Suicide Risk , Aggression and Violence in Major Psychiatric Disorders

Background: Aggression, violence and Suicide are important problems of mental health in our society. They almost always cause disability, death, or other social problems. Appropriate measures can be taken if the distribution of behaviors and suicide risk are well studied in various psychiatric disorders. Methods: This was a cross-sectional study. We studied 801 psychiatric patients who were admitted in a psychiatric emergency unit in Isfahan, Iran, for aggression, violence and risk of suicide. Information was obtained from a 30-item questionnaire, filled by the same physician. Results: About one-third of patients had aggression and/or violence on admission or during hours before it. It was most prevalent in men of 12-26 years old and in bipolar mood disorder patients. "High suicide risk" was markedly found in patients with major depressive disorder. Differences of these phenomena were statistically

ggression is a "verbal or physical" sudden, goal-directed behavior for devaluating, threatening, or injuring others 1 . Violence is a "physical ", sudden, goal-directed behavior for injuring or killing others, and is commonly more forceful than aggression, and is commonly done against humans 1 . Suicide, "Attempt for ending one's own life", is an important mental health problem that causes many deaths every year 1 , these three phenomena are prevalent, and cause disability, death and other social problems. Previous studies showed relations between these issues 2,3 , their co-occurrence in the same disorders 4 and their relationship with common etiologic factors 5,6,7,8 ; but there are fewer data about their prevalence in different psychiatric disorders 3,9 . ″Suicide Risk″ refers to the likelihood of a person's intention to attempt suicide, and usually it is a here and now condition. It is recognized based on light of changes in symptoms and alterations in personal, domestic, social, and legal circumstances of patient 1 .
There are many studies on suicide but there are fewer comparative data about "Suicide Risk" in different psychiatric disorders 10, 11 . So, we studied these three emergency phenomena i.e. aggression, violence, and suicide risk and their relationship with three major psychiatric disorders namely major depressive disorder (MDD), bipolar mood disorder (BMD) and schizophrenia , in the central psychiatric emergency unit of Isfahan province, Iran.

Materials and Methods
This was a cross-sectional study including 801 (650 outpatient and 151 inpatient) emergency psychiatric cases done at Isfahan's Noor hospital, Iran, in 2000. The patients were clinically diagnosed based on DSM-IV criteria by an emergency psychiatrist 9 . They were asked questions about suicide risk, aggression and violence. the answers were recorded on questionnaires that classified patients into "high risk" and "low risk" by 12 items on suicide risk factors. These factors were about: social profile, health, suicidal activity, and resources 9 . The data were analyzed by Chisquare 2 and P value <0.05 considerd significant.

Results
From 801 patients, 51.9% were male, 48.1% were female, 81.1% of them were treated on an outpatient basis and 18.9% admitted and managed as inpatients. From inpatients, 34.5% were bipolar mood disorder (BMD) patients, 22.5% were major depressive disorder (MDD) patients, 15% were schizophrenic and 33.1% had other disorders. 32.6% of all patients showed aggression and violence at the time of admission or just before it (24.9 % of out patients and 65.6% of in-patients). 68.2% of males and 31.8% of females were aggressive, and it was most prevalent in 21-28 year old group (33.7% of total), and then in 29-36 year old group. More than 3/4 of aggressive cases were 12-36 years of age (77.3%).
Most aggressive and violent patients were diagnosed to have one of the three following major disorders: bipolar mood disorder, schizophrenia and major depressive disorder. BMD. manic episode patients showed maximum aggressive and violent behaviors (82% of total BMD aggressive cases). In BMD patients, aggressive behavior was more found in BMD mixed episode (13.1%) patients, and then in BMD major depressive episode patients (4.9%). P-value<0.05 showed significant difference for aggression and violence among these psychiatric disorders.
Most of "high risk" suicidal cases were found in MDD (44.1%), and least of them were among BMD patients.
The difference among psychiatric disorders were also statistically significant (P value <0.05).

Discussion
In this study the occurrence of aggressive and violent behavior in emergency psychiatric patients was 32.6%, being much more than reported rates of other countries 9 , this value had been 10% in previous similar studies 1 . This abundance may be due to a higher prevalence of BMD patients in the field of our study. Of course, it must be followed by a study on aggression and violence in other parts of society.
The Frequency of such behaviors in inpatients was 2.6 greater than in outpatients. Another study in Germany showed similar findings (75% of males, and, 53 % of female in-patients) 12 , they recommended that "aggression and violence" are the most important predictors of emergency psychiatry admission. These findings also confirm the important role of these behaviors in patients' long hospital stay and large medical expenses. Most abundance of these behaviors in adolescent and young patients (12-26 years old), who are the active part of society, was another outstanding finding of this study. Considering the high rate of aggression and violence on oneself and others in our patients, priority of preventive programs in this area will be warranted. Another study in Malaysia also showed similar findings (61 % of 18-34 years patients 5 ).
Other findings of this study were about "suicide risk". These findings showed the most "high risk" cases in MDD and in schizophrenic patients sequentially. Previous studies showed highest prevalence of "suicide" in MDD 1, 9 . Asberg 14 and, Solof et al. 15 simply showed some relationships between aggression and suicide risk while our study depicted a small epidemiologic map.
According to this map, aggression and violence were most prevalent in BMD, schizophrenia, and MDD sequentially. This order turned vice versa for suicide risk. This sequences may reflect the main defense mechanisms namely introjection, projection, and denial in these disorders.

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As a whole, by presenting disorders with the highest frequency of aggression, violence and suicide risk, this study can guide us to plan practical preventive programs against the above mentioned behaviors in our society.