One of the most significant psychosocial injuries worldwide is suicide.1,2 Suicide and suicide prevention are important topics for health professionals, politicians in the health care field, and cultural and educational authorities in many countries.1 Because the median age of those attempting suicide has decreased and the number of people attempting suicide has increased (up to 60% over the past 50 years3), suicide remains an important public health concern around the world.2
Iran is a country with a high suicide rate.2 Although the rates of suicide attempts and successful suicides in Iran are lower than in most Western countries, it ranks the highest among the World Health Organization's Eastern Mediterranean Regional Office (EMRO) countries.4 According to the latest statistics from the Iranian Ministry of Health,5 there are 13 suicides per day with an average age of younger than 29 years in Iran. Self-poisoning is the most commonly used method of attempting suicide in Iran, and is the third leading cause of completed suicides.1,6 The statistics on attempted suicides and deaths from deliberate poisoning in Iran reveal a 4-fold increase over the past decade.2,7
The growth and spread of cognitive psychology along with conducting methodical studies in this field in recent decades have affected various areas of psychology. Psychological pathology is the area that has experienced the most impact,8,9 leading to fundamental and structural changes in etiology, development, intervention, and treatment of mental disorders, especially emotional disturbances. Psychosocial evaluation of the patient, the choice of appropriate treatment (ie, outpatient treatment or hospitalization), and the choice of pharmacotherapy or psychotherapy are important issues that should be considered before the onset of treatment for the person who has attempted suicide.8
Experts believe that those who attempt suicide have psychological disturbances and show fewer positive psychological characteristics than those who do not attempt suicide. Therefore, psychologists need to teach these positive psychological methods to patients to reduce the rates of completed suicides.10 Although the existence of psychological differences between those who attempt suicide and those who do not attempt is confirmed by all the experts, the psychological context in which these two groups show more difference has not been identified yet. This study aimed to investigate the psychological differences between patients with deliberate self-poisoning (the most often used method in suicide attempts in Iran) and patients who do not attempt suicide (nondeliberate poisoning). Through that we can develop prevention plans to control self-harm behaviors as well as suicidal crises.
This was a case-control study with 400 participants, including 200 people who attempted suicide via self-poisoning and 200 people with non-deliberate poisoning who were hospitalized in Imam Khomeini Hospital of Kermanshah, Iran. To select this population, all patients hospitalized in Imam Khomeini during July and August 2017 (during the morning shift) with deliberate and nondeliberate self-poisoning were included in the study.
The control group was selected via frequency match based on age, sex, and marital status. By choosing each case based on adjusted variables, we chose one control among eligible patients with nondeliberate poisoning who were hospitalized.
The Imam Khomeini Hospital Poisoning Center is the largest and best-equipped center in western Iran, admitting more than 90% of deliberate and nondeliberate poisoning patients. Data collection was done with the help of psychologists working in the hospital who routinely visit patients who attempted suicide. To gather data, patients were interviewed after their condition was stable (usually between 2 and 4 hours after poisoning) in a quiet, safe, and secure environment.
Inclusion and exclusion criteria. The inclusion criteria for the case group were deliberate poisoning, nondenial of poisoning, ability to answer questions, and informed consent. The inclusion criteria for the control group were no experience of suicidal attempt by any method, ability to answer the questions, and informed consent to participate in the study.
The following questionnaires were employed to psychologically evaluate the deliberate poisoning patients.
The Defense Styles Questionnaire consisted of 40 questions evaluating 20 defense mechanisms in 3 styles of immature response (Cronbach's alpha of 80, mature with Cronbach's alpha of 63, and neurotic with Cronbach's alpha of 60 in Iranian samples).11,12
The Beck Self-Concept Test (BSCT) consisted of 25 questions with 5 parts and scales ranging from 25 to 125. Co-validity was used for validation purposes, and the correlation coefficient was 0.68. To measure the reliability, internal consistency with a correlation coefficient of 0.88 was used. Content validity was used to determine scientific validity in Iran.13
The General Health Questionnaire consisted of 28 questions evaluating 4 sub-scales: somatic symptoms, anxiety and sleep disorder, social functional scale, and depression symptoms scale. Each scale in this questionnaire included 7 questions. To test the reliability of the questionnaire, three methods including re-evaluation, description, and Cronbach's alpha were investigated showing validity coefficients of 0.7, 0.93, and 0.90, respectively. The validity of the questionnaire was evaluated using the three methods of simultaneous, clauses integrity with general scale grade, and factor analysis, with correlation coefficients of 0.55, 0.72 and 0.87, respectively. Accordingly, the General Health Questionnaire was found to be suitable for use in psychological research and clinical activities.
After collecting data, in addition to statistics (mean and standard deviation), a t-test to compare means and a chi-square test were employed to compare proportions among groups. All analyses were performed using Stata software (version 14.0) considering a statistical significance level of 0.05.
To collect data, a group of psychologists working in Imam Khomeini Hospital who routinely interviewed patients who had attempted suicide collaborated with us. This study was conducted according to guidelines in the Helsinki Declaration. In addition, the study was approved by the Medical Research and Ethical Committee of Kermanshah University of Medical Sciences, Kermanshah, Iran (registration number KUMS.REC.1394.318).
Among the 200 patients who attempted deliberate poisoning, 154 (77%) were male and 46 (23%) were female. The mean age of deliberate poisoning patients was 28.1 ± 7 years, and the mean age of nondeliberate poisoning patients was 28.0 ± 1 year (the difference was not statistically significant; P = .97). As Table 1 shows, deliberate and nondeliberate poisoning patients were appropriately adjusted based on age, gender, and marital status.
Frequency Distribution of Epidemiologic Characteristics in Suicide Group and Control Group
In patients with both deliberate and nondeliberate poisoning, medicine use was the main cause. In patients with deliberate poisoning there were 76 cases (48.4%) of medication abuse, and in patients with nondeliberate poisoning there were 62 (38.2%) cases of medicine abuse. In patients with deliberate poisoning tramadol with was the medicine most abused (27 cases [35.5%], and methadone was second (15 cases [19.7%]). In patients with nondeliberate poisoning, methadone was the most common medicine (25 cases [40.3%]), followed by tramadol (18 cases [29%]). The second most common class of poison in the deliberate-poisoning group was narcotics (45 cases [28.7%]), whereas in the nondeliberate-poisoning group, ingestion of contaminated food was the second leading cause of poisoning (30 cases [18.5%]).
In terms of the period thinking about suicide, 30 cases (16.6%) did this without planning and intention, 52 cases (26%) thought about it for between 2 and 7 days, and most attempters thought more than 7 days about committing suicide.
In terms of psychological characteristics, there was a significant association between deliberate and nondeliberate poisoning patients in all defense mechanisms, except for rationalization and displacement in immature defense style, and the sublimation in the mature defense style and intellectualization in neurotic style (Table 2). In general, there was a significant difference between suicidal attempts and undeliberate poisonings in all three defense styles of mature, immature, and neurotic; however, there was no significant difference between the general health of patients in any of the subscales including social symptoms, anxiety and sleep disorders, social function, and depressive symptoms. Also, the average of self-concept scores did not show significant difference in two groups (Table 2).
Scores of Defense Styles, General Health Questionnaire, and Beck Self-Concept Test In Suicide Group and Control Group
The main cause of poisoning among deliberate and nondeliberate cases in this study was the use of medication. This result is consistent with results obtained by multicenter studies conducted in 14 European countries, which revealed that 73% of men and 84% of women use medicine for deliberate self-poisoning.14 However, it is not consistent with results from studies conducted in Asian countries, especially in Southeast Asia, where the most commonly used substance is poisons found in the home.15 In this study, tramadol and methadone were abused in at least one-half of the cases. Multicenter studies conducted in European countries revealed that about 70% of medicines used in France, Luxembourg, Portugal, and Spain were biologic drugs however, in Scotland, narcotics and psychodysleptics were most used.14 A low percentage of poisoning cases in this study was due to alcohol abuse, whereas in Western countries alcohol is one of the most commonly used agents by those who attempt suicide.16,17 This difference in substance abuse can be due to the availability of substances and cultural differences.18 The method of deliberate poisoning is associated with sociocultural factors of regions as well as toxins and drugs available.19 An important point about suicide attempts through poisoning is that this method is much more common than other suicide methods.20 Considering the fact that the most important cause of poisoning in both groups is medicine (especially tramadol and methadone), politicians could develop a plan to restrict access to these medicines.
The present study revealed that mental health defense styles have an influence on suicide attempts. Defense styles are patterns of emotional regulation that are aimed at reducing anxiety and relieving emotional pain in stressful situations.12 Patients who deliberately self-poisoned used immature and neurotic defense styles more than patients who nondeliberately poisoned themselves, and people with nondeliberate self-poisoning used more mature defense styles compared to patients who attempted suicide. Similar studies showed the same results, as studies conducted in other countries revealed that immature and neurotic defense styles are more common among those who attempt suicide.21,22 Considering the effect of defense styles, it can be concluded that people with pathological personality traits with psychological injuries, aggression, disappointment, and negative life events who use immature and neurotic defense styles are more prone to psychological injuries and suicide attempts. Defense styles are particularly important in confronting mental turmoil and to prevent suicide attempts.23,24
Research shows that there is a correlation between the physical image and the real physical properties of the person.25 For example, the disagreement between the person's ideal-self and the real-self, as well as how he or she values his or her appearance, can cause psychological disturbances such as depression and anxiety. Physical deformities increase this disagreement. These disagreements are due to poor assessments of real-self or excessive expectations from ideal-self or both. In this study, there was no difference between the self-concept scores of the two groups. Studies conducted in different countries showed different results for the correlation between self-concept and suicide attempt.26,27 Other studies conducted in Iran also show different results.28 One reason for this inconsistency may be the low validity and reliability of the BSCT. In the present study, although symptoms of general health disorders were higher in the deliberate-poisoning group in all subcategories than the other group, there was no significant difference in the general health of people in any of the subgroups in the two groups, which is inconsistent with previous studies.29,30
Limitations and Strengths
Studies on suicide are always accompanied by limitations such as the small size of the samples and lack of cooperation of patients who attempted suicide. On other hand, because we only investigated the deliberate self-poisoning cases, generalizing of research findings to all methods of suicide will not be statistically correct. Despite these limitations this study has strengths, among which are the gathering of information via psychologists in a safe and secure environment, and controlling variables such as socioeconomic status, family disputes, as well as religious beliefs to better show the effect of psychological state on suicide attempt.
Preventing suicide requires a deep insight into personality traits that may be correlated to suicidal ideation and behavior. There are many psychological and demographic factors affecting suicide. Having a low level of extroversion and developing immature and neurotic defense styles increase the risk of suicidal attempts. In general, one can say that when a person lacks the ability to adapt to difficult and stressful situations, he or she may turn to mechanisms that make the situation worse rather than better.
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- Bonsack C, Despland J, Spagnoli J. Psychometric features of the French version of Defense Style Questionnaire (DSQ). Eur Psychiatry. 1996;11(suppl 4):S384. https://doi.org/10.1016/0924-9338(96)89242-X doi:10.1016/0924-9338(96)89242-X [CrossRef]
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Frequency Distribution of Epidemiologic Characteristics in Suicide Group and Control Group
||Deliberate Suicide Attempts N (%)
||Nondeliberate Poisoning Cases N (%)
|Age group, years
|Method of poisoning
|Narcotics and alcohol
Scores of Defense Styles, General Health Questionnaire, and Beck Self-Concept Test In Suicide Group and Control Group
|Defense Style or Test
||Case, Mean (SD)
||Control, Mean (SD)
|Passive aggressive behavior
|General Health Questionnaire
|Anxiety and sleep disorder
|Beck Self-Concept Test
||Beck Self-Concept Test