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Enfermería Global

On-line version ISSN 1695-6141

Enferm. glob. vol.20 n.63 Murcia Jul. 2021  Epub Aug 02, 2021

https://dx.doi.org/10.6018/eglobal.451351 

Originals

Levels of suicidal ideation associated with alcohol use

Clara Ananda Pimentel de Sousa Santos1  , Claudete Ferreira de Souza Monteiro2 

1 Enfermera, Maestra en Enfermería, Universidad Federal de Piauí. Teresina/Piauí/Brasil. claraanandapimentel@hotmail.com

2 Enfermera, Doctora en Enfermería, Profesora de graduación y posgraduación en Enfermería de la Universidad Federal de Piauí. Teresina/Piauí/Brasil.

ABSTRACT:

Objective:

To analyze the association between suicidal ideation and alcohol use in an adult population assisted in primary health care in Teresina, Piauí, Brazil, from June to September 2019.

Material and Method:

This is an observational, analytical and cross-sectional study conducted with 380 adults in 11 Basic Health Units. The source population consisted of 14,062 adults aged 20 to 59 years, registered in the e-SUS information system of the Family Health Teams. Data collection took place between June and September 2019, using a sociodemographic questionnaire, the Beck Scale for Suicide Ideation, and the Alcohol Use Disorders Identification Test.

Results:

The prevalence of suicidal ideation in the sample was 17.9%. Among these, 39.7% had clinically significant suicidal ideation. The prevalence of alcohol use by people with suicidal ideation was 42.6%, and 44.4% used alcohol among those with clinically significant suicidal ideation. There was an increase in the prevalence of suicidal ideation (33.3%) and clinically significant suicidal ideation (16.7%) in individuals with possible dependence. Those who did not have a partner were 1.4 times more likely to have suicidal ideation. Those with a history of discrimination were 1.9 times more likely to have suicidal ideation. Having a stressful event increased the chances of clinically significant suicidal ideation by 3.1 times and problems with sleep by 2.9 times.

Conclusion:

The study showed that alcohol use influenced suicidal ideation and clinically significant suicidal ideation in the sample.

Keywords: Adult; Suicidal ideation; Alcohol abuse; Mental health; Collective health

INTRODUCTION

Suicidal ideation involves fleeting thoughts that life is not worth living and often passive vague ideas about dying. Additionally, suicidal ideation can involve careful planning on how to die by suicide. Due to the severity of suicidal ideation, nowadays, the concern of professionals and health policies include measures that must be taken before this idea leaves the mental plane and becomes a harsh reality - a suicide attempt or suicide 1. Because suicidal ideation is the first intention, this ideation is studied within the suicidal behaviour that basically involves three manifestations: suicidal ideation, suicide attempts, and suicide 2.

There are around 11 thousand suicide deaths in the Brazilian context, equivalent to 30 suicides per day. Data collected from 2011 to 2017 show records of 80,352 deaths by suicide in the population aged ten and over, indicating that suicide is the fourth leading cause of death in the young Brazilian population. In the state of Piauí, Northeast region, the rate of deaths by suicide in the 15 to 29 age group, in the same period, went from 8.7 to 11.4, varying 32% 3.

Data from the Epidemiological Bulletin 24 of the Health Surveillance Secretariat/Ministry of Health of Brazil (2011-2018) shows that the total number of notified cases of self-harm and deaths by suicide among young people aged 15 to 29 was 154,279. This bulletin also has a new component stating that self-inflicted violence comprises suicidal ideation, self-harm, suicide attempts, and suicides. It should be noted that not all self-inflicted violence characterizes a suicide attempt. Self-inflicted violence can be a way of relieving suffering without the objective of ending life. Also, suicidal ideation is not notifiable 3.

The data are indeed alarming, and there are several attempts to explain suicide. When studying the individual side of people who died by suicide, mental health disorders (particularly depression and alcohol abuse) are considered. Social and economic dimension analysis highlights that suicide may arise from social cohesion pressures4.

For the World Health Organization, suicide is prevenTable. Among the various measures to prevent and control suicide and its attempts, early identification is included. The aim is to treat and care for people with mental disorders or substance use, chronic pain, and acute emotional stress5. It is important to mention that the use of substances is also related to suicidal behaviour.

According to the National Survey of Alcohol and Drugs (Brazilian acronym: Levantamento Nacional de Álcool e Drogas - LENAD), 5% of Brazilians have already tried to commit suicide, and in about 24% of these attempts, alcohol was used 6. Alcohol is an issue in several areas, emphasizing its relationship with suicidal behaviour 7.

Factors associated with suicidal ideation are studied considering the statistical panorama of suicide, the suffering involving victims, family and society, and the difficulty of identifying this intention. Therefore, this study aimed to analyze the association between suicidal ideation and alcohol use in an adult population served in primary health care in Teresina, Piauí, Brazil.

MATERIAL AND METHOD

This is an observational, analytical and cross-sectional study carried out in the Basic Health Units (Brazilian acronym: Unidades Básicas de Saúde - UBS) that have matrix support with the Family Health Support Centers (Brazilian acronym: Núcleos de Apoio à Saúde da Família - NASF) in the city of Teresina, Piauí, Brazil. This study included people who were registered at the UBS, aged between 20 and 59 years old.

The source population consisted of 14,062 inhabitants (adults aged 20 to 59 years), registered in the e-SUS information system of the Family Health Teams (eSF). The sample was calculated using the formula for social research for finite populations, taking into account an assumed prevalence (50%) of individuals with suicidal behaviour seeking primary care services 8. It was adopted a confidence level of 95% and a maximum error of 5%. The sample totalled 380 individuals.

Data collection happened between June and September 2019, in 11 UBS (including only those with matrix support by NASF). A questionnaire containing data on sociodemographic characteristics, health conditions, and lifestyle habits was used. The Beck Scale for Suicide Ideation (BSI) and the Alcohol Use Disorders Identification Test (AUDIT) were also used.

AUDIT was used to investigate the suspicion of harmful alcohol use. AUDIT is an easy-to-use instrument composed of 10 questions. This instrument is consistent with the ICD-10 definition of harmful alcohol use and dependence, validated in Brazil by Méndez (1999). According to this study, there was 78% sensitivity and 81% specificity for the following categories: harmful use, dependency syndrome, and withdrawal. The answers to each question are scored from 1 to 4, and the highest scores indicate problems. The instrument predicts four risk zones, according to the score obtained: zone I (up to 7 points: low risk or abstinence); zone II (8 to 15 points: medium risk); zone III (from 16 to 19 points: harmful use); and zone IV (above 20 points: possible dependence) 9.

BSI was used to assess the presence of suicidal ideation. Created in 1979 by Beck and colleagues, this self-assessment instrument is used to check the severity of suicidal ideation. The instrument consists of 21 items scored on a scale of 0 to 3, with a variation in the score of 0-38, calculated only by the sum of the first 19 items. Items 20 and 21 are for information only. Based on the validation carried out by Cunha 10, nationwide, people who had a score below 6 points were considered to have suicidal ideation. On the other hand, individuals who scored six or more were considered clinically significant suicidal ideation cases. In this study, the application of this instrument did not aim to raise a clinical diagnosis but data within the scope of the study. A professional psychologist assisted in the analysis of the results obtained by the referred instrument.

The data were analyzed using the Statistical Package for the Social Science (SPSS) software, version 20.0. The sample was characterized with descriptive statistics, including central tendency measures (simple frequency, mean, and median) and dispersion measures (standard deviation). The Kolmogorov-Smirnov test was applied to continuous numerical variables to verify the assumption of normality. The homogeneity of variances was assessed by the Levene test, while linearity was assessed with scatter plots.

For the study of associations between quantitative variables, Spearman's correlation coefficient was used. The chi-square test was used to assess the association between nominal categorical variables. The multivariate logistic regression test was also applied to estimate the probability associated with the occurrence of the event given the set of explanatory variables. For all the analyzes, the significance level of 0.05 was adopted.

The principles of ethics, secrecy, and confidentiality were followed, as recommended by Resolution no. 466/2012 of the National Health Council of Brazil, which deals with research involving human beings. Participants were invited and informed about the objectives of the study and, after they agreed to participate, they signed a Free and Informed Consent Form. The Research Ethics Committee of the Federal University of Piauí approved this study (Opinion No. 121623/2018).

RESULTS

The prevalence of suicidal ideation was 17.9% in the sample. Among these, 39.7% had clinically significant suicidal ideation (Figure 1). The mean BSI score was 1.24 (standard deviation 4.17), with a maximum value of 31 points.

Figure 1:  Prevalence of suicidal ideation and clinically significant suicidal ideation according to BSI. Teresina, 2019. (n = 380). 

Figure 2 shows that the prevalence of alcohol use by people with suicidal ideation was 42.6%, and 44.4% used alcohol among those with clinically significant suicidal ideation. There was no association between alcohol use and suicidal ideation (p = 0.435) and alcohol use and clinically significant suicidal ideation (p = 0.429) in the bivariate analysis.

Figure 2:  Alcohol use by people with suicidal ideation and clinically significant suicidal ideation. Teresina, 2019. (n = 380). 

Among people who used alcohol, the prevalence of suicidal ideation was 18.6% (n = 29). Figure 3 shows the prevalence of suicidal ideation and clinically significant suicidal ideation according to alcohol use patterns. In individuals with scores of possible dependence, there was an increase in the prevalence of suicidal ideation (33.3%) and clinically significant suicidal ideation (16.7%). There was no significant association between suicidal ideation and alcohol use pattern (p = 0.060) and between clinically significant suicidal ideation and alcohol use pattern (p = 0.030) in the bivariate analysis.

Figure 3:  Prevalence of suicidal ideation and clinically significant suicidal ideation according to alcohol use pattern. Teresina, 2019. (n = 380). 

In the multivariate logistic regression model for suicidal ideation, not having a partner and history of discrimination were statistically significant. Those who had no partner were 1.4 times more likely to have suicidal ideation. Participants with a history of discrimination were 1.9 times more likely to have suicidal ideation (Table 1).

Table 1:  Logistic regression including suicidal ideation, socioeconomic variables, and living conditions among people who use alcohol. Teresina, 2019. (n = 156). 

In the multivariate logistic regression model for clinically significant suicidal ideation, statistically significant associations were too found for the following variables: female sex, being single (with previous marriage) or without a partner, having reported a stressful event or sleep problems, and having a history of discrimination. Females were 3 times more likely to have clinically significant suicidal ideation. Singles (with previous marriage) were 4 times more likely to have clinically significant suicidal ideation. People without a partner were 2.9 times more likely to have clinically significant suicidal ideation. Having a stressful event increases the chances of clinically significant suicidal ideation by 3.1 times and the chances of sleep problems by 2.9 times. Having a history of discrimination increases the chances of having clinically significant suicidal ideation 3.7 times (Table 2).

Table 2:  Logistic regression including clinically significant suicidal ideation, socioeconomic variables, and living conditions among people who use alcohol. Teresina, 2019. (n = 156). 

DISCUSSION

In the analysis of the prevalence of suicidal ideation and clinically significant suicidal ideation, the cut-off of 6 points in the BSI was adopted. Of the 380 participants, 17.9% had a level of suicidal ideation. A similar result was identified in other studies 11,12. Clinically significant suicidal ideation was found in 39.7% of individuals with a non-zero score on the BSI 13. In the same Brazilian region of this study (Northeast), strong suicidal ideation was identified in 63% of the sample 13. This potential concern must be seen both in the individual and collective context.

Although the relationship between suicidal behaviour and mental disorders (particularly depression and substance use) is well established, people who die by suicide often act impulsively in crisis times. For example, there may be a breakdown in the ability to deal with life's stressors, such as financial problems, breakups or chronic pain, and illness. Thus, poor conflict management, disasters, violence, abuse or losses, and a sense of isolation are strongly associated with suicidal behaviour 5.

The data analyzed in this study showed that the prevalence of alcohol use by people with suicidal ideation was 42.6%. Similarly, the prevalence of suicidal ideation in those with clinically significant suicidal ideation was 44.4%. The association of alcohol use with suicidal ideation was verified in a study carried out in people over 18 years old who attended a public university in Piauí 14. In this study, it was observed that 90.3% of the individuals who reported using alcohol had some level of suicidal ideation 14. The use of alcoholic drinks increases the chances of having suicidal ideation by 7.11 times 14. This same association was verified in national and international studies 15,16.

The association between substance abuse and suicidal behaviour has been reported in the literature, mainly under the assumption that alcohol misuse can trigger suicidal thoughts. The presence of suicidal ideation can lead to alcohol misuse, and alcohol misuse can trigger suicidal behaviour. Therefore, the relationship between substance use and suicidal behaviour seems to be reciprocal and multidirectional, highlighting the need for preventive measures for both issues 17.

It was observed in this study that the increase in the pattern of alcohol use increased with the prevalence of suicidal ideation and clinically significant suicidal ideation. These findings show that higher values of the two levels of suicidal ideation point to possible alcohol dependence. These data converge with another study in which alcohol dependence was present in 13% of individuals with low-severity suicidal ideation and in 16% of participants with high-severity suicidal ideation 11.

A study with data from the combined 2008-2012 National Survey on Drug Use and Health aimed to verify the impact of binge drinking on suicidal behaviour in the United States of America 18. This study found that suicidal ideation was more prevalent in individuals who binged drinking (29.0%) 18. This prevalence was estimated compared to participants who were not compulsive drinkers, showing that as the severity of consumption increases, suicidal ideation also increases 18.

With the multivariate logistic regression model for the presence of significant suicidal ideation, it was observed that being female presented a statistically significant association, and women were 3 times more likely to manifest suicidal ideation. This finding was also evidenced in another study that reported a statistically significant association between suicidal ideation and women 19.

Some elements must be taken into account when it comes to factors that lead these women to consider suicide, and one of them is related to gender issues. These aspects may involve rigid gender roles. These women may find themselves undervalued or lacking power over their children, husbands, and families. Suicidal ideation can also be related to violence (psychological, verbal, physical, sexual or institutional violence). The summation of such experiences compromises women's mental health, contributing to isolation, anxiety, low self-esteem and depression, and culminating in suicidal ideation 20.

A history of discrimination showed a statistically significant association with the two levels of suicidal ideation addressed in this study. This factor increased the chances of having suicidal ideation (by 1.9 times) and the risk of clinically significant suicidal ideation (by 3.7 times). People who suffer discrimination are left with marks about self-respect and personal power, compromising autonomy and self-determination competence over their own lives. Suicide rates are high in vulnerable groups that experience discrimination, such as refugees, migrants, indigenous people, lesbians, gays, bisexuals, transgender and intersex (LGBTI) people, and people deprived of their freedom 5.

Stigma, therefore, increases the vulnerability of individuals and groups, directly reflecting on their health conditions. Regardless of the source of the stigma, the implications for the affected individual's life include the following: violation of human dignity, social isolation and exclusion, less access to health services, impaired chances of life, poor quality of life, and risk of death 21.

Being divorced or widowed (single, with previous marriage) increased the chances of clinically significant suicidal ideation by 4 times. Also, being single (without a partner) increased by 2.9 times the risk of presenting clinical suicidal ideation. One of the causes for this phenomenon is the relationship of emotional dependence on the spouse. This relationship is expressed, for example, by the conception that it is not possible to live without the other. Emotional dependence comprises a persistent pattern of psychological needs that have not been met, resulting in a lack of self-esteem and idealization of the other. These factors predispose to behavioural changes, resulting in psychological distress and its consequences 22.

History of a stressful event in the last year increased the chances of clinically significant suicidal ideation by 3.1 times. A study aimed to identify different categories of stressful events and the interference of these categories in suicidal ideation and attempted suicide 23. This study identified that 14.4% of the research participants stated they had had a stressful event 23.

Stressful events are defined as events in life that alter the environment and cause tension that interferes with individuals’ responses. Despite the biological and genetic influence on suicidal behaviour, external psychosocial factors are considered (unstructured family, unemployment, poverty, difficulty accessing health and education, illness in the family, death of a loved one, divorce, and so on). These events can cause stress, modify the environment, and increase the probability of emotional problems interfering with the individual's behaviour 24.

Individuals with sleep problems were 2.9 times more likely to have clinically significant suicidal ideation. Changes in sleep can cause emotional balance and lead to depression, anxiety, and stress disorders in individuals. Disorders in sleep patterns can result in a high risk of somatic and psychological disorders, which negatively affect the quality of life. The reduction in normal sleep duration favours increased aggression, irritability, emotional lability, and reduced tolerance to frustration 25.

CONCLUSION

The data show a high prevalence of suicidal ideation, with a high percentage of clinically significant suicidal ideation. There was also a direct association between suicidal ideation and alcohol use because alcohol use increased with the prevalence of suicidal ideation and clinically significant suicidal ideation. Suicidal ideation was significantly associated with female sex, stressful event, sleep problems, history of violence, and discrimination.

Such findings reveal the influence that alcohol use has on suicidal ideation and constitute a situational diagnosis for primary health care services to promote actions to prevent and deal with these issues.

The inclusion of only individuals over 20 years old is a limitation in this study, considering that alcohol use starts early in adolescence. Future research should include adolescents.

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Received: October 19, 2020; Accepted: January 13, 2021

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