Suicidal behaviour among youths associated with psychopathology in both parents and youths attending outpatient psychiatric clinic in Kenya

Worldwide, suicide is among the top five causes of mortality in the 15- to 19-year-olds [1, 2]. It is the third leading cause of death worldwide in people aged 15–34 years, re-identified to have 1.4% of disease burden globally [3, 4]. Previous studies show that youths with a history of admission or attendance to a medical facility come from a dysfunctional family or have parents with a psychiatric illness [5–7]. These studies on the history of admission or attendance to a medical facility also show that the affected youths aged 10–19 years have an increased risk of developing suicidal behaviour.

The relationship between psychiatric disorders or substance abuse and suicidal behaviour among youths has been studied in the developed world, with few studies from low- and middle-income countries [8, 9]. Research findings indicate that depressive disorder is associated with suicidal behaviour [10]. Unfortunately, if depression remains untreated, co-morbid disorders: anxiety, bipolar mood and substance use disorders, develop which are associated with severe suicidal behaviour [11–13]. Studies have further documented that youths with substance abuse disorders have higher rates of depression (15%–24%) than youths in the general population (2%–8%) [14–16]. It has also been shown that youths diagnosed with co-morbid disorders have severe substance abuse with poorer drug treatment outcomes [16]. These youths with psychopathology come from dysfunctional families where one or both parents have psychiatric or substance use problems associated with maladaptive parenting behaviour [17–22]. Bridge et al. showed that between 80% and 90% of adolescents who had suicide plan and/or had attempted suicide had co-morbid psychiatric disorders [23]. In 2004, Wilcox et al. showed that there is an association between completed suicide and drug abuse [24]. Therefore, the co-morbidity of psychiatric disorders, particularly of mood, disruptive, and substance abuse disorders, significantly increases the risk for youths to develop suicidal behaviour.

In Africa, Ndosi identified schizophrenia, substance abuse, HIV/AIDS and personality disorders as co-morbid psychiatric and medical conditions associated with suicidal behaviour [25]. Ndosi indicated that 90% of people who commit suicide have co-morbid psychiatric disorders, although social factors have a predominant influence on their suicidal behaviour [25]. Existing data from the South African Stress and Health Study on the prevalence and correlates of suicidal behaviour revealed that having a psychiatric disorder is a risk factor for suicidal behaviour [26]. In this South African study [26], respondents with at least one Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) disorder were four times more likely to attempt suicide, while those with three or more disorders were eight times more likely to attempt suicide or develop suicidal ideation than those with no psychiatric disorder. This paper is written in order to document the association between psychiatric disorders in youths and their parents and perceived parenting behaviour and suicidal behaviour in Kenya.

Suicidal behaviour is considered a worldwide problem and an increasing source of concern. This study shows a significant tendency toward an increased rate of severe suicidal behaviour (prevalence of 82%) among youths with psychiatric disorders which has been documented in previous studies [10, 23, 24].

The family dysfunctions in this study include the following: youths from a single-parent family (never married, separated widows/widowers), youths who have parents with psychiatric disorders (alcohol use, mood disorders), a family history of severe suicidal behaviours and violent and abusive family structures (parenting behaviour with no emotional attachment), maladaptive maternal rejecting parenting behaviour, parents' inadequate authority (under-protective parenting behaviour) and parents’ lack of time to observe and deal with the child’s emotional distress. These findings are comparable to previous studies that have shown that mental health problems compromise a mother’s or a father’s parenting abilities, and this poses a threat to their youths’ adjustment and behaviour [17, 18]. Thus, a parent with a psychiatric disorder has also a maladaptive parenting behaviour. The perceived maternal-parental rejection or paternal under-protection obstructs interaction between parents and their children. The parenting behaviour in such a family setting is perceived by children to be a poor emotional expression: ‘I have no interest in you’. This, therefore, disconnects children from their parents, creating a barrier for children to explore and form connecting bonds with their parent(s). This un-connectedness between the child and a parent leads to confusion, conflict and frustration in the growing child, a precursor for a youth/child to develop psychopathology and suicidal behaviour.

These findings are comparable to evidence from previous studies which have documented that parents of depressed youths also have depression [33–35]. These relationships seen in other studies are similar in this outpatient setting in Kenya. These findings are also consistent with other studies which assessed the co-morbidity of psychiatric disorders and showed a significantly increased risk for youth suicidal behaviour [5, 6, 10, 23, 36]. It is also comparable to a study by Beautrais et al., which examined precipitating factors and life events in serious suicide attempts among youths aged 13 through 24 years [37]. Also, these relationships between maternal rejecting behaviour and depression and offspring suicidality may suggest the need for therapeutic approaches that treat the family unit, not just individuals separately, and the relationship between paternal death and child suicidal behaviour may suggest that those whose parents die should receive targeted suicide prevention programming.

Another important finding of this study is the relationships between psychopathology (MDD and alcohol/substance use disorder) and suicidal behaviour among youths that did not show any significant difference according to gender. This striking finding emerging from this study is the extent to which suicidal behaviour co-exists with psychiatric disorders among youths. Majority of the youths had severe psychiatric disorders (depression, alcohol use problems, multiple substance use disorders and anxiety disorders). Unlike in earlier studies, women were more likely to engage in suicidal behaviours than men, probably because they had a higher prevalence of depression, which was a strong predictor of suicide attempts. In this study, alcohol dependence in youths may be the equivalent of depression or anxiety. These are externalizing syndromes which may have been un-documented in previous studies and therefore may explain why there is no difference in gender in this study. This was documented by Buglass and Horton in 1974 and Appleby in 1992 [38, 39].

It can be postulated, therefore, that youths resort to suicidal behaviour so that they can externalize their problems, which is a reflection of increased risk associated with the co-morbidity of internalizing axis disorders, such as depression and anxiety disorders.

The results also indicate that the presence of multiple disorders is associated with an increased risk for suicidal behaviour (two to three co-morbid disorders and four or more co-morbid disorders compared to only one disorder). This indicates that the increasing presence of co-morbid psychiatric disorders increases the number of psychiatric symptoms and therefore difficulty to bear, hence the increased odds of suicidal behaviour. This is consistent with previous study findings [32, 39–41] which have documented that suicidal behaviour co-exists among patients with multiple psychiatric disorders. This finding is also similar to several surveys which have indicated that up to three-quarter of those who eventually take their own lives show one or more symptoms of depression co-existing with other psychiatric disorders or substance abuse disorders [15, 16]. These results are comparable to other findings which have revealed that youths who use alcohol and illicit drugs (multiple substance use) have co-morbid depressive disorder and are identified among adolescents who commit suicide [15, 16, 42, 43]. Nonetheless, these results suggest that gender differences in the link between psychopathology and suicide should be explored further in other samples in which rates of suicide attempts are higher, especially among male respondents.

Certain limitations of the current study should be considered in interpreting the findings. The diagnosis and symptom assessment relied on the DSM-IV criteria. Future research should confirm these results using the most recent version of DSM. However, the use of the DSM-IV criteria allowed comparative data to be obtained from both parents and youths who were assessed concurrently for psychopathological symptoms, increasing the reliability of our statistics. An additional weakness of the current study is the binary index (yes/no) of both psychiatric disorders and suicidal behaviour that was utilized as sum criteria in making the DSM-IV diagnoses. Another weakness of this study is that we could not fully examine the important relationship between suicide and symptoms of anxiety disorders, conduct disorder, schizophrenia and bipolar disorder because of the low base rates of these syndromes in the studied population.

These results have clinical implications. In general, this work informs the development of interventions to prevent individuals from engaging in behaviours that are destructive to the self and to others. Psychiatric and substance abuse disorders are strong predictors of suicidal behaviour, and these associations are more often pronounced when there is more than one co-existing psychiatric or substance abuse disorders. This suggests some universality of the relevant mechanisms underlying the genesis of suicidal behaviour. Suicidal behaviour is therefore a common problem among youths identified with psychiatric or substance abuse disorder, and these results suggest that clinicians and health care providers would improve care for their patients’ benefit from paying closer attention to the assessment of suicidal impulses in youths seen with psychiatric disorders. The findings in this study can therefore be used to develop a more comprehensive understanding and assessment of adolescent suicide risk factors, which may promote early assessments that lead to targeted interventions, thus reducing future risk of poor psychiatric health outcomes and suicidal behaviours.