
| History of psychiatry disease (%) | 0.012 | |||
| Yes | 28 (18.5) | 3 (6.1) | 25 (24.5) | |
| No | 123 (81.5) | 46 (93.9) | 77 (75.5) | |
SD Standard deviation, GAD-7 Generalized anxiety disorder-7, PHQ-9 Patient health questionnaire-9, SES-10 Self-esteem scale-10, BHS-20 Beck hopelessness scale-20, SSQ-10 Social support questionnaire-10
anone anxiety or depression indicates a GAD-7 or PHQ-9 score of 0 to 4, mild anxiety or depression indicates a score of 5 to 9, moderate anxiety or depression indicates a score of 10 to 14, and severe anxiety or depression indicates a score of 15 or above
Regarding mental health status, suicide patients had significant higher severity of anxiety (P < 0.001) and depression (P < 0.001), lower SES-10 (P < 0.001) and SSQ-10 (P < 0.001) scores, and a higher BHS-20 score (P < 0.001) than patients who did not attempt suicide. The findings indicated that suicide patients had severe mental health problems. What’s more, compared to patients without suicide, suicide patients had a significantly higher rate of history of depression (P < 0.001) and psychiatry disease (P = 0.012).
In terms of the characteristics of self-poisoning patient’s family members, suicide patient’s family members were more likely to be the patient’s parents (P = 0.002), have an education level of high school (P = 0.003), and have an introvert personality (P = 0.015) than non-suicide patient’s family members (Table 2). Nonetheless, the two groups did not differ significantly in terms of anxiety (P = 0.110) and depression (P = 0.190).
Table 2.
A comparison of characteristics in terms of patient’s family members based on the presence of self-poisoning suicide among patients
| Characteristics | Overall | Suicide | P | |
|---|---|---|---|---|
| No | Yes | |||
| n | 151 | 49 | 102 | |
| Family relationship (%) | 0.002 | |||
| Parents | 59 (39.1) | 8 (16.3) | 51 (50.0) | |
| Spouse | 42 (27.8) | 21 (42.9) | 21 (20.6) | |
| Siblings | 4 (2.6) | 2 (4.1) | 2 (2.0) | |
| Kids | 12 (7.9) | 4 (8.2) | 8 (7.8) | |
| Others | 34 (22.5) | 14 (28.6) | 20 (19.6) | |
| Gender (%) | 0.396 | |||
| Male | 55 (36.4) | 15 (30.6) | 40 (39.2) | |
| Female | 96 (63.6) | 34 (69.4) | 62 (60.8) | |
| Age (mean (SD), years) | 42.15 (9.85) | 42.49 (10.59) | 41.99 (9.53) | 0.772 |
| Live together (%) | 0.468 | |||
| Yes | 109 (72.2) | 33 (67.3) | 76 (74.5) | |
| No | 42 (27.8) | 16 (32.7) | 26 (25.5) | |
| Education level (%) | 0.003 | |||
| Primary | 60 (39.7) | 23 (46.9) | 37 (36.3) | |
| High school | 37 (24.5) | 3 (6.1) | 34 (33.3) | |
| University | 48 (31.8) | 20 (40.8) | 28 (27.5) | |
| Graduate | 6 (4.0) | 3 (6.1) | 3 (2.9) | |
| Sedentary time (%, hours) | 0.087 | |||
| Less than 1 | 38 (25.2) | 11 (22.4) | 27 (26.5) | |
| 1 ~ 3 | 60 (39.7) | 14 (28.6) | 46 (45.1) | |
| 3 ~ 6 | 21 (13.9) | 9 (18.4) | 12 (11.8) | |
| Above 6 | 32 (21.2) | 15 (30.6) | 17 (16.7) | |
| Sport frequency per week (%) | 0.134 | |||
| 0 | 17 (11.3) | 9 (18.4) | 8 (7.8) | |
| 1 ~ 2 | 72 (47.7) | 23 (46.9) | 49 (48.0) | |
| 3 ~ 5 | 28 (18.5) | 10 (20.4) | 18 (17.6) | |
| Above 5 | 34 (22.5) | 7 (14.3) | 27 (26.5) | |
| Drinking (%) | 1.000 | |||
| Yes | 11 (7.3) | 4 (8.2) | 7 (6.9) | |
| No | 140 (92.7) | 45 (91.8) | 95 (93.1) | |
| Smoking (%) | 0.478 | |||
| Yes | 28 (18.5) | 7 (14.3) | 21 (20.6) | |
| No | 123 (81.5) | 42 (85.7) | 81 (79.4) | |
| Monthly income (%, ￥) | 0.107 | |||
| Less than 3000 | 52 (34.4) | 11 (22.4) | 41 (40.2) | |
| 3000 ~ 6000 | 59 (39.1) | 20 (40.8) | 39 (38.2) | |
| 6000 ~ 9000 | 21 (13.9) | 10 (20.4) | 11 (10.8) | |
| Above 9000 | 19 (12.6) | 8 (16.3) | 11 (10.8) | |
| Personality (%) | 0.015 | |||
| Outgoing | 68 (45.0) | 21 (42.9) | 47 (46.1) | |
| Middle | 56 (37.1) | 23 (46.9) | 33 (32.4) | |
| Introvert | 16 (10.6) | 0 (0.0) | 16 (15.7) | |
| Unclear | 11 (7.3) | 5 (10.2) | 6 (5.9) | |
| Intimacy score (mean (SD)) | 88.13 (16.74) | 88.20 (13.48) | 88.09 (18.16) | 0.968 |
| Severity of anxiety (GAD-7, %) a | 0.110 | |||
| None | 99 (65.6) | 29 (59.2) | 70 (68.6) | |
| Mild | 31 (20.5) | 15 (30.6) | 16 (15.7) | |
| Moderate | 17 (11.3) | 5 (10.2) | 12 (11.8) | |
| Severe | 4 (2.6) | 0 (0.0) | 4 (3.9) | |
| Severity of depression (PHQ-9, %) a | 0.190 | |||
| None | 95 (62.9) | 27 (55.1) | 68 (66.7) | |
| Mild | 26 (17.2) | 12 (24.5) | 14 (13.7) | |
| Moderate | 19 (12.6) | 8 (16.3) | 11 (10.8) | |
| Severe | 11 (7.3) | 2 (4.1) | 9 (8.8) | |
SD Standard deviation, GAD-7 Generalized anxiety disorder-7, PHQ-9 Patient health questionnaire-9
anone anxiety or depression indicates a GAD-7 or PHQ-9 score of 0 to 4, mild anxiety or depression indicates a score of 5 to 9, moderate anxiety or depression indicates a score of 10 to 14, and severe anxiety or depression indicates a score of 15 or above
Comparison of mental health status between patients and their family members
A matched-pair analysis showed that poisoned patients had significant higher GAD-7 (P < 0.001, Fig. 2A) and PHQ-9 (P < 0.001, Fig. 2B) scores than their matched family members. After eliminating poisoned patients who did not attempt suicide, self-poisoning suicide patients had even significant higher GAD-7 (P < 0.001, Fig. 2C) and PHQ-9 (P < 0.001, Fig. 2D) scores than their matched family members. To clarify, when non-suicide patients were not included for analysis, subgroup analysis of suicide patients revealed that the difference in GAD-7 increased from 4.97 (95%CI: 3.69–6.26) to 7.91 (95%CI: 6.55–9.28) and the difference in PHQ-9 increased from 6.91 (95%CI: 5.27–8.56) to 10.71 (95%CI: 9.04–12.38). Therefore, poisoned patients experienced more severe anxiety and depression than their matched family members, and this pattern was especially pronounced among patients who attempted suicide and their matched family members.
Fig. 2.
Subgroup analysis of anxiety and depression between patients and their matched family members. A A comparison of GAD-7 scores among all enrolled patients. B A comparison of PHQ-9 scores among all enrolled patients. C A comparison of GAD-7 scores specifically among self-poisoning patients. D A comparison of PHQ-9 scores specifically among self-poisoning patients
In addition, self-poisoning suicide patients had significant higher GAD-7 (P < 0.001) and PHQ-9 (P < 0.001) scores compared to patients without suicide (Fig. 3). However, both GAD-7 and PHQ-9 scores were very similar between suicide patient’s family members and non-suicide patient’s family members. As anticipated, suicide patients performed worse on the BHS-20 (P < 0.001), lower SES-10 (P < 0.001) and SSQ-10 (P < 0.001) scores than their counterparts (Fig. 4). The data above showed that, in contrast to suicide patients, their family members did not experience serious mental health issues.
Fig. 3.
Radar plots of anxiety and depression according to the presence of self-poisoning suicide among patients and their matched family members. Red indicates self-poisoning suicide patients or their matched family members; Green indicates patients without self-poisoning suicide or their matched family members. GAD-7, Generalized anxiety disorder-7; PHQ-9, Patient health questionnaire-9
Fig. 4.
Radar plots of hopelessness, self-esteem, and social support status according to the presence of self-poisoning suicide among patients. Red indicates self-poisoning suicide patients; Green indicates patients without self-poisoning suicide. SES-10, Self-esteem scale-10; BHS-20, Beck hopelessness scale-20; SSQ-10, Social support questionnaire-10
Association of mental health status between patients and their family members
Correlation matrix was used to visualize the association of mental health between patients and their matched family members. Among all poisoned patients, Fig. 5 demonstrated that patient’s GAD-7, PHQ-9, SES-10, BHS-20, and SSQ-10 scores were significantly interrelated with each other. Also, among the patient’s family members, there was a strong correlation between GAD-7 and PHQ-9 scores. Family members reported intimacy score with patients were statistically relevant to patient’s PHQ-9 and SES-10 scores. Nonetheless, family member’s GAD-7 and PHQ-9 scores were not significantly associated with patient’s mental health. However, when non-suicide patients and their family members were taken out, the GAD-7 score of the family member was significantly and favorably correlated with the patient’s GAD-7 score and negatively correlated with the intimacy score (Fig. 6). The PHQ-9 score showed a similar pattern; family member’s PHQ-9 score was significantly and favorably related to patient’s PHQ-9 and BHS-20 scores and adversely related to the intimacy score. Pearson correlation coefficients, scatter diagrams, and histograms were all shown.
Fig. 5.
Correlation matrix for scales including patient’s anxiety, depression, self-esteem, hopelessness, and social support status, family member’s anxiety and depression, and intimacy score between patients and family members among all enrolled patients and their matched family members. Lower left panels depict the scatted diagrams between scales, Upper right panels depict the correlation coefficients between scales and significance is given (* indicates P<0.05, ** indicates P<0.01, *** indicates P<0.001), and diagonal panels depict histograms of scales. GAD-7, Generalized anxiety disorder-7; PHQ-9, Patient health questionnaire-9; SES-10, Self-esteem scale-10; BECK-20 indicates BHS-20, Beck hopelessness scale-20; SSQ-10, Social support questionnaire-10; “Intimacyf” indicates intimacy score between patients and their family members and it was reported by family members; GAD-7f, Generalized anxiety disorder-7 for family members; PHQ-9f, Patient health questionnaire-9 for family members
Fig. 6.
Correlation matrix for scales including patient’s anxiety, depression, self-esteem, hopelessness, and social support status, family member’s anxiety and depression, and intimacy score between patients and family members specifically among self-poisoning patients and their matched family members. Lower left panels depict the scatted diagrams between scales, Upper right panels depict the correlation coefficients between scales and significance is given (* indicates P<0.05, ** indicates P<0.01, *** indicates P<0.001), and diagonal panels depict histograms of scales. GAD-7, Generalized anxiety disorder-7; PHQ-9, Patient health questionnaire-9; SES-10, Self-esteem scale-10; BECK-20 indicates BHS-20, Beck hopelessness scale-20; SSQ-10, Social support questionnaire-10; “Intimacyf” indicates intimacy score between patients and their family members and it was reported by family members; GAD-7f, Generalized anxiety disorder-7 for family members; PHQ-9f, Patient health questionnaire-9 for family members
Risk factors associated with self-poisoning suicide
Multivariable analysis showed that married marital status (P = 0.038), not smoking (P = 0.003), sedentary time of 1 to 6 h (P = 0.013), and participation in sports more than five times per week (P = 0.046) were significantly associated with a lower risk of suicide by self-poisoning, while a severer anxious state (P = 0.001) was a significant contributor to self-poisoning suicide (Table 3). In the predictive evaluation of risk factors for self-poisoning suicide, the area under the curve (AUC) values for the five variables were 0.765 (95% CI: 0.699–0.832, Fig. 7A), 0.539 (95% CI: 0.463–0.615, Fig. 7B), 0.605 (95% CI: 0.515–0.69, Fig. 7C), 0.643 (95% CI: 0.547–0.739, Fig. 7D), and 0.881 (95% CI: 0.827–0.936, Fig. 7E), respectively, and when the five variables were combined, the AUC value was 0.956 (95% CI: 0.926–0.986, Fig. 7F). After adjusting for age and gender among the above significant characteristics, married marital status nearly attained significance (P = 0.062), whereas other five significant variables persisted in significance (Supplementary table 2).
Table 3.
Multivariable analysis of characteristics for predicting self-poisoning suicide among patients (n = 151)
| Characteristics | OR | 95% CI | P | |
|---|---|---|---|---|
| LL | UL | |||
| Intercept | 1.64 | 1.15 | 2.32 | 0.007 |
| Gender | ||||
| Male | Ref | |||
| Female | 1.14 | 1.00 | 1.31 | 0.055 |
| Age | 1.00 | 0.99 | 1.01 | 0.792 |
| Marital status | ||||
| Single | Ref | |||
| Dating | 0.88 | 0.68 | 1.13 | 0.320 |
| Married | 0.80 | 0.65 | 0.98 | 0.038 |
| Divorced or widowed | 0.73 | 0.52 | 1.03 | 0.074 |
| Education level | ||||
| Primary | Ref | |||
| High school | 0.93 | 0.79 | 1.10 | 0.415 |
| University | 0.91 | 0.78 | 1.06 | 0.220 |
| Graduate | 1.33 | 0.93 | 1.91 | 0.117 |
| Habitation geographic area | ||||
| City | Ref | |||
| Countryside | 1.12 | 0.98 | 1.28 | 0.099 |
| Bland diet | ||||
| No | Ref | |||
| Yes | 1.06 | 0.93 | 1.21 | 0.387 |
| Greasy food | ||||
| No | Ref | |||
| Yes | 1.07 | 0.89 | 1.28 | 0.468 |
| Smoking | ||||
| Yes | Ref | |||
| No | 0.78 | 0.66 | 0.91 | 0.003 |
| Drinking | ||||
| Yes | Ref | |||
| No | 0.97 | 0.81 | 1.17 | 0.771 |
| Sedentary time (hours) | ||||
| Less than 1 | Ref | |||
| 1 ~ 3 | 0.82 | 0.71 | 0.96 | 0.013 |
| 3 ~ 6 | 0.81 | 0.67 | 0.98 | 0.035 |
| Above 6 | 0.90 | 0.74 | 1.09 | 0.268 |
| Sport frequency per week | ||||
| 0 | Ref | |||
| 1 ~ 2 | 1.24 | 1.05 | 1.45 | 0.011 |
| 3 ~ 5 | 1.04 | 0.87 | 1.25 | 0.637 |
| Above 5 | 0.81 | 0.67 | 0.99 | 0.046 |
| Monthly income (￥) | ||||
| Less than 3000 | Ref | |||
| 3000 ~ 6000 | 0.97 | 0.84 | 1.12 | 0.720 |
| 6000 ~ 9000 | 1.08 | 0.78 | 1.48 | 0.644 |
| Above 9000 | 0.82 | 0.63 | 1.07 | 0.138 |
| Severity of anxiety (GAD-7) a | ||||
| None | Ref | |||
| Mild | 1.33 | 1.07 | 1.66 | 0.012 |
| Moderate | 1.75 | 1.35 | 2.27 | 0.000 |
| Severe | 1.58 | 1.21 | 2.06 | 0.001 |
| Severity of depression (PHQ-9) a | ||||
| None | Ref | |||
| Mild | 1.20 | 0.95 | 1.52 | 0.125 |
| Moderate | 1.15 | 0.91 | 1.46 | 0.229 |
| Severe | 1.14 | 0.88 | 1.48 | 0.307 |
| History of depression | ||||
| Yes | Ref | |||
| No | 1.04 | 0.89 | 1.22 | 0.579 |
| History of psychiatry disease | ||||
| Yes | Ref | |||
| No | 1.11 | 0.91 | 1.35 | 0.300 |
OR Odds ratio, CI Confident interval, LL Lower limit, UL Upper limit, GAD-7 Generalized anxiety disorder-7, PHQ-9 Patient health questionnaire-9
anone anxiety or depression indicates a GAD-7 or PHQ-9 score of 0 to 4, mild anxiety or depression indicates a score of 5 to 9, moderate anxiety or depression indicates a score of 10 to 14, and severe anxiety or depression indicates a score of 15 or above
Fig. 7.
The area under the curve of significant risk factors for predicting self-poisoning suicide. A Marital status. B Smoking. C Sedentary time. D Sport frequency. E Anxiety. F All the five features combined together
Regarding characteristics in terms of the matched family members, this study found that an education level of high school (P = 0.004) and an introvert personality (P = 0.023) were significantly associated with a greater rate of suicide (Table 4), while spouse (P < 0.001) and female (P = 0.047) were significant protective variables. After adjusting for age and gender among significant characteristics, the four variables were still significant (Supplementary table 3).
Table 4.
Multivariable analysis of characteristics in terms of matched family members for predicting patient’s self-poisoning suicide (n = 151)
| Characteristics | OR | 95% CI | P | |
|---|---|---|---|---|
| LL | UL | |||
| Intercept | 5.95 | 2.50 | 14.18 | 0.000 |
| Family relationship | ||||
| Parents | Ref | |||
| Spouse | 0.64 | 0.51 | 0.81 | 0.000 |
| Siblings | 0.79 | 0.47 | 1.32 | 0.377 |
| Kids | 0.82 | 0.62 | 1.09 | 0.167 |
| Others | 0.65 | 0.42 | 1.01 | 0.060 |
| Gender | ||||
| Male | Ref | |||
| Female | 0.78 | 0.61 | 0.99 | 0.047 |
| Age | 0.99 | 0.98 | 1.00 | 0.055 |
| Live together | ||||
| Yes | Ref | |||
| No | 0.91 | 0.71 | 1.16 | 0.442 |
| Education level | ||||
| Primary | Ref | |||
| High school | 1.47 | 1.14 | 1.90 | 0.004 |
| University | 1.10 | 0.87 | 1.39 | 0.449 |
| Graduate | 1.03 | 0.67 | 1.59 | 0.890 |
| Sedentary time (hours) | ||||
| Less than 1 | Ref | |||
| 1 ~ 3 | 1.12 | 0.89 | 1.41 | 0.339 |
| 3 ~ 6 | 1.06 | 0.76 | 1.48 | 0.722 |
| Above 6 | 0.83 | 0.63 | 1.10 | 0.206 |
| Sport frequency per week | ||||
| 0 | Ref | |||
| 1 ~ 2 | 0.83 | 0.62 | 1.11 | 0.217 |
| 3 ~ 5 | 0.97 | 0.71 | 1.32 | 0.825 |
| Above 5 | 0.84 | 0.60 | 1.17 | 0.302 |
| Drinking | ||||
| Yes | Ref | |||
| No | 1.16 | 0.79 | 1.71 | 0.444 |
| Smoking | ||||
| Yes | Ref | |||
| No | 0.93 | 0.70 | 1.24 | 0.623 |
| Monthly income (￥) | ||||
| Less than 3000 | Ref | |||
| 3000 ~ 6000 | 0.86 | 0.68 | 1.07 | 0.184 |
| 6000 ~ 9000 | 0.81 | 0.58 | 1.15 | 0.242 |
| Above 9000 | 0.78 | 0.59 | 1.04 | 0.093 |
| Character | ||||
| Outgoing | Ref | |||
| Middle | 0.95 | 0.79 | 1.14 | 0.571 |
| Introvert | 1.41 | 1.05 | 1.88 | 0.023 |
| Unclear | 0.80 | 0.55 | 1.17 | 0.258 |
| Intimacy score | 1.00 | 0.99 | 1.00 | 0.486 |
| Severity of anxiety (GAD-7) a | ||||
| None | Ref | |||
| Mild | 0.75 | 0.54 | 1.04 | 0.090 |
| Moderate | 0.82 | 0.51 | 1.32 | 0.418 |
| Severe | 1.31 | 0.57 | 2.98 | 0.524 |
| Severity of depression (PHQ-9) a | ||||
| None | Ref | |||
| Mild | 1.04 | 0.72 | 1.49 | 0.841 |
| Moderate | 1.12 | 0.78 | 1.62 | 0.537 |
| Severe | 1.00 | 0.58 | 1.74 | 0.989 |
OR Odds ratio, CI Confident interval, LL Lower limit, UL Upper limit, GAD-7 Generalized anxiety disorder-7, PHQ-9 Patient health questionnaire-9
anone anxiety or depression indicates a GAD-7 or PHQ-9 score of 0 to 4, mild anxiety or depression indicates a score of 5 to 9, moderate anxiety or depression indicates a score of 10 to 14, and severe anxiety or depression indicates a score of 15 or above
Risk factors associated with anxiety and depression among self-poisoning suicide patients
To investigate risk factors related to anxiety and depression specifically among self-poisoning suicide patients, non-suicide patients were excluded for analysis. Multivariable analysis showed that married marital status (P = 0.011) and the absence of psychiatry disease history (P < 0.001) were protective factors against anxiety, while divorced or widowed marital status (P = 0.002), a sedentary time of 1 to 3 h (P = 0.022), and a higher monthly income (P = 0.027) were significant contributors to more anxiety specifically among suicide patients by self-poisoning (Table 5). Sedentary time lost significance after correcting for age and gender, but other three variables remained significance (Supplementary table 4). Higher age (P = 0.010) and monthly income (P = 0.008) were significant risk factors for depression, whereas married marital status (P < 0.001), abstinence from alcohol (P = 0.007), and no history of psychiatry illness (P < 0.001) were significant protective factors for depression. After adjusting for age and gender among significant characteristics, drinking did not achieve significance, but the other four variables still did (Supplementary table 5).
Table 5.
Multivariable analysis of characteristics for predicting patient’s anxiety and depression specifically among patients with self-poisoning suicide (n = 102)
| Characteristics | Anxiety | Depression | ||||||
|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | P | OR | 95% CI | P | |||
| LL | UL | LL | UL | |||||
| Intercept | 34.08 | 14.69 | 79.04 | 0.000 | 31.93 | 13.49 | 75.57 | 0.000 |
| Gender | ||||||||
| Male | Ref | Ref | ||||||
| Female | 1.23 | 0.81 | 1.87 | 0.338 | 1.38 | 0.90 | 2.12 | 0.148 |
| Age | 1.01 | 0.99 | 1.03 | 0.358 | 1.03 | 1.01 | 1.06 | 0.010 |
| Marital status | ||||||||
| Single | Ref | Ref | ||||||
| Dating | 0.62 | 0.29 | 1.30 | 0.208 | 1.06 | 0.49 | 2.27 | 0.891 |
| Married | 0.37 | 0.17 | 0.78 | 0.011 | 0.21 | 0.10 | 0.45 | 0.000 |
| Divorced or widowed | 4.10 | 1.72 | 9.73 | 0.002 | 1.78 | 0.73 | 4.31 | 0.208 |
| Education level | ||||||||
| Primary | Ref | Ref | ||||||
| High school | 1.07 | 0.63 | 1.83 | 0.796 | 1.38 | 0.80 | 2.37 | 0.254 |
| University | 0.84 | 0.53 | 1.33 | 0.465 | 0.96 | 0.60 | 1.52 | 0.850 |
| Graduate | 1.43 | 0.40 | 5.13 | 0.580 | 0.84 | 0.23 | 3.10 | 0.798 |
| Habitation geographic area | ||||||||
| City | Ref | Ref | ||||||
| Countryside | 0.74 | 0.48 | 1.13 | 0.163 | 0.82 | 0.53 | 1.27 | 0.369 |
| Bland diet | ||||||||
| No | Ref | Ref | ||||||
| Yes | 0.86 | 0.57 | 1.31 | 0.493 | 0.66 | 0.43 | 1.01 | 0.059 |
| Greasy food | ||||||||
| No | Ref | Ref | ||||||
| Yes | 1.34 | 0.83 | 2.19 | 0.237 | 1.43 | 0.87 | 2.36 | 0.161 |
| Smoking | ||||||||
| Yes | Ref | Ref | ||||||
| No | 1.10 | 0.66 | 1.83 | 0.710 | 1.60 | 0.95 | 2.68 | 0.080 |
| Drinking | ||||||||
| Yes | Ref | Ref | ||||||
| No | 0.81 | 0.43 | 1.50 | 0.497 | 0.40 | 0.21 | 0.76 | 0.007 |
| Sedentary time (hours) | ||||||||
| Less than 1 | Ref | Ref | ||||||
| 1 ~ 3 | 1.76 | 1.09 | 2.84 | 0.022 | 1.47 | 0.90 | 2.39 | 0.128 |
| 3 ~ 6 | 1.01 | 0.55 | 1.86 | 0.966 | 0.97 | 0.52 | 1.81 | 0.927 |
| Above 6 | 1.38 | 0.74 | 2.57 | 0.313 | 0.98 | 0.52 | 1.85 | 0.944 |
| Sport frequency per week | ||||||||
| 0 | Ref | Ref | ||||||
| 1 ~ 2 | 0.79 | 0.47 | 1.34 | 0.383 | 1.46 | 0.85 | 2.51 | 0.171 |
| 3 ~ 5 | 0.91 | 0.51 | 1.63 | 0.752 | 1.73 | 0.96 | 3.14 | 0.074 |
| Above 5 | 1.00 | 0.39 | 2.57 | 1.000 | 1.75 | 0.67 | 4.61 | 0.259 |
| Monthly income (￥) | ||||||||
| Less than 3000 | Ref | Ref | ||||||
| 3000 ~ 6000 | 0.79 | 0.48 | 1.30 | 0.347 | 1.18 | 0.71 | 1.98 | 0.519 |
| 6000 ~ 9000 | 4.35 | 1.82 | 10.41 | 0.001 | 6.83 | 2.80 | 16.68 | 0.000 |
| Above 9000 | 5.44 | 1.24 | 23.78 | 0.027 | 8.07 | 1.78 | 36.55 | 0.008 |
| History of depression | ||||||||
| Yes | Ref | Ref | ||||||
| No | 1.03 | 0.67 | 1.58 | 0.894 | 0.83 | 0.53 | 1.28 | 0.399 |
| History of psychiatry disease | ||||||||
| Yes | Ref | Ref | ||||||
| No | 0.36 | 0.21 | 0.61 | 0.000 | 0.34 | 0.20 | 0.59 | 0.000 |
OR Odds ratio, CI Confident interval, LL Lower limit, UL Upper limit
Regarding the variables in terms of their family members, an education level of high school (P = 0.040), relative higher monthly income (P = 0.035), and higher severity of anxiety (P = 0.011) were significant risk factors for patient’s anxiety (Table 6), whereas middle (P = 0.027) or unclear (P = 0.07) personality were protective. Age and gender adjustments among the above significant characteristics revealed that the all four variables were significant (Supplementary table 6). A sport frequency above five per week (P = 0.023) and a higher severity of depression (P = 0.013) among families were risk factors for patient’s depression, whereas middle personality (P = 0.030) and mild anxiety (P = 0.039) were protective factors. After adjusting for age and gender among significant characteristics, the four variables were still significant (Supplementary table 7).
Table 6.
Multivariable analysis of characteristics in terms of family members for predicting patient’s anxiety and depression specifically among self-poisoning patients (n = 102)
| Characteristics | Anxiety | Depression | ||||||
|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | P | OR | 95% CI | P | |||
| LL | UL | LL | UL | |||||
| Intercept | 22.26 | 1.91 | 259.01 | 0.016 | 3.33 | 0.28 | 39.01 | 0.341 |
| Family relationship | ||||||||
| Parents | Ref | Ref | ||||||
| Spouse | 1.23 | 0.57 | 2.67 | 0.596 | 0.93 | 0.43 | 2.02 | 0.858 |
| Siblings | 1.21 | 0.27 | 5.45 | 0.806 | 1.26 | 0.28 | 5.71 | 0.763 |
| Kids | 0.77 | 0.34 | 1.73 | 0.529 | 0.69 | 0.31 | 1.55 | 0.373 |
| Others | 1.25 | 0.64 | 2.43 | 0.523 | 1.27 | 0.65 | 2.49 | 0.484 |
| Gender | ||||||||
| Male | Ref | Ref | ||||||
| Female | 1.71 | 0.92 | 3.16 | 0.094 | 1.48 | 0.80 | 2.75 | 0.215 |
| Age | 0.98 | 0.96 | 1.01 | 0.220 | 1.01 | 0.98 | 1.04 | 0.476 |
| Live together | ||||||||
| Yes | Ref | Ref | ||||||
| No | 1.46 | 0.74 | 2.89 | 0.281 | 0.77 | 0.39 | 1.53 | 0.464 |
| Education level | ||||||||
| Primary | Ref | Ref | ||||||
| High school | 2.27 | 1.05 | 4.90 | 0.040 | 0.95 | 0.44 | 2.05 | 0.895 |
| University | 1.08 | 0.49 | 2.40 | 0.850 | 0.59 | 0.26 | 1.31 | 0.196 |
| Graduate | 1.14 | 0.26 | 5.06 | 0.864 | 3.03 | 0.68 | 13.53 | 0.150 |
| Sedentary time (hours) | ||||||||
| Less than 1 | Ref | Ref | ||||||
| 1 ~ 3 | 0.97 | 0.53 | 1.77 | 0.909 | 1.44 | 0.79 | 2.65 | 0.241 |
| 3 ~ 6 | 1.09 | 0.44 | 2.74 | 0.850 | 1.34 | 0.53 | 3.36 | 0.538 |
| Above 6 | 0.48 | 0.21 | 1.09 | 0.085 | 0.61 | 0.27 | 1.40 | 0.251 |
| Sport frequency per week | ||||||||
| 0 | Ref | Ref | ||||||
| 1 ~ 2 | 1.59 | 0.59 | 4.27 | 0.362 | 1.53 | 0.57 | 4.12 | 0.403 |
| 3 ~ 5 | 1.13 | 0.41 | 3.12 | 0.822 | 1.76 | 0.63 | 4.89 | 0.285 |
| Above 5 | 1.75 | 0.68 | 4.51 | 0.252 | 3.07 | 1.19 | 7.95 | 0.023 |
| Drinking | ||||||||
| Yes | Ref | Ref | ||||||
| No | 0.87 | 0.34 | 2.24 | 0.776 | 2.16 | 0.84 | 5.59 | 0.115 |
| Smoking | ||||||||
| Yes | Ref | Ref | ||||||
| No | 0.87 | 0.40 | 1.92 | 0.739 | 1.05 | 0.48 | 2.31 | 0.897 |
| Monthly income (￥) | ||||||||
| Less than 3000 | Ref | Ref | ||||||
| 3000 ~ 6000 | 1.03 | 0.58 | 1.83 | 0.910 | 0.85 | 0.48 | 1.51 | 0.592 |
| 6000 ~ 9000 | 2.01 | 0.79 | 5.13 | 0.149 | 1.48 | 0.58 | 3.79 | 0.415 |
| Above 9000 | 2.29 | 1.08 | 4.88 | 0.035 | 1.84 | 0.86 | 3.93 | 0.118 |
| Character | ||||||||
| Outgoing | Ref | Ref | ||||||
| Middle | 0.57 | 0.35 | 0.93 | 0.027 | 0.58 | 0.36 | 0.94 | 0.030 |
| Introvert | 1.44 | 0.72 | 2.88 | 0.306 | 1.67 | 0.83 | 3.36 | 0.151 |
| Unclear | 0.23 | 0.08 | 0.65 | 0.007 | 0.50 | 0.18 | 1.40 | 0.190 |
| Intimacy score | 1.00 | 0.98 | 1.01 | 0.676 | 1.00 | 0.99 | 1.02 | 0.755 |
| Severity of anxiety (GAD-7) a | ||||||||
| None | Ref | Ref | ||||||
| Mild | 0.37 | 0.16 | 0.85 | 0.022 | 0.40 | 0.17 | 0.94 | 0.039 |
| Moderate | 1.97 | 0.58 | 6.72 | 0.282 | 0.35 | 0.10 | 1.21 | 0.101 |
| Severe | 6.07 | 1.57 | 23.40 | 0.011 | 0.76 | 0.20 | 2.95 | 0.697 |
| Severity of depression (PHQ-9) a | ||||||||
| None | Ref | Ref | ||||||
| Mild | 1.22 | 0.52 | 2.86 | 0.642 | 1.54 | 0.66 | 3.62 | 0.321 |
| Moderate | 0.92 | 0.38 | 2.24 | 0.862 | 1.08 | 0.44 | 2.63 | 0.865 |
| Severe | 0.70 | 0.16 | 2.96 | 0.626 | 6.55 | 1.54 | 27.97 | 0.013 |
OR Odds ratio, CI Confident interval, LL Lower limit, UL Upper limit, GAD-7 Generalized anxiety disorder-7, PHQ-9 Patient health questionnaire-9
anone anxiety or depression indicates a GAD-7 or PHQ-9 score of 0 to 4, mild anxiety or depression indicates a score of 5 to 9, moderate anxiety or depression indicates a score of 10 to 14, and severe anxiety or depression indicates a score of 15 or above
An overview of all risk factors
An overview of all risk factors for suicide, anxiety, and depression based on the features in terms of patients or their family members is shown in Fig. 8. The summary of risk factors for anxiety and depression were specifically among self-poisoning patients. It provided a thorough analysis of risk and parental factors. In detail, married marital status was a protective factor for suicide, anxiety, and depression among patients, and it could explain that spouse was a protective factor for preventing patient’s suicide. Regarding lifestyles, quitting smoking, giving up drinking, getting more exercise, and managing appropriate sedentary time were beneficial to reduce poor mental health and even suicide behavior. In addition, no prior history of psychiatry disease was linked to lower levels of anxiety and depression. Regarding the clinical characteristics of family members, sport frequency and monthly income were associated with depression and anxiety, respectively. An introvert personality among family members might have contributed to patient’s suicide. Of note, family member’s education level might also have a significant impact on the risk of suicide and anxiety, as this study showed that an education level of high school was associated with more patient’s suicide and anxiety. The overview of all risk factors also demonstrated that family member’s anxiety and depression were closely associated with patient’s anxiety and depression. In addition, the majority of factors still had the same importance after being adjusted for age and gender specifically among significant characteristics.
Fig. 8.
An overview of risk factors for suicide, anxiety, and depression based on the features in terms of patients or their family members. The summary of risk factors for anxiety and depression were specifically among self-poisoning patients. Red indicates risk factors; Green indicates protective factors. Odds ratio is summarized in the boxes. a indicates the results after adjusting for age and gender among significant characteristics
Discussion
Suicide has developed into a serious global public health problem linked to significant psychological disability, mortality, and impairment [22]. This study showed that compared to non-suicide patients who were admitted to the hospital due to poisoning, self-poisoning suicide patients experienced more serious mental health issues, such as anxiety, depression, hopelessness, and a lack of social support. The findings highlighted the need for more mental health care for people who were prone to self-poisoning. Also, among self-poisoning patients in particular, family members’ mental health state was substantially correlated with patients’ psychiatric status, despite the fact that they scored statistically significantly lower on anxiety and depression than patients did. It suggested that not only self-poisoning patients but also their matched family members should seek professional assistance and access to mental healthcare. Hence, an emphasis on modifiable aspects is now necessary to enable the value of the evidence in suicide prevention.
In the present study, multivariable analysis showed that married marital status, sedentary time of 1 to 6 h, and participation in sports more than five times per week were significantly associated with a lower rate of self-poisoning suicide, while current smoking and anxiety were significant risk factors. Previous studies have shown that divorce was a risk factor for self-poisoning [23], and anxiety was one of most relevant risk factors for suicide [24]. In addition, anxiety disorders raised the chance of subsequent episodes of purposeful self-harm among adolescents and young adults [25]. A meta-analysis showed that depressive and anxious symptoms and comorbid substance use increased the risk of suicide attempts [26]. Another meta-analysis also demonstrated that anxiety increased suicide risk [27]. Interestingly, in this study, we further identified risk factors for self-poisoning based on variables from patient’s matched family members. Family member’s identity, gender, education level, and personality had an impact on patient’s self-poisoning rates. Spouse was severed as a protective factor which was confirmed by the result that married marital status was associated with a lower risk of self-poisoning suicide. A larger monthly income for family members was associated with a tendency for a reduction in the probability of self-poisoning suicide. Yet, patients with higher monthly incomes can experience more worry and depression as opposed to a reduction in the probability of self-poisoning suicide. To earn a high salary, a patient might need to work more and take on more tasks, which could lead to anxiety and sadness owing to the strain of the labor. Patients were more likely to receive financial assistance from their family members if they made a greater monthly income, which may have lessened the patient’s suicidal thoughts. In addition, high school education and an introverted personality trait among family members were additional risk factors for self-poisoning among patients. Previous study also showed that higher introversion increased the risk of suicide ideation [28], and our present study demonstrated that introvert personality among family members also increased the risk of suicide attempts. Family members with introvert personality might not have effective communications with patients, which might possibly affect the mental health of patients. Family members living together with patients might be beneficial to curb anxiety, and this could be explained that such accompany was a protective factor for anxious status. Previous study had already showed that female was vulnerable to self-poisoning suicide [10, 14], and our study also depicted a similar trend. But, interestingly, having female family members helped to prevent self-poisoning suicide for patients. The above-mentioned findings demonstrated a connection of psychiatric health between self-poisoning patients and their family members.
In addition, specifically among self-poisoning suicide patients, multivariable analysis demonstrated that married marital status and no history of psychiatry disease were protective factors for preventing anxiety and depression, while older age, divorced or widowed marital status, a sedentary time of 1 to 3 h, drinking, and a higher monthly income were significant contributors to anxiety or depression. As shown in the above, anxiety was one of main contributors to self-poisoning [25–27]. Our study further depicted concise suggestions for patients to deal with anxiety, such as finding a partner, treating previous psychiatry disease, and cultivating health lifestyle. Among the parental traits, a meta-analysis revealed less warmth, more interparental conflict, over-involvement, and aversiveness were linked to higher rates of depression and anxiety [29], indicating that a peaceful home environment was helpful in preventing anxiety and depression. In addition, a more recent study found that having a depressed mother increased the probability of adolescent anxiety and depression, as well as the amount of peer stress these adolescents experienced [30].
National restrictions on harmful pesticides were thought to be one of the most effective ways to avoid self-poisoning suicide [5, 6]. However, this intervention had relatively less impact on preventing suicide by self-poisoning, and toxic substances such as pesticides were still readily accessible among many countries, including China. In addition, Weerasinghe et al. [31] showed that pesticide vendors were willing to be a “gatekeeper” to prevent patient’s access to pesticides from their stores. Nonetheless, it was challenging for the sellers to differentiate between consumers who might be self-poisoning and those who bought pesticides for agricultural use [32]. Thus, the matter at hand is complicated. Even worse, illicit drugs and medically prescribed drugs are also readily accessible and the most frequently misused medicine [7, 8]. But one was sure that suicides was able to, at least partially, be decreased by limiting the accessibility of means to suicide [24], by training hospital doctors and community medical workers to screen people at high risk of suicide, manage self-poisoning patients more appropriately, as well as provide adequate follow-up health care [24]. Suicidality is a significant social and medical issue, and hence it should be prioritized in many areas.
Limitations
This study still needs to be improved in a few areas. Initially, a longitudinal cohort study is required to investigate because it is challenging to establish a causal relationship between variables and suicide due to the cross-sectional study’s nature. Secondly, the meaning of the term “suicide” in the literature that is currently available is occasionally unclear, which may result in patient’s selection bias. On the other hand, for the current study, we gathered patients who had been admitted to the hospital’s department for self-poisoning suicide. Thus, those patients are highly specific. Thirdly, as the data were gathered from a medical center, certain possible biases may still remain as a result of unmeasured confounding variables. A planned multicenter validation study is therefore necessary.
Conclusions
Self-poisoning suicide patients have severe mental health issues. Patients who self-poison have a close connection to their family member’s mental health, particularly their levels of anxiety and depression. According to the findings, being married and adopting healthy lifestyle habits, such as quitting smoking and drinking, increasing their physical activity levels, and managing their idle time, are able to help patients with mental health concerns and even suicidal thoughts.
Supplementary Information
Additional file 1: Supplementary table 1. Measures of mental health among patients and their family members.
Additional file 2: Supplementary table 2. Multivariable analysis of significant characteristics for predicting self-poisoning suicide among patients after adjusting for age and gender (n=151).
Additional file 3: Supplementary table 3. Multivariable analysis of significant characteristics in terms of matched family members for predicting self-poisoning suicide among patients after adjusting for age and gender (n=151).
Additional file 4: Supplementary table 4. Multivariable analysis of significant characteristics for predicting anxiety among self-poisoning suicide patients after adjusting for age and gender (n=102).
Additional file 5: Supplementary table 5. Multivariable analysis of significant characteristics for predicting depression among self-poisoning suicide patients after adjusting for age and gender (n=102).
Additional file 6: Supplementary table 6. Multivariable analysis of significant characteristics in terms of matched family members for predicting anxiety among self-poisoning suicide patients after adjusting for age and gender (n=102).
Additional file 7: Supplementary table 7. Multivariable analysis of significant characteristics from matched family members for predicting depression among self-poisoning suicide patients after adjusting for age and gender (n=102).
Acknowledgements
Not applicable.
Abbreviations
- BHS-20
Beck hopelessness scale-20
- CI
Confident interval
- COVID-19
Corona Virus Disease 2019
- GAD-7
Generalized anxiety disorder-7
- LL
Lower limit; OR, Odds ratio
- PHQ-9
Patient health questionnaire-9
- SD
Standard deviation
- SES-10
Self-esteem scale-10
- Std. Error
Standard error
- SSQ-10
Social support questionnaire-10
- UL
Upper limit
Authors’ contributions
WZ, LH, and YF conceived and designed this study together. WZ undertook the data analysis, results interpretation and manuscript preparation. XP and YY performed supervision. All authors read and approved the final manuscript.
Funding
None.
Availability of data and materials
The data are available under reasonable request to the corresponding author.
Declarations
Ethics approval and consent to participate
The Ethics Committee of the Fifth Medical Center of PLA General Hospital approved the study protocol (No. KY-2021–12-34–1). Data were anonymously analyzed and informed written consent was obtained from all patients and family members. All experiments were performed in accordance with relevant guidelines and regulations.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Wenjing Zheng and Limei Han contributed equally to the paper.
Contributor Information
Xiaobo Peng, Email: xiaobopeng911@163.com.
Ying Yang, Email: 68176134@qq.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Additional file 1: Supplementary table 1. Measures of mental health among patients and their family members.
Additional file 2: Supplementary table 2. Multivariable analysis of significant characteristics for predicting self-poisoning suicide among patients after adjusting for age and gender (n=151).
Additional file 3: Supplementary table 3. Multivariable analysis of significant characteristics in terms of matched family members for predicting self-poisoning suicide among patients after adjusting for age and gender (n=151).
Additional file 4: Supplementary table 4. Multivariable analysis of significant characteristics for predicting anxiety among self-poisoning suicide patients after adjusting for age and gender (n=102).
Additional file 5: Supplementary table 5. Multivariable analysis of significant characteristics for predicting depression among self-poisoning suicide patients after adjusting for age and gender (n=102).
Additional file 6: Supplementary table 6. Multivariable analysis of significant characteristics in terms of matched family members for predicting anxiety among self-poisoning suicide patients after adjusting for age and gender (n=102).
Additional file 7: Supplementary table 7. Multivariable analysis of significant characteristics from matched family members for predicting depression among self-poisoning suicide patients after adjusting for age and gender (n=102).
Data Availability Statement
The data are available under reasonable request to the corresponding author.