SM 12.01.06 - Depression and suicidal behavior.pmd

Transcripción

Salud Mental 2012;35:39-44
Depression and suicidal behavior among high school students
Depression and suicidal behavior
among high school students in Sonora
María José Cubillas Rodríguez,1 Rosario Román Pérez,1 Elba Abril Valdez,1
Ana Lourdes Galaviz Barreras2
Original article
1
2
ABSTRA
CT
ABSTRACT
RESUMEN
Objective
To document the association between depression and suicidal behavior
in a sample of high school students in the Mexican state of Sonora.
Also, to reflect on variables of regional significance, corresponding to
a region in which one third of young people reports depressive
symptoms.
Objetivo
Documentar la asociación entre la depresión y los comportamientos
suicidas en una muestra de jóvenes estudiantes de educación media
superior del Estado de Sonora. Se busca además aportar una reflexión sobre las variables del contexto regional en el que una tercera
parte de los jóvenes de ambos sexos reportan rasgos depresivos.
Materials and Methods
This study is descriptive, cross-sectional and comparative. A total of
1,358 male and female students ranging from 15 to 19 years old
were included. The Center for Epidemiological Studies Depression Scale
(CES-D) and the Roberts Suicidal Ideation Scale were used.
Material y métodos
El estudio es descriptivo, transversal y comparativo, participando 1358
estudiantes de ambos sexos, de 15 a 19 años de edad. Se utilizó la
Escala de Depresión del Centro de Estudios Epidemiológicos CES-D y
la Escala de Ideación Suicida de Roberts.
Results
Depression occurs in 67.3% of those who have attempted to commit
suicide and in 81.1% of those that report suicidal ideation. Such
differences are statistically significant when compared to those who
do not demonstrate suicidal behavior. No statistically significant
differences are found by gender in young people who report suicidal
ideation and/or attempted suicide, but the results do reveal a slightly
higher tendency among women. Statistically significant increased rates
of depression were found in women, as compared to men, among
groups that do not present with these behaviors/thoughts. Young people
with depression are 16 times more likely to experience suicidal ideation
and 5 times more likely to attempt suicide.
Resultados
La depresión aparece en 67.3% de quienes han intentado suicidarse y
en 81.1% de quienes manifiestan ideas suicidas. Estas diferencias son
estadísticamente significativas al compararlas con quienes no tienen
comportamientos suicidas. No se presentan diferencias estadísticamente
significativas por sexo en jóvenes con ideación e intento de suicidio,
pero sí tiende a ser mayor en las mujeres. En los grupos que no presentan estos comportamientos, las mujeres tienen porcentajes estadísticamente significativos más altos de depresión que los varones. Los y
las jóvenes con depresión tienen un riesgo 16 veces mayor de tener
pensamientos suicidas y cinco veces mayor para intentos de suicidio.
Discussion
Depression, which is more common among women, is significantly
associated with suicidal behavior. At present, contemporary youth
experiences feelings of disappointment due to the challenges faced
on a daily basis. Often, general feelings of discouragement that end
up triggering depressive problems are hidden under an appearance
of conformity. This places youth in a highly vulnerable situation, given
the lack of opportunities and spaces, which can affect their emotional
health. For these reasons, it is important to address the issue of
depression and suicidal behavior using a gender-based and
multidisciplinary approach.
Discusión
La depresión aparece asociada significativamente con los comportamientos suicidas, siendo mas frecuentes en las mujeres. Actualmente la
juventud contemporánea experimenta sentimientos de decepción por
las contradicciones que enfrenta. La mayoría de las veces oculta bajo
una apariencia de conformidad sentimientos generalizados de desánimo e incomprensión ante búsquedas no satisfechas, lo que desencadena problemas depresivos. Todo ello coloca a la juventud actual en
una situación de franca vulnerabilidad ante la falta de oportunidades y
espacios, lo que puede repercutir en su salud emocional. De ahí también la importancia de abordar el tema de la depresión y los comportamientos suicidas desde una perspectiva de género e interdisciplinaria.
Key words: Adolescents, depression, suicide attempted, suicidal
ideation.
Palabras clave: Adolescentes, depresión, ideación suicida, intento
suicida.
Centro de Investigación en Alimentación y Desarrollo, A.C. (Center for Nutrition and Development Research), Department of Regional Development.
State Commission for Prevention and Treatment of Domestic Violence, Department of Mental Health. Secretariat of Health, Sonora.
Correspondence: María J. Cubillas R. Centro de Investigación en Alimentación y Desarrollo, A.C. Dirección de Desarrollo Regional. Carretera a La Victoria
km 0.6, Apartado Postal 1735, 83000 Hermosillo, Son., Mexico. Tel: +52 (662) 289-2400 ext. 374. E-mail: [email protected]
Vol. 35, No. 1, January-February 2012
39
Cubillas Rodríguez et al.
INTRODUCTION
«If we lose hope, that will be the end; but God saves
us from losing hope.» Zygmunt Bauman
Despite the fact that the youth of Mexico is one our most
important assets of this country, at present those aged 15 to
24 years are experiencing situations that endanger their
development and their very survival as an integral part of
our society. One such situation is the risk of suffering from
depression, which can lead them to want or try to end their
own lives.
Much has been written regarding the competitive
advantage of our country, often referred to as the
«demographic dividend.» This refers to the development
opportunities represented by the fact that 26.8% of the
population is between 15 and 29 years of age.1 Evidence
shows that young people have greater access to education
and information and communication technology (ICT) and
in general enjoy more opportunities to change their life path
as compared to prior generations.2 With this significant
social capital, it is difficult to imagine a young person
suffering from depression, much less one who would inflict
self-harm or even try to take his/her own life.
In this article we present the results of a study that
documents the association between depression and suicidal
behavior in a sample of high school students from the state
of Sonora in Mexico, which shares a border with the United
States. We also seek to demonstrate, using statistics, the
reliability of the scale used to measure both phenomena,
and reflect on certain variables relating a regional context
in which one third of young people (both men and women)
participating in the study report symptoms of depression.
This is an important point, as the fact remains (identified
by Jiménez and González [2003]),3 that a large majority of
studies on this topic (67%) are conducted in Mexico City,
the capital of the country. Thus, a more complete nationwide
picture of mental health must be developed.
While there is some difficulty in establishing a
conceptual definition for the term «depression,» in general
it refers to a series of characteristics, such as marked changes
in mood, reflected in states of irritability and behavioral
problems, despair and an inability to enjoy everyday
activities. 4 Regarding suicidal behavior, this has been
referred to by several authors as various forms of expression
which may or may not occur successively: passive suicidal
ideation, active contemplation of suicide, planning and
preparation, completion of an attempt at suicide, and finally
the actual act of suicide. 5-7 There is also some debate
regarding the intentionality of these behaviors as to whether
or not there is actual desire to take one’s life, whether it is a
way of seeking someone’s attention, or if it represents a lucid
way of treating one’s own body.8-10 Depression coupled with
suicidal ideation or attempted suicide has been studied from
40
different perspectives and using various tools, often in order
to offer basic elements for preventive measures.4,11-14 One of
the most widely used and validated tools is the Center for
Epidemiological Studies Depression Scale (CES-D).15 The
fact that many studies confirm this tool to be easy to apply
in groups, objective in identifying the main components of
depressive symptomatology, and highly statistically reliable,
allows this tool to effectively identify recent signs of
depression.3,16,17 Research in this regard has documented the
relationship between depression and suicidal behavior, as
well as differences between genders.
It is especially important that we study both these
phenomena among young people, given the fact that, as was
mentioned at the beginning, this population enjoys certain
conditions which ideally would make depression and
suicidal behavior less likely. National statistics would
suggest otherwise. In Table 1 we observe that states along
the northern border with the United States (with the exception
of Baja California) have the highest rates of suicide in the
country. Breaking down these statistics by gender, we can
confirm the trend identified by the INEGI (2009)18 and by
other authors3 regarding the predominance of this behavior
among men in Mexico. Regarding depression, this condition
must be further researched, as it represents 3.4% of the global
burden of disease, measured in terms of disability-adjusted
life years, just above heart disease.4
The national environment has in recent years been
characterized by economic and security uncertainty, and the
future for many appears uncertain. For young people, this
situation is particularly worrying, as both their present and
future are seen as unpromising. To be young in a region
such as Sonora implies certain gaps between the modernity
of an economy driven by commercial and industrial
development, yet rooted in primary activities related to
agriculture and farming.19 Levels of development achieved
thus far have not been sufficient to generate, for example,
investment in recreational activities. Likewise, education
remains insufficient, particularly at the high school level,
where graduation levels are below national averages (55.2%
and 57%, respectively), while job prospects remain a
Table 1. Comparison of suicide rates in mexican states bordering
the USA among individuals aged 15 to 29 years
State
Baja California
Coahuila
Chihuahua
Nuevo León
Sonora
Tamaulipas
Nacional
Men
Women
Total
Number Rate*
Number Rate*
Number Rate*
38
56
86
68
70
50
1461
8.7
15.8
18.9
11.3
21.0
11.8
10.3
6
5
17
14
6
5
366
1.5
1.5
4.0
2.5
1.9
1.2
2.5
44
61
103
82
76
55
1827
5.3
8.7
11.7
7.0
11.7
6.6
6.4
* Per 100,000 inhabitants.
Source: Data from «Mortality by External Cause.» 2005 INEGI report and
CONAPO 2050 projections.
problem, with high unemployment levels (6.26 and 5.27,
respectively).20 In such an environment, it is appropriate that
we study the levels of depression reported by young people,
particularly adolescents studying high school, while
analyzing their relationship to suicidal behaviors such as
ideation and attempted suicide.
METHODS AND MA
TERIALS
MATERIALS
Design
This is a descriptive, cross-sectional, comparative study with
a representative sample of adolescents attending high
schools in the Mexican state of Sonora.
Participants
1,358 students from public and private high schools
participated in the study, ranging in age from 15 to 19 years.
All were in their second semester of either their first, second
or third year of high school. The number of students, both
men and women, from each grade was proportional to their
representation among enrolled students.
Sampling
The sample was defined according to state enrollment of
students attending public and private high schools in
Sonora. A sample of 1,358 students was calculated using
simple proportional sampling, with a confidence level of
95% and a margin of error of 0.3. Numerical distribution
was based on the size of the location (city), proportion of
students enrolled at public and private schools, proportion
of students enrolled by sub-system (in the case of public
schools), enrollment in each academic year and enrollment
in daytime/evening classes (when possible). Proportion by
sex and type of school (public/private) reflects the
distribution of the enrolled population.
Environment
In the case of public schools, all sub-systems were included
(COBACH, CBTYS, CBTA, CECYTES and CONALEP). 18
cities/communities from Sonora were selected that
represented rural areas, large and small urban centers, and
the region near the border with the United States of America.
Data collection tools
a)
Center for Epidemiological Studies Depression Scale (CESD), designed by Radloff15 and made up of 20 questions:
This scale collects information on the main components
of depressive symptomatology. The responses provided
b)
allow researchers to understand the occurrence of such
symptoms during the week prior to application: 0 = 0
days, 1 = 1-2 days, 2 = 3-4 days and 3 = 5-7 days. Internal
reliability of the overall scale was α=.88.
Suicidal Ideation Scale: This scale, created by Roberts21,
contains four questions. The questions used to identify
suicidal ideation are: «I couldn’t go on,» «I thought about
death,» «I felt that my family would be better if I was dead»
and «I thought about killing myself.» There are four
response options which follow the same format as the
CES-D to evaluate the frequency of symptoms during
the past week: 0 = 0 days, 1 = 1-2 days, 2 = 3-4 days and
3 = 5-7 days. Internal reliability of the overall scale was
α=.78.
Pilot stage of the study
The instrument was applied to a population with
characteristics similar to those of the definitive sample, but
which was not included in said definitive sample. 94
students from two high schools participated, one private
and one public.
Application times were adjusted, and initial estimators
were generated for the parameters to be evaluated. Training
was conducted on application of the tool for those who
participated in giving the survey. The survey was given from
March to May of 2005.
Procedure
Official procedures were carried out with the respective
Directors of the different state sub-systems and private
schools. The questionnaires were administered during the
school day, guaranteeing confidentiality for the institution
and the student, whose participation was voluntary. The
questionnaires were self-administered.
Data analysis
To evaluate suicidal ideation, the Robert’s scale21 was used,
which is composed of four questions that evaluate how the
student felt the week prior to completing the questionnaire,
indicating the number of days they felt a certain way, from
0 to 7 days. This scale has been validated and re-validated
for Mexican adolescents.16,17,22 As the subject moves through
the questionnaire, the intensity of the experience measured
increases.
To estimate the prevalence of suicidal ideation in the
sample, the intensity of the experience was considered,
assigning a different numerical weight to each of the items
depending on its severity, as well as the number of days the
adolescent reported experiencing such feeling. A cutoff point
was established at mean plus one standard deviation,
considering the group of students above such level to have
41
experienced suicidal ideation. It was thus determined that
15% of the subjects experienced suicidal ideation during the
week prior to taking the questionnaire.
For the depression scale, analysis was conducted based
on the scores obtained by the population, dividing them into
tertiles, and estimating that those in the third tertile
presented with depressive symptomatology (score equal to
or greater than 20). Later, statistical significance was
analyzed using a X2 test. To estimate depression as a risk
factor, the odds ratio was used. Information was collected
and analyzed using the SPSS statistical software suite,
version 17.0.
RESUL
TS
RESULTS
Socio
Socio--demographic characteristics
of participants
The average age of the students was 16.6 years. 58.1% of
subjects were women and 41.9% were men. 78.7% of
participants were from public schools, while 21.3% were
from private schools. Distribution by grade (academic year)
was as follows: 36.9% in their first year, 32.3% in their second
year and 30.8% in their third year (Table 2). This information
is consistent with academic enrollment for the year the
surveys were administered.
Depression and suicidal behavior
Young people that present with suicidal ideation and
attempted suicide show higher levels of depression as
compared to those who do not share these behaviors.
Depression appears in 67.3% of those who have attempted
suicide, and 81.1% of those who show suicidal ideation.
These differences are statistically significant when
comparing the contrasting groups. Likewise, it was observed
that a significant percentage of young people without
suicidal ideation or attempted suicide showed signs of
depression (Table 3).
Table 2. Characteristics of the participants (n=1358)
Characteristic
Age
Sex
• Men
• Women
Type of school
• Public
• Private
Grade
• 1st year
• 2nd year
• 3rd year
42
F
16.6
566
785
% Media, SD
(DE .953)
41.9
58.1
1069
289
78.7
21.3
501
439
418
36.9
32.3
30.8
Table 3. Depression associated with suicidal behaviors
Suicidal ideation1
Levels of
depression
No
n
%
No depression 686 77.7
Depressive
197 22.3
symptomatology
1
2
Attempted suicide2
Yes
n
No
%
27 18.9
116 81.1
n
%
678 73.6
243 26.4
Yes
n
%
36 32.7
74 67.3
P<.000, X2=200.76, D.F.=1.
P<.000, X2=77.15, D.F.=1.
Levels of depression and suicidal ideation by sex
Regarding depression and differences by sex, an analysis of
the group of young people without suicidal ideation shows
that women present with more depressive symptoms than
men. This difference is statistically significant (p<.000). In
the case of the group with suicidal ideation, the differences
between men and women are not significant (p<.278),
although there is a slight tendency toward higher levels of
depression among women (Table 4).
Levels of depression and attempted suicide by sex
In the case of subjects that claim to have attempted suicide,
a similar picture emerges with regard to differences between
the sexes. Greater depressive symptoms are found among
women that have not attempted suicide. This difference was
only significant when comparing young people who did not
report having attempted suicide (p<.000) (Table 5).
In analyzing depression as a risk factor for the
occurrence of suicidal thoughts, it was found that young
people with depression are 16 times more likely to
experience suicidal ideation (OR 16.01, CI 9.9-25.6). In the
case of attempted suicide, which can have occurred at any
time in the past, depression implied a risk of such behavior
five times greater (OR 5.81, CI 3.77-8.94) (Table 6).
DISCUSSION
Depressive symptomatology among participants was
greater than levels found in other studies. 10,17,23 These
symptoms of depression appear to be significantly associated
with suicidal behaviors. Depression during youth can predict
Table 4. Levels of depression and suicidal ideation by sex
No Ideation1
Levels of
depression
Men
n
%
No depression 316 83.4
Depressive
63 16.6
symptomatology
1
2
Ideation2
Women
n
%
367 73.4
133 26.6
Men
n
%
9 25.0
27 75.0
P<.000, X2=12.38, D.F.=1.
P<.278, X2=1.17, D.F.=1.
Women
n
%
18 16.8
89 83.2
Table 5. Levels of depression and attempted suicide by sex
No ideation1
Levels of
depression
No depression
Depressive
symptomatology
1
2
Men
n
%
320 81.0
75 19.0
Ideation2
Women
n
%
355 68.0
167 32.0
Men
n
%
Women
n
%
5 22.7 31 35.2
17 77.3 57 64.8
P<.000, X2=19.57, D.F.=1.
P<.264, X2=1.24, D.F.=1.
a more serious condition during adult life,12,24,25 which
together with suicidal ideation and attempted suicide are
the most direct predictors of suicide.
A study conducted in Sonora by Miranda et al.26 among
a child population aged 10 to 13 years shows levels of
depression equally high as those reported in other studies
for similar ages: 68% of children have moderate to high levels
of depression, slightly less than the figure found in this study
of adolescents. This indicates that depression is a problem
that, if left untreated, will persist over time, facilitating
suicidal behavior among youth.
Regarding differences by sex, Miranda et al.26 found
that depression appeared more often among boys than girls.
To the contrary, this study confirms the findings of other
studies in which women show higher levels of depression.
These differences regarding depression and suicidal
behavior have not been fully studied, and results in general
are not entirely conclusive. Some studies have found no
differences between sexes in levels of depression among
children.13 Others, such as Allison et al.27 with adolescents,
indicate that women have a higher incidence of depressive
symptoms associated with suicidal ideation.
This suggests a need to analyze this symptomatology
from a gender-based perspective, allowing us to uncover
new clues so as to better understand the differences between
men and women. Nolen-Hoeksema and Girgus28 suggest
that women are more likely than men to be exposed to risk
factors for depression, but that depression itself only occurs
when the individual has difficulties meeting the challenges
they face. Some such factors may be related to biological
Table 6. Depression as a risk factor for the presence of suicidal
behaviors
Levels of
depression
None/moderate
High
None/moderate
High
No
ideation
n
Ideation
n
666
217
23
120
No
attempt
Attempted
suicide
659
268
33
78
OR*
CI**
16.01 9.9-25.6
OR*
CI**
5.81 3.77-8.94
* Odds ratio.
** Confidence interval.
changes and the gender roles and stereotypes. Theses issues
have yet to be studied in terms of their relationship with
suicidal behaviors.
At present, adolescents of both sexes experience feelings
of disappointment. Data from the 2005 National Youth
Survey show that in the Northeastern Region, 44% of the
population from 12 to 29 years of age believe it is better to
«live for today,» while 19% justified drinking and driving,
and 32% affirmed that in cases of impunity, it was
appropriate to take justice in one’s own hands.29 While such
data are not disaggregated for Sonora, they indicate some
of the contradictions faced by today’s youth. Although in
most cases, individuals will hind behind an appearance of
conformity and superficial enjoyment via consumption or
youth recreation, general feelings of discouragement and
lack of understanding regarding unfulfilled desires may
trigger depressive symptoms.30
Being an adolescent today involves a stereotypical
burden characterized by ambivalence, biological and social
changes, contradictions, weakening of traditional values,
indecision regarding responsibilities, selfishness, hedonism
and the search for and redefinition of identity.31 All these
factors place today’s youth in a seriously vulnerable
situation, given the lack of opportunities and spaces, which
can affect emotional health. Thus it is important to study
the issue of depression and suicidal behaviors using a
gender-based and multidisciplinary approach.
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Declaration of conflict of interest: None
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SM 12.01.06 - Depression and suicidal behavior.pmd

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