Determinants of Suicide Behavior among the Mentally Ill in a Tertiary Hospital in South-South Nigeria

Background: Suicide has been recognized as one of the commonest causes of death globally and mental disorders have been found to contribute about 70% to 80% of causes of suicide. A number of factors can predict or increase the risk of suicide among those who have mental illnesses.

Aim: This study aimed to look at the factors influencing suicide behavior among mentally ill patients at the University of Port Harcourt Teaching Hospital.

Materials and Methods: This was a cross-sectional study conducted among attendees of Neuropsychiatric Outpatient Clinic of the University of Port Harcourt Teaching Hospital. A structured questionnaire covering socio-demographic characteristics and other factors were self-administered to 75 patients diagnosed with various psychiatric disorders by consultants Psychiatrists and attending the out-patient clinic via a systematic random sampling. Ethical approval was obtained from the ethical committee of the University of Port Harcourt Teaching Hospital and all other ethical provisions were followed. Descriptive and inferential statistics were used to analyze the data. p value ≤ 0.05 was considered statistically significant.

Results: Majority of the respondents were male (81%), single (76.0%), unemployed (36.0%), low income earners (73.4%) and between the ages of 21 and 30 (44%). Majority had tertiary education (58.7%) followed by respondents with secondary education (33.3%). Those who were dissatisfied with life due to mental illness constituted 34.9% while those who were dissatisfied with living were 22.5%. Nineteen (25.3%) of the respondents has had suicidal thoughts while 7(9.3%) had attempted suicide. Major determinant of the suicide behavior were stigmatization from mental illness, advice childhood experience, job loss, substance abuse, history of assault and poor premorbid personality. There was a statistically significant association between suicidal behavior and stigma as well as childhood or family history (χ² = 3.828, p = 0.05; χ² = 6.334, p = 0.042), but association between suicidal behavior and drug use, sexual assaults, job loss and query respectively was not statistically significant (χ² = 0.456, p = 0.5; χ² = 3.111, p = 0.078; χ² = 6.921, p = 0.009; χ² = 0.009, p = 0.922).

Conclusion: Suicide behavior was common among those with mental illness and unemployment, substance abuse, male gender, higher level of education, stigmatization, poor premorbid history, adverse childhood experience are among the factors that could affect suicide behavior. Association exits between suicide behavior and drug use, stigma, childhood or family history, sexual assaults, job loss, and query etc. It is, therefore, important to provide adequate attention and care to the mentally ill to help reduce the prevalence of suicidal behavior among them.

Over the past year, suicidal behavior has victimized people with mental illnesses. The aforementioned is because mentally sick individuals are not always psychologically healthy. Suicidal behavior, which includes intentional automobile crashes and drug overdoses, is distinct from suicide, defined as the intentional taking of one's own life [1,2]. The reasons why people engage in suicide behavior have changed over time due to a variety of behaviors or situations. Regarding what triggers suicide behavior, numerous authors have expressed varying opinions. For instance, some authors asserted that individuals with bipolar disorder, borderline personality disorder, depression, and other similar conditions are more likely to engage in suicidal thoughts and activities [3-5].

On the other hand, another group of academics argued that people who attempt suicide frequently want to escape an uncomfortable environment. As a result, the authors believe that many people who attempt suicide do so to escape feelings of rejection, loss, or loneliness as well as shame, guilt, or burden to others [6,7]. Contrarily, another group of people argued that suicidal behavior could happen when a person considers a circumstance or event to be overwhelming, such as ageing, the death of a loved one, drug or alcohol usage, unemployment, or financial difficulties, among other things [8,9]. Whatever the reason for the suicide, the opinions of various authors have demonstrated that suicidal behavior is real and that, in the 21st century era, it is one of the most prevalent silent killers in the world.

People who are mentally ill have the highest risk of committing suicide out of all the contributing variables and reasons. The preceding is due to the urgent need for research on the factors that increase the risk of suicide among those who have mental illnesses [10,11]. In High-Income Countries (HIC), 80% to 90% of suicide fatalities are reported to involve psychiatric illnesses; however, this link is less evident in Low and Middle-Income Countries (LMIC) [12]. Additionally, psychological autopsies performed beginning in the middle of the previous century have shown that most of those who have died by suicide have had mental illnesses [10]. According to a recent statistic, this number may be at least 90% [10]. However, most individuals with mental illnesses do not pass away by their own hands. For several mental diseases, including depression, alcoholism, and schizophrenia, the probability of suicide has been estimated to be between 5 and 8% [13].

Although depression is highly associated with suicidal ideation and attempt, it lacks specificity as a predictor, and little is known about the factors that make depression more likely to result in suicide [14]. The association between depression and suicidal behavior was examined as part of the Australian Rural Mental Health Study. Three hundred sixty-four participants out of 1051 reported having had depression their entire lives. Of these, 48% claimed having had suicidal thoughts all their lives and 16% said they had attempted suicide [15]. Suicide attempts were much more common in females with younger onset ages of depression and higher numbers of psychiatric comorbidities. However, depression severity was a major predictor of suicidality in both men and women.

In Nigeria, suicide is also widely used. For instance, studies have revealed that in Nigeria, completed suicide was the most frequently reported suicidal behavior. The most frequently recorded technique was hanging, then poisoning [16]. Based on this, this study aimed to look at the factors influencing suicidal behavior among the mentally ill at the University of Port Harcourt Teaching Hospital.

This was a descriptive cross-sectional study conducted among attendees of Neuropsychiatric Outpatient Clinic of the University of Port Harcourt Teaching Hospital. A structured questionnaire covering socio-demographic characteristics and other factors were self-administered to 75 patients diagnosed with various psychiatric disorders by consultants Psychiatrists and attending the out-patient clinic via a systematic random sampling. Ethical approval was obtained from the ethical committee of the University of Port Harcourt Teaching Hospital and all other ethical provisions were followed. Descriptive statistics was used to analyze the data.

Descriptive statistics analysis of the sample of people with mental illness (socio- demographic analysis).

Table 1 presents socio-demographic and prevalence data for a sample of people with mental illness. The table includes variables such as age, gender, tribe (ethnicity), highest level of education, marital status, religion, employment status, occupation and average monthly income level. In terms of age, the majority of the respondents (44%) are between the ages of 21 and 30, followed by those between the ages of 31 and 40 (32%). There are relatively fewer respondents in the other age categories. With regard to gender, the majority of the respondents are male (81%), while a smaller percentage are female (19%).

The table also includes information on the respondents' tribes or ethnicities. The largest percentage of respondents are Igbo (37.3%), followed by those who belong to other tribes or ethnicities (37.3%). There are smaller percentages of respondents from other tribes, such as Hausa (9.3%), Yoruba (2.7%), Ikwerre (10.7%), Ogoni (1.3%), and Kalabari (1.3%). There are also other relatively fewer respondents in the other tribe categories. The highest level of education for the majority of respondents is tertiary (58.7%), followed by secondary education (33.3%). A small percentage of respondents have primary education (4.0%) and an even smaller percentage have no education (4.0%).

In terms of marital status, the majority of respondents are single (76.0%), followed by those who are married (18.7%). There are smaller percentages of respondents who are divorced (1.3%), separated (2.7%), or widowed (1.3%). The majority of respondents identify as Christian (93.3%), with a smaller percentage identifying as Muslim (5.3%) or Traditional (1.3%). There are no respondents who identify as having no religion. With regard to employment status, the largest percentage of respondents are unemployed (36.0%), followed by those who are self-employed (33.3%), students (18.7%), or employed by the government (4.0%). A small percentage of respondents are employed by the private sector (2.7%), or are apprentices (4.0%). The table also includes information on occupation, with the largest percentage of respondents in unskilled occupations (22.6%), followed by those in skilled occupations (24.7%) or professional occupations (24.7%). There is also a large percentage of respondents with no response in this category (28.0%). Finally, the table includes data on average monthly income level, with the majority of respondents earning between 0 and 50,000 Naira (73.4%), followed by those earning between 51,000 and 100,000 Naira (24.7%). There is a small percentage of respondents earning between 101,000 and 200,000 Naira (2.7%), and no respondents earning above 500,000 Naira

Table 2 presents information on mental illness and suicide history; it can be seen that 56% of persons with mental illness are satisfied with their life while 34.7% are dissatisfied with life because of their mental illness. Additionally, individuals that are satisfied with living had a high percentage rate of 64% compared to 29.3% of persons that are dissatisfied with living. Suicidal thought was common among persons with mental illness with 25.3% responding yes and 66.7% responding no. The result also indicates that 9.3% of the respondents have attempted suicide, while 44% never attempted suicide.

Table 2 presents data on individuals with suicidal tendency, ideations or have attempted suicide and employment history. The table includes information on whether the individuals in the group have lost a job due to their illness and whether they have been queried by their employer about their illness. According to the table, a relatively large percentage of the individuals in the group (37.5%) reported losing a job due to their illness, while a smaller percentage (31.3%) reported not losing a job due to their illness. A significant percentage (31.3%) did not provide a response for this question. The table also shows that a relatively small percentage of the individuals in the group (25.0%) reported being queried by their employer about their illness, while a larger percentage (43.8%) reported not being queried by their employer. A significant percentage (31.3%) did not provide a response for this question.

Table 3 presents data on individuals with mental illness who have suicidal tendency, ideations or have attempted suicide and their substance abuse or addiction. The table includes information on the use of various psychoactive drugs (such as alcohol, nicotine, cannabis, and cocaine) and risky behaviors related to drug use (such as rape, unprotected sex, gambling, and theft). According to the table, individuals with mental illness who have suicidal tendency, ideations or have attempted suicide shows a relatively small percentage of (9.4%) reported using alcohol as a psychoactive drug, while a slightly larger percentage (12.5%) reported using nicotine. A larger percentage (21.9%) reported using cannabis, and an even larger percentage (18.8%) reported using cocaine. A smaller percentage (15.6%) reported using heroin, and a very small percentage (3.1%) reported using volatile substances. A significant percentage (18.8%) did not provide a response for this question.

The table also shows that for the individuals who have suicidal tendency, ideations or have attempted suicide in the group, a relatively large percentage (56.3%) reported using any psychoactive drugs, while a smaller percentage (18.8%) reported not using any such drugs. A significant percentage (25%) did not provide a response for this question.

In terms of risky behaviors related to drug use, the table shows that the individuals who have suicidal tendency, ideations or have attempted suicide, a significant percentage of (18.8%) reported engaging in rape, while a smaller percentage (15.6%) reported engaging in unprotected sex. A smaller percentage (12.5%) reported engaging in gambling or theft, and a very small percentage (6.3% or 3.1%, respectively) reported engaging in middle shell, theory or bullying. A significant percentage (34.4%) did not provide a response for this question.

Overall, the results in this table suggest that substance abuse or addiction may be a factor in some cases of suicidal ideations, tendencies or attempt as a relatively large percentage of the individuals in the group reported using psychoactive drugs and engaging in risky behaviors related to drug use.

Table 4 presents data on suicidal ideations, tendency and attempt and stigmatization related to mental illness. The table includes information on whether individuals with suicidal tendency, ideations or have attempted suicide have been stigmatized for their mental illness, whether their rights have been denied due to their mental illness, and the source of the stigmatization (such as the workplace, professional colleagues, or church members).

According to the table, a relatively large percentage of the individuals in the group (53.1%) reported being stigmatized for their mental illness, while a smaller percentage (25.0%) reported not being stigmatized. A significant percentage (22%) did not provide a response for this question. The table also shows that a relatively large percentage of the individuals in the group (56.3%) reported having their rights denied due to their mental illness, while a smaller percentage (37.5%) reported not having their rights denied. A small percentage (6.2%) did not provide a response for this question.

In terms of the source of stigmatization, the table shows that a significant percentage of the individuals in the group (18.8%) reported being stigmatized by their workplace, while a smaller percentage (9.4%) reported being stigmatized by their professional colleagues. A small percentage (12.5%) reported being stigmatized by their church members, and a relatively large percentage (31.3%) reported being stigmatized by their family members. A small percentage (6.3%) reported being stigmatized by others, and a significant percentage (21.9%) did not provide a response for this question. Overall, the results in this table suggest that stigmatization related to mental illness may be a factor in some cases of suicide, as a relatively large percentage of the individuals in the group reported being stigmatized and having their rights denied due to their mental illness.

Table 4 also presents data on individuals with suicidal tendency, ideations or has attempted suicide and childhood or family history. The table includes information on whether there is a history of mental illness in the family, whether the parents of the individuals in the group are together, the family setting (monogamy or polygamy), whether there were challenges during pregnancy, labor or delivery, the relationship of the affected person with other family members, and whether there were difficulties during the individual's childhood.

According to the table, a relatively small percentage of the individuals in the group (25.0%) reported a history of mental illness in their family, while a larger percentage (75.0%) reported no such history. The table also shows that a relatively large percentage of the individuals in the group (75.0%) reported that their parents are together, while a smaller percentage (15.6%) reported that their parents are not together. A small percentage (9.4%) did not provide a response for this question. In terms of the family setting, the table shows that a relatively large percentage of the individuals in the group (78.1%) reported living in a monogamous setting, while a smaller percentage (21.9%) reported living in a polygamous setting. The table also shows that a relatively small percentage of the individuals in the group (12.5%) reported experiencing challenges during pregnancy, labor, or delivery, while a larger percentage (65.6%) reported no such challenges. A small percentage (21.9%) did not provide a response for this question.

In terms of the relationship of the affected person with other family members, the table shows that a small percentage (3.1%) reported being related to an affected sibling, a slightly larger percentage (6.3%) reported being related to both parents, and a relatively large percentage (40.6%) reported being related to a distant relation. A significant percentage (50.0%) did not provide a response for this question.

Finally, the table shows that a relatively large percentage of the individuals in the group (40.6%) reported experiencing difficulties during their childhood, while a smaller percentage (56.3%) reported no such difficulties. A small percentage (3.1%) did not provide a response for this question. Overall, the results in this table suggest that factors related to family history and childhood experiences may be relevant in understanding suicide risk. Table 4 presents data on individuals with suicidal tendency, ideations or have attempted suicide and sexual assault. The table includes information on whether the individuals in the group have experienced sexual assault and the identity of the perpetrator of the assault. According to the table, a relatively small percentage of the individuals in the group (21.9%) reported experiencing sexual assault, while a larger percentage (68.8%) reported not experiencing sexual assault. A small percentage (9.4%) did not provide a response for this question.

The table 4 also shows that a relatively small percentage of the individuals in the group who reported experiencing sexual assault (6.3%) identified their mother as the perpetrator, while a slightly larger percentage (9.4%) identified a sibling as the perpetrator. A small percentage (3.1%) identified a neighbor as the perpetrator, and a significant percentage (81.3%) did not provide a response for this question. Overall, the results in this table suggest that sexual assault may be a factor in some cases of suicide, as a small percentage of the individuals in the group reported experiencing sexual assault.

Table 4 also presents data on individuals with suicidal tendency, ideations or have attempted suicide and employment history. The table includes information on whether the individuals in the group have lost a job due to their illness and whether they have been queried by their employer about their illness. According to the table, a relatively large percentage of the individuals in the group (37.5%) reported losing a job due to their illness, while a smaller percentage (31.3%) reported not losing a job due to their illness. A significant percentage (31.3%) did not provide a response for this question. The table also shows that a relatively small percentage of the individuals in the group (25.0%) reported being queried by their employer about their illness, while a larger percentage (43.8%) reported not being queried by their employer. A significant percentage (31.3%) did not provide a response for this question. Overall, the results in this table suggest that employment-related factors may be relevant in understanding suicide risk, as a significant percentage of the individuals in the group reported losing a job due to their illness or being queried by their employer about their illness.

Table 4 equally presents data on individuals with suicidal tendency, ideations or have attempted suicide and premorbid history. The table includes information on how individuals in the group described themselves before their illness. According to the table, a relatively large percentage of the individuals in the group (28.1%) described themselves as friendly before their illness, while smaller percentages described themselves as sociable (15.6%), hardworking (12.5%), loving (18.8%), consultative (6.3%), hostile (6.3%), lazy (3.1%) or disrespectful (6.3%). A small percentage (3.1%) did not provide a response for this question. Overall, the results in this table suggest that premorbid personality traits may be relevant in understanding suicide risk, as a significant percentage of the individuals in the group described themselves as having certain personality traits before their illness.

Table 5 presents the results of a statistical analysis of the association or relationship between suicidal ideations and drug use or addiction. Overall, the results in this table suggest that there is an association between suicide behavior and drug use or addiction; however it is not significant statistically. The table 5 shows the Chi-square (χ²) value of 0.456 and p = 0.5. This is > 0.05. Therefore, suicide is significantly not related nor associated with drug abuse/addiction as p > 0.05 i.e. p is .877 is greater than .005. This implies that people with mental illness whether they are suicidal or not, it is not significantly dependent or associated with whether they will abuse drugs or not. Table 5 also presents the results of an analysis of the association between suicide and stigma. It shows the Chi-square (χ²) value of 3.828 and p = 0.05. This is statistically significant since p ≤ 0.05. The results of the statistical tests suggest that there is association between suicide and stigma implying that suicidal behavior is significantly associated with stigma. This table also shows the association between suicide behavior and childhood or family history. It shows Chi-square (χ²) value of 6.334 and p = 0.042. This is statistically significant since 0.042 is < 0.05. Therefore, suicide behavior is significantly associated with childhood or family history.

The table also shows the association between suicide behavior and sexual assault with the chi-square (χ²) value of 3.111and p = 0.072. P value is greater than 0.05 and this is not statistically significant at the chosen alpha level of 0.05. Therefore, suicide is significantly not associated with sexual assault as p is greater than 0.05 i.e. p is .078 is greater than .005. This implies that people with mental illness whether they are suicidal or not, it is significantly not associated with their being sexually assaulted or not assaulted. The table also shows the association between suicide behavior and job loss with the chi-square (χ²) value of 6.921 and p = 0.009. p > 0.05 and this is not statistically significant at the chosen alpha level of 0.05. Suicide behavior is not significantly associated with job loss. The table also shows the association between suicide behavior and query with the chi-square (χ²) value of 0.009 and p = 0.922. p = 0.922 is greater than 0.05. Therefore, this is not statistically significant at the chosen alpha level of 0.05. Hence, suicide is not significantly associated with query at place of job.

This study adopted a cross-sectional study design aimed at determining the factors influencing suicide behavior among the mentally ill patients attending a tertiary Hospital in South-South Nigeria. The study revealed that mental illness is more common among those between the ages of 21 and 30. The aforementioned supports [17] conclusion when they study "the epidemic of COVID-19 in China and accompanying psychiatric issues." The authors confirmed that people between the ages of 20 and 40 are more prone to mental disorders. Furthermore, this claim is consistent with the research by Foster K, et al. [18]. "Mental health matters: A cross-sectional study of mental health nurses' health-related quality of life and work-related stressors," which found that people between the ages of 21 and 30 are more susceptible to mental health issues.

According to the demographic information gathered those who attended postsecondary institutions were more likely to suffer from mental illness. This is in line with research by Hakimi D, et al. [19] and Abu S, et al. [20] which claim that students in higher education are at risk for mental illness due to their first taste of freedom, their relationships, stress, and responsibility. In a similar vein, secondary school students come in second place among the group of people who develop mental disease. According to Hakimi D, et al. [19] and Abu Suhaiban H, et al. [20], periods of transition, substance use, parental pressure, culture shock, and severance from previous supports are what make secondary school students more susceptible to mental illness than university students.

Additionally, the present study revealed that unemployment also plays a role in mental illness and suicide behavior. This seems to be the case because several researchers have stated over the years that stress brought on by unemployment has long-term physiological health effects and can have a negative impact on people's mental health, including depression, anxiety, and low self-esteem [21,22]. Furthermore, this study has demonstrated that there is a statistically significant association between suicidal behavior and stigma as well as childhood/family history, but association between suicidal behavior and drug use, sexual assaults, job loss and query was not statistically significant. For instance, this study shows that people who use psychoactive drugs like cannabis and have experienced sexual assault are likely to think of committing suicide. This finding is consistent with the seriousness of studies by Gobbi G, et al. [23] and Carvalho AF, et al. [24], which affirm that cannabis usage may be linked to suicide behavior among youths. This study also concluded that stigmatizing those with mental illness and denying that they exist were factors that made persons more likely to commit suicide.

It is important to interpret the findings of this study cautiously, as several exposures of bias may have been introduced during the course of the study, especially due to the cross-sectional design adopted. Although the study design may not permit cause inferences, it enabled the identification of associations. Furthermore, the self-reported information which the study relied on could have been subject to recall bias. Also, the sample size of this study could have resulted in selection bias. Lastly, this study only aimed at determining the factors influencing suicide behavior among the mentally ill patients; it didn’t attempt to establish cause and effect relationships. Further studies are therefore needed to make further conclusions on the suicidal behavior of the patients.

This research aimed to look at the determinants of suicidal behavior among the Mentally Ill at the University of Port Harcourt Teaching Hospital. It is evident that mental illness is more common among those between the ages of 21 and 30. Unemployment, substance abuse, higher level of education, stigmatization, poor premorbid history, adverse childhood experience are among the factors that could influence suicide behavior. Association exits between suicide behavior and drug use, stigma, childhood or family history, sexual assaults, job loss, and query etc. It is therefore important to provide adequate attention and care to the mentally ill to help reduce the prevalence of suicidal behavior among them.

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