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Psychosomatic Medicine 67:241-245 (2005)
© 2005 American Psychosomatic Society

ORIGINAL ARTICLES

Lifetime Prevalences of Physical Diseases and Mental Disorders in Young Suicide Victims

Kaisa M. Viilo, BSc, Markku J. Timonen, MD, PhD, Helinä H. Hakko, PhD, Terttu Särkioja, MD, PhD, V. Benno Meyer-Rochow, PhD and Pirkko K. Räsänen, MD, PhD

From the Department of Psychiatry, University of Oulu (K.M.V., M.J.T., P.K.R.), Finland; Oulu Health Center (M.J.T.), City of Oulu, Finland; Department of Psychiatry, Oulu University Hospital (H.H.H., P.K.R.), Finland; Department of Forensic Medicine, University of Oulu (T.S.), Finland; School of Engineering & Science, International University Bremen (IUB) (V.B.M.-R.), Bremen, Germany; and Department of Physiology, University of Oulu (V.B.M.-R.), Finland.

Address correspondence and reprint requests to Helinä Hakko, Oulu University Hospital, Department of Psychiatry, Box 26, 90029 OYS, Finland. E-mail: helina.hakko{at}oulu.fi


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 
Objective: Evaluation was done of a possible link between psychiatric and physical illnesses in suicide victims 25 years of age or younger.

Methods: This was a follow-up study based on a 13-year database (n = 1,585) of all suicides committed during the years 1988 to 2000 in northern Finland with linkage to national hospital discharge registers. The setting for the study was the province of Oulu, located in northern Finland. Subjects comprised 202 male and 27 female suicide victims aged 25 years or less.

Results: Despite the young age of the suicide victims, lifetime prevalence of physical illness was about 70% in both males and females. In relation to mental disorders, female suicide victims were affected significantly more (45%) than their male counterparts (21%). About 27% of the subjects with physical illnesses had also suffered from mental disorders, but the respective proportion among those without any physical illness was only 7%. An increased prevalence of mental disorders was found in victims with diseases of the skin and subcutaneous tissues, musculoskeletal, respiratory, and digestive systems. Furthermore, increased incidences of mental disorders were also noticed in connection with injuries, poisonings, and symptoms or signs of infectious diseases. Prevalence of mental disorders in these physical disease categories varied from 25% to 44%.

Conclusion: We recommend a greater attention to young people with physical illnesses and other symptoms in the hope that such screening may lead to an early recognition of psychiatric disorders and suicidal tendencies.

Key Words: physical disorders • suicide • depression • young people

Abbreviations: FHDR = Finnish Hospital Discharge Register; ICD = International Classification of Diseases.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 
A history of admission with mental illness has found to be the strongest risk factor for suicide in young people aged 10 to 19 along with other covariates such as dysfunctional family background, socioeconomic adversity of the parents, and a family history of mental illness or suicidal behavior (1). It has also been emphasized that suicide risk may be associated with physical signs and that these should be taken into account as well when estimating the risk of suicidal behavior in younger people (2).

Suicidal ideation is one of the core symptoms of major depression. The association between suicidal ideation and somatic symptoms paired with severe physical illness is not new, but it has rarely been reported in young people (3–6). Somatic symptoms have frequently been found to be present in patients with depression (7,8). In fact, Carson et al. suggested that a co-morbid depression could play an essential role in suicidal ideation of somatic patients (9). Somatic disorders have also been shown to be highly prevalent in patients with other major mental disorders such as schizophrenia (10).

Finland has one of the world’s highest suicide rates. According to Finnish statistics, 33.7 males and 10.6 females per 100,000 inhabitants committed suicide in the year 2000. Thus, suicide is a major public health problem in Finland and for young people in Finland, suicide is one of the leading causes of death (11).

Access to the Finnish National Registers of hospital discharges and causes-of-death allowed us to examine all hospital admissions in relation to physical disease and mental disorders that the young suicide victims, 25 years of age or less, had suffered from in northern Finland. We evaluated lifetime prevalence of physical illnesses and mental disorders according to the main diagnostic categories as they appear in the system of the International Classification of Diseases. Because of the small number of cases involving females, the possible link between lifetime prevalence of physical illness and mental disorder was examined for male suicide victims only.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 
Study Material
The original study material consisted of the large population-based dataset for all suicides (1,296 males, 289 females) committed during 1988 to 2000 in the province of Oulu in northern Finland. The present study included those subjects, who were 25 years of age or younger at the time of the death due to suicide. Information was extracted from official death certificates, which were based on medico-legal investigations involving autopsies and forensic examinations. The study protocol was approved by the Ethics Committee of the University of Oulu.

Lifetime diagnoses of physical illnesses and mental disorders of suicide victims and all relevant diagnostic codes (based on the system of the International Classification of Diseases) were extracted from the Finnish Hospital Discharge Register (FHDR) up to the end of 1999. The FHDR is maintained by the Finnish National Board of Health and covers all treatment periods in general, private, mental, military, and prison hospitals as well as the inpatient wards of local health centers nationwide. It contains information on the personal and hospital identification codes, and data on age, gender, and length of stay as well as primary diagnosis at discharge, together with three subsidiary diagnoses. In the past the FHDR has been found to be a reliable source of information in epidemiological research (12).

Physical Illnesses
In Finland, diagnoses are coded according to the system recommended by the International Classification of Diseases: ICD-8: 1969 to 1986; ICD-9: 1987 to 1995; ICD-10: 1996 and later. For this study, we recategorized all diagnoses of infectious diseases into a single group of infections, because in the ICD, many infections are coded by site. In all other cases, the physical diseases of young suicide victims were classified according to the main diagnostic categories (of physical diseases) as they appear in the ICD-classification system.

Mental Disorders
The following hospital treated psychiatric disorders were extracted from the FHDR: Depression (ICD-8: 2960, 2980, 3004; ICD-9: 2961, 2968, 3004; ICD-10: F32-F34.1), psychotic disorders (ICD-8: 295–299; ICD-9: 295, 2961–4E, 2967A, 297, 298, 2990,2999; ICD-10: F20–25, F28, F29, F30.2, F31.2, F31.5, F32.3, F33.3), and other psychiatric diagnoses (eg, nonpsychotic and nondepressive disorders).

Differences in categorical variables between subgroups were scrutinized with the aid of Fisher’s exact test. The statistical software used was the SPSS for Windows, version 11.0.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 
The study population consisted of 202 (88.2%) male and 27 (11.8%) female victims, who had committed suicide during 1988 to 2000 in the province of Oulu in northern Finland. The median age in years (with range in parentheses) was 21 (11–25) for males and 21 (14–25) for females at the time of death due to suicide.

The results (Table 1) show that about 70% of both male and female suicide victims had a history of physical illness by the age of 25. About one third of the male suicide victims had received hospital treatment because of injuries or poisonings or infections. More than 10% of the men had suffered from diseases of the respiratory tract or had been admitted to a hospital because of symptoms or signs. A considerable number of the female suicide victims had been in the hospital because of injuries or poisonings (44%) and infections (20%). The most common physical illness category among women involved diseases of the nervous system (11.1%).


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  		TABLE 1. Diagnostic Breakdown of Physical Diseases (Based on the International Statistical Diagnostic Classification System) in Male and Female Suicide Victims, 25 Years of Age or Younger, in the Province of Oulu in Northern Finland

 

Among victims with physical diseases, 63% of the males and 67% of the females belonged to only one diagnostic ICD category for physical diseases, whereas at least two different types of physical disease were associated with 37% of the male and 33% of the female victims ({chi}2 = 0.04, p = 0.843).

Table 2 presents the prevalences for mental disorders. Lifetime prevalence of any mental disorder in female suicide victims was more than twice that of the men (Fisher’s exact test, p < .001).


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  		TABLE 2. Diagnostic Breakdown of Mental Disorders Among Male and Female Suicide Victims, 25 Years of Age or Younger, in the Province of Oulu in Northern Finland

 

Table 3 shows the results of an examination, carried out to assess whether mental disorders and physical diseases in male suicide victims were linked. A significantly higher prevalence of mental disorders was found among victims with at least one hospital treatment because of some physical disease (27%), compared with those without any history of physical illnesses (7%) (rate ratio 3.27, 95% CI 1.33–8.03). When specific categories of physical diseases were considered, a notable excess of a mental disorder was found among victims with diseases of the skin and subcutaneous tissues, and musculoskeletal, respiratory, and digestive systems. In addition, increased incidences of mental disorders were also noted in connection with injuries, poisonings, and symptoms or signs of infectious diseases. Prevalence of lifetime mental disorders in these physical disease categories varied from 25% to 44%.


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  		Table 3. Prevalence of Hospital-Treated Comorbid Mental Disorders in Physical Disease Categories of Male Suicide Victims, 25 Years of Age or Younger, in Northern Finland Between 1988 to 2000

 

Psychotic disorders, ranging from 11% to 22%, were more common in men with a lifetime prevalence of injuries and poisonings, and diseases of the genitourinary tract, skin, or subcutaneous tissues, and the respiratory system. An excess of mental disorders other than depression or psychosis was present in male suicide victims, who had suffered from diseases of the musculoskeletal or digestive systems or who had a lifetime history of symptoms or signs of infectious diseases compared with men who had no such history of physical disease. The results of additional analyses (not reported in Table 2) showed that increased lifetime prevalence of hospital-treated depression was present in male suicide victims with a history of injuries and poisonings (9%) compared with men without such histories (0%, Fisher’s exact test, p < .01). Statistical tests to demonstrate whether an association between mental disorders and physical diseases existed in women were not feasible because of the small number of female suicide victims in our dataset.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 NOTES
 REFERENCES
 
Despite the young age and gender of the suicide victims in our dataset, the great majority of the subjects, at some point in time, had been admitted to a hospital for treatment of a physical disease. Female suicide victims had exhibited a significantly higher lifetime prevalence of hospital-treated mental disorders than men. A strong association was also noted between lifetime history of mental disorders and physical diseases in male suicide victims.

In our study, 71% of male and 67% of female suicide victims had had physical illnesses severe enough to warrant hospital treatment. Our finding is well in line with results obtained earlier from the Northern Finland 1966 Birth Cohort, in which 69% of men and 58% of the women had been hospitalized due to physical diseases up to the age of 28 years (10). About one third of the male and more than 40% of the female suicide victims had been hospitalized because of injuries, poisonings, or accidents. Deliberate self-harm among young people is known to parallel the increase in prevalences of injuries, poisonings, and accidents (13), which may also be part of an explanation for our findings. Furthermore, one third of the men had received hospital treatment against infectious diseases. Mäkikyrö et al. have reported that more than 60% of all treatment episodes due to infectious diseases in men aged 28 or less had occurred in military hospitals during obligatory military service, which may also explain our finding of the high prevalence of these diseases (10).

Hospital-treated mental disorders were more than three times more common among male suicide victims with a history of physical diseases (27%) than among victims without such a history (7%). Our findings differ from those reported in the Northern Finland 1966 Cohort’s 28-year follow-up (10), in which the prevalence of mental disorders was 5.4% and 3.1%, respectively, in subjects with and without a lifetime history of hospitalization due to physical disease (10). Thus, our result indicates that a history of physical illnesses may serve as a useful predictor for suicidality. The association between mental disorders and physical diseases was strongest in male subjects with diseases of the circulatory, respiratory, digestive, and musculoskeletal systems, disorders of the skin and subcutaneous tissues, and a history of hospital-treated injuries or poisonings, and symptoms or signs of infectious diseases. This is in line with earlier findings based on a Finnish general population birth cohort, in which physical disorders were shown to be highly prevalent among patients with major mental disorders (10).

Statistically significant associations of any lifetime mental disorder with diseases of the respiratory system as well as with diseases of the skin and subcutaneous tissues were observed in this study. An association between atopic disorders (ie, asthma, allergic rhinitis, atopic eczema, and allergic conjunctivitis) and depression has been demonstrated in several earlier studies (reviewed by Wamboldt and colleagues) (14). Because suicidal ideation is considered to be a core symptom of major depression (15), we speculate that our findings with respect to the respiratory system and the diseases of the skin and the subcutaneous tissue might be explained by comorbid depression associated with these disorders. Even though these suicide victims had not been hospitalized due to depression, it is possible that they had been treated as outpatients or had been diagnosed as having depression.

Several neurological illnesses such as multiple sclerosis, for instance, have been suggested to increase the risk of suicide (16). However, in our database, the prevalence of neurological disorders was low. Because our data included suicide victims aged 25 years or less, it is most likely that the young age of our study subjects explains our findings: the potential neurological disorders would not yet have appeared.

Mental disorder lifetime prevalence of female suicide victims was approximately twice that of male suicide victims. Marttunen et al. reported an overall psychiatric comorbidity of adolescent suicide victims being about 50% in both genders (17). In our study, hospital-treated depressive disorders as well as psychotic disorders were more common among female suicide victims, although the gender difference failed to reach statistical significance because of the small number of cases. A Finnish psychological autopsy study also revealed a higher prevalence of major depression in females (46%) rather than males (26%) (18).

Although in our study population the total number of hospital-treated subjects with depressive disorders was small, we found a significant excess of depression among male suicide victims with a history of injuries or poisonings. In men, alcohol abuse and violent behavior can be signs of psychosocial distress (19). Thus, we speculate that in male suicide victims, the psychosocial distress may also become manifest as masked depression, ie, self-violent behavior and alcohol problems, resulting in injuries and poisonings.

In our study, there was an increased prevalence of mental disorders in relation to subjects with diseases of the musculoskeletal system, although because of the small number of cases, it was not possible to single out one psychiatric disorder category. Egger et al. had reported a significant relationship between musculoskeletal pains and depression in boys and girls aged 9 to 16 (20). In a recent population-based survey conducted in Finland, prevalence of depression was found to be elevated in adolescents suffering from recurrent pain symptoms, eg, lower back pain or neck or shoulder pain (8). Thus, we believe that musculoskeletal pain can be a sign of depression, which has in the past often remained unrecognized by clinical practitioners.

Methodological Considerations
The strength of our study was that the original data came from the Finnish statistical practice, which has provided reliable information for scientific purposes before (21). One limitation was that we were not able to study the actual causal relationships between psychiatric and physical illnesses in the young suicide victims. However, because of the young age of the suicide victims, we have reason to assume that the two types of illness occurred sufficiently close to each other in time, allowing us to consider them comorbid. Had it been available, information on the history of self-harm, such as suicide attempts, could have shed further light on the risk of suicide in people with both physical disorders and a history of self-harm. More information on the association of physical diseases and suicidality could have been available, if we had been able to compare the prevalence of physical diseases of suicide victims with those observed in people of the same age-range, but who have not committed suicide. This should be a focus of future studies. Our data on prevalences of mental disorders were based on the information available from national registers, which might explain, at least in part, the lower rates of mental disorders in our study as compared, for example, with psychological autopsy studies.


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
NOTES
 REFERENCES
 
Our study is the first in which an association between hospital-treated mental disorders and physical illnesses has been investigated in a population of young suicide victims. Previous studies were mainly based on information obtained through psychological autopsies.

The results of our study demonstrate a noteworthy association between mental disorders and physical illnesses among young suicide victims. Our findings suggest that young people may benefit from a thorough biopsychosocial evaluation when they are admitted to the hospital for treatment of a physical illness and that clinical practitioners should always consider the possibility of a masked depression behind physical symptoms.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
REFERENCES
 

Received for publication December 9, 2003; revision received July 5, 2004.

DOI:10.1097/01.psy.0000151488.71789.7f


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 

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