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INTRODUCTION

Suicide is the 10th most common cause of death in the world (1). Many different factors play a role in the emergence of suicidal behavior, which is known to have a close relationship with psychiatric disorders. Ninety percent of suicide victims have a mental disorder (2). The risk of suicide in patients with psychiatric disorders is 5-15 times higher than in the general population (3). Therefore, features associated with suicidal behavior in psychiatric disorders have been investigated in several studies (4,5).

Adjustment disorder is characterized by improper responses given to daily life challenges and complex emotional and behavioral pathologies. It is a psychiatric disorder that significantly disrupts functionality (6). The prevalence of adjustment disorder was 1.0% in the general population, 12.0-35.9% among inpatients, and 37.6-40.0% in the military (7). In suicide attempts, 50.0% of patients had adjustment disorder, and adjustment disorder is the most common psychiatric diagnosis in women with recurrent suicide attempts (40.8%) (8). Moreover, the second most common cause of death due to suicide in low- and middle-income communities, after alcohol use, is adjustment disorder (9). In recent years in the UK, adulthood suicide-related deaths due to schizophrenia, personality disorders, and substance abuse diagnosis have decreased. However, deaths due to adjustment disorders and other psychiatric disorders have increased (10).

In adjustment disorder, the time between suicidal ideation and completed suicides was shorter than in other psychiatric disorders (11). Past suicide attempts, a history of psychiatric treatment, poor psychosocial functioning, dysphoria, and psychomotor restlessness have all been identified as risk factors for suicide in adolescents with a diagnosis of adjustment disorder (12). In another study, being young and single and the presence of severe depressive symptoms have also been shown to be risk factors for suicide (13). In addition, substance use was found to be an independent risk factor for suicide attempt in a large-scale follow-up study conducted on adolescents (14). Similarly, it was stated in reviews that chronic use of cannabis can predict suicide and legal sympathomimetic agents create a suicide risk (15,16).

In this study, we determined the risk factors associated with suicide attempts in young men with a diagnosis of adjustment disorder during military service.

METHOD

We enrolled 202 patients admitted to the psychiatric clinic during their military service with a diagnosis of adjustment disorder, made by two psychiatrists according to the DSM-IV-TR criteria. They were followed for three months and were enrolled consecutively. The patients were divided into two groups, one consisting of patients who were admitted with suicide attempts and one without suicide attempts. Sociodemographic data (age, education, marital status), drug use, history of psychiatric diagnoses, suicide attempts and methods, familial suicide attempts and completed suicides history, and self-mutilation as well as physical and sexual trauma history of patients were inquired about on admission. Monthly check-ups were made by different psychiatrists for 3 months. Patients meeting substance dependence criteria on admission and those who did not voluntarily agree to participate in the study were excluded. Patients with psychiatric disorders other than adjustment disorder and substance use disorder were excluded from the study. Patients who were intoxicated due to substance use and who were in the substance withdrawal period were not included in the study.

The trial was performed in accordance with the Declaration of Helsinki and subsequent revisions and approved by an ethics committee (GATA Ethics Committee 09.07.2015/10-343). Written informed consent was obtained from subjects before being admitted to the study.

Statistical Analysis

The data were analyzed with SPSS 15.0. Continuous variables were expressed as mean±standard deviation, while categorical variables were expressed in numbers and percentages. To compare adjustment disorder patients showing suicidal behavior with those who did not, the Student t test was used for continuous variables and chi-square test for discrete variables. Statistical significance was set at p<0.05.

RESULTS

Of the male patients diagnosed with adjustment disorder (n=202), 125 (61.9%) were admitted without suicide attempts and 77 (38.1%) with suicide attempts. Of patients with attempted suicide (n=77), 83.1% (n=64) chose a method that made escape/rescue unlikely (firearms, hanging, jumping, using sharp tools, and burning); 16.9% (n=13) chose a method with a greater chance of escape/rescue (drug overdose). In male patients diagnosed with adjustment disorder, we distinguished two groups – those having attempted suicide and those who did not. There were significant differences in terms of age, years of education, and marital status (Table 1).

While significant differences were found between the two groups (with a previous suicide attempt and without) in terms of self-mutilation and synthetic cannabinoid (SC) use (p<0.05), no statistically significant differences were found for history of mental illness, family history of suicide, suicide attempt history, physical/sexual trauma, and substance use (cannabis, ecstasy, heroin, cocaine, volatile solvents, and alcohol) (Table 2).

There was a significant relationship between the use of SC and suicide attempts (Table 3). No statistically significant relationship was found between the suicide attempt and other substances except SC.

DISCUSSION

In this study, the use of SC and the presence of self-mutilation have been associated with suicide attempts in patients diagnosed with adjustment disorder. A relationship between other psychoactive agents (cannabis, ecstasy, heroin, cocaine, volatile solvent, and alcohol) and suicide attempts could not be found. While 16 of 77 adjustment disorder patients (20.8%) who had made suicide attempts had used SC, this rate was 8.8% in cases without suicide attempts. Sixteen out of 27 people who used SC attempted suicide (59.3%). Also, a significant association was found between the use of SC and a history of suicide attempts; 18 of 96 patients with a history of suicide attempts (18.8%) had used SC. This ratio was 8.5% in patients without a history of suicide attempts; 18 of 27 cases using SC (66.7%) have a history of suicide attempts.

SC is a next-generation drug class produced in the laboratory. SC use is on the rise because it is easily available and cheap. However, it has many negative consequences. SCs are shown to trigger psychotic symptoms including paranoia, hallucinations, disorganized behavior, hypomania, and suicidal thoughts among individuals with or without concomitant psychiatric disorders. Many chemical agents react with them, and they interact with the cental nervous system (CNS) via endogenous cannabinoid receptors.

There are very few studies in the literature suggesting that there is a relationship between suicidal attempts and the use of SC in adjustment disorder. In addition to a case presentation that discussed suicidal thoughts caused by the use of SC and self-mutilation behavior (17), it was found that 10.8% of patients showed self-mutilative behaviors. In a retrospective study that investigated the acute effects of SC intoxication, 0.8% had attempted suicide or self-mutilation (18). It is not known what type of effect SC use has on long-term suicidal thoughts. Postmortem studies indicate that endocannabinoid levels in the dorsal prefrontal cortex are increased in completed suicides linked to depression and alcoholism. It is not known whether this situation is a result of a compensatory mechanism or a cause of suicide. It is also thought that CB1 receptor sensitivity in the prefrontal cortex can play a role in the pathophysiology of suicide (19). Cannabis use can lead to suicidal behavior associated with disinhibition, and SCs are 4-100 times more potent and long-lasting than cannabis (20). A disinhibition-mediated relationship between SC use and suicide attempts may be present. In a recent study conducted in a large sample in soldiers, disinhibition was found to be a predictor of suicide. Biological research in this area is critical (21).

In this study, the suicide attempt rate in young male patients with a diagnosis of adjustment disorder was 38.1%. In similar studies, suicide rates were 19.7% and 26.8%, respectively, in adjustment disorder (13,22). The rate we found is higher when compared to other studies investigating the suicide rate in adjustment disorder. This may be due to the rapid discharge of patients who have attempted suicide because of the hospital’s low capacity for treatment and follow-up. Adjustment disorder patients who did not attempt suicide are mostly treated and followed at local hospitals.

Of the patients who attempted suicide, 83.1% selected methods with a low chance of escape/rescue. This finding suggests that young men with a diagnosis of adjustment disorder largely choose irreversible suicide methods, and they carry strong suicidal intent. Male sex and being adult is known to be decisive in the choice of a more lethal method of suicide (23). When the intensity of suicide intention and the lethality of the method chosen are additive, adjustment disorder in young men can lead to very serious consequences.

In the study, suicide attempts were associated with self-mutilation. In other words, self-mutilation history is an indicator for future suicide attempts. In another study conducted on an adult military population, self-mutilation was a prospective predictor for suicide attempts. Researchers indicated that self-mutilation is an avoidance behavior associated with failure to regulate negative emotions caused by stressful life events. It is a sign of the tendency to develop suicidal behavior (24). Similarly, a strong association between suicide attempts and self-mutilation in a civilian adult population has been found (25).

In this study, a significant relationship between suicide attempt history and current suicide attempt has not been determined. Similarly, Bryan et al. (24)reported that the suicide attempt history in a military sample is not an indicator of subsequent suicide. But if self-mutilation history accompanies previous suicide attempts, it may predict further suicide attempts. On the other hand, a publication studying the risk factors associated with suicide showed that suicide attempt history is a strong predictor for repeated and completed suicides (26). The main reason for this difference might be that the research was done in different communities (military vs. civilian).

The literature states that stressful life events can double alcohol use disorders (27). There is a high substance abuse comorbidity in adjustment disorder (28). On the other hand, it was reported that substance-dependent individuals had a suicide attempt history of 40.0% (29). There was a relationship between suicide attempts and the use of certain substances including alcohol and cannabis (30). In this light, our study examined the relationship between suicide attempts and abuse of different substances. The use of SC has been associated with self-mutilation and suicide attempts.

There are some limitations of our study. First, the study was performed in young men during the period of military service. This makes it difficult to generalize the results of the study to all patients with adjustment disorder. Second, the level of disinhibition was not measured – although this was thought to play a role in suicide. Finally, we did not carry out toxicology assessments for SC and other drugs. This is another limitation of the study.

In summary, this study has shown that self-mutilation history and SC use predict suicide attempts in patients with an adjustment disorder diagnosis during military service, and these patients choose suicide methods that have a small chance of escape/rescue. Although adjustment disorder occurring due to stressful life events generally has a positive prognosis, clinical presentation and outcome in high-risk groups is negative. Therefore, there is a need for new studies that reveal high-risk groups and risk factors for adjustment disorders. Also, the use of SC is gradually increasing, and biological research is needed to illuminate the relationship between these drugs and suicide attempts. The results of such studies may identify biological responses that play a role in the emergence of suicide.

Informed Consent: Written consent was obtained from the participants.

Peer-review: Externally peer-reviewed.

Conflict of Interest: Author declared no conflict of interest.

Financial Disclosure: Author declared no financial support.

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