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The relationship between childhood traumas and stressors of recent year with suicide attempt and general health in adulthood

Hourivash Ghaderi1, Mohsen Khosravi2, Ali Hasanpour Dehkordi3

1 Assistant Professor, Department of Psychiatry, Shahrekord University of Medical Sciences, Shahrekord, Iran

2 General Practitioner, Shahrekord University of Medical Sciences, Shahrekord, Iran

3 Associated Professor, Social Determinants of Health Research Center, School of Allied Medical Sciences, Shahrekord University of Medical Sciences, Shahrekord, Iran

 

Received: 01/01/2019 – Accepted: 31/08/2020

DOI: 10.15761/0101-60830000000270

Abstract

Background and Objective: Suicide is a major health problem in adult, and it is estimated that by 2020 every 20 seconds, a death due to suicide occurs on average every 20 seconds. Therefore, by comprehensive investigating of this social problem and finding ways to cope, the deaths from suicide should be minimized. Since base of adulthood has been built in childhood, this study aimed to investigate the relationship between childhood injuries and stressors of a recent year with suicidal attempts and general health in adulthood. Materials and Methods: This is a case-control study. The sample of this study was 156 people referred and hospitalized to Kashani Hospital in Shahrekord city. The samples were randomly divided into two groups: control (78) and case (experiment) (78). Data were collected by Childhood Trauma questionnaire (CTQ: physical neglect, emotional neglect, sexual abuse, physical abuse, emotional abuse), General Health Questionnaire (GHQ), Holmes and Rahe Stress Scale Questionnaire and were analyzed using SPSS 20 software. In this study, Chi-square, T test, Mann-Whitney, Scheffe and variance analysis were used. Results: GHQ scores in case and control groups were 45.47 and 35.34 respectively. In CTQ items results show that only emotional neglect has higher score in case group (16.33 versus 14.32 in control group). Scores of Holms and Rahe Questionnaire were 180.20 and 173.88 in case and control groups respectively. According to these results there was a significant difference between general health (p=0.006) and emotional neglect (p=0.012) in two groups. But there was no significant difference between two groups in terms of stressors (P =0.701). Conclusion: According to the results of this study, general health and childhood traumas especially emotional neglect are effective on attempt to suicide in adulthood.

Ghaderi H / Arch Clin Psychiatry. 2021;48(1):06-11

Keywords

suicide, stressors, psychological traumas, childhood injuries

Introduction

Suicide is among the top ten causes of death in different countries of the world, and annually more than 1 million people per year suicide1.The suicide rate in Iran, though lower than that of other countries, but a survey conducted in the country shows that it has increased by 6 times in the years 1986-1997, regardless of population growth over recent years2. The number of people who commit suicide in Iran is about 5,000 in a year, in addition to the number of people who commit suicide in different parts of the country, but are not included in the annual statistics. Since every person who commits suicide is a member of a six-member Iranian household, at least 30,000 people in our country somehow deal with the problem of suicide and its psychological and social consequences. Suicide prevention has always been a health issue and has always been a concern of the Ministry of Health. Therefor Plans are currently underway to "Prevent Suicide by treatment of Depression “and” Develop an Integrated Suicide Prevention Program" at PHC since 2007 with the aim of planning to reduce suicide rate through national planning. According to published statistics, the rate of suicide has increased from 1.3 in 100,000 in 1986 to 6.4 in 2005. Suicide was the ninth leading cause of death in men with 7.6 per 100,000 populations and tenth in mortality rate of 1.5 per 100,000. In recent years, due to the increase in suicide attempt and other social problems that have caused it, it has become necessary to pay more attention to suicide prevention planning and to implement a suicide prevention integration plan in the health network2. Investigations, had detected that people with various chronic diseases such as diabetics, chronic renal failure and cancer patients are more prone to suicide3-7. Prevention of suicide has always been a health problem8. Although the rate of suicide in Iran is very low compared to other advanced (developed) industrial countries, studies from the past two decades have shown that this problem is rising9. According to data from 53 countries in 1996, the standardized suicide rate according to age was 15.1 per 100,000 people. This rate was reported 24 per 100000 in men and 6.8 per 100,000 in women10. Today, population density in cities, heterogeneity of people together, feeling homesick, loneliness, decreasing the number of families and decreasing family affection, are among the factors of suicide attempt11. Many suicidal behaviors, especially in adolescents, are related to social factors, and these are more common in people whose family life has been stressed for a long time12-15. According to the World Health Organization (WHO), about 1 million people died due to suicide in 2000, and it is estimated that 1,530,000 people would commit suicide in 202016. Considering the increasing rate of suicide in the world as well as in Iran, and considering the social, economic and psychological consequences of suicide, the study of the underlying causes of this problem seems necessary to prevent this global crisis. Studies conducted in other countries attest to the relationship between childhood traumatic and suicide attempts, but so far this relationship has not been studied in Iran. Despite the fact that all people with severe stressful experiences did not commit suicide, however, all those who committed suicide had experienced stress17. Research shows that children's disorders are closely linked to their parents' psychological problems and their parental practices, and spirituality affects suicide18. Several studies have also shown that long-term emotional, physical, and sexual abuse of childhood lead to cases such as personality disorders19-21. Substance abuse22, major depression and suicide20-24. These conditions may be due to previous anomalies or organ dysfunction that leads to major depression and even suicide25-29. However, there is still no specific mechanism for explaining the relationship between childhood abuse and mental health problems in adulthood21,22,24. Studies on substance abusers have shown that suicide history in the family, as well as trauma in childhood and adolescence, have been correlated with suicidal attempts in adulthood30,31. Severe traumas increase impulsivity, which results in a reduction in brain capacity to inhibit activities and control negative emotions. This impulsivity and not inhibiting negative emotions increases self-harm behaviors and suicide attempts23. The results of the studies show that in the individuals who attempted suicide several times, the family history of suicidal behavior and the rate of childhood and adolescence abuse are higher32. Child abuse is a widespread international problem and the consequences of it are different33. Emotional stress, viral, malignancy, neural and endocrine organ malfunctions may be the consequences of child abuse34-38. Child abuse is a general term used to describe all forms of abuses: negligence, physical abuse, sexual harassment, neglect and emotional harassment and, more recently, domestic violence39. Child abuse affects children of any race, color, social class, and religion, for all ages40. Of all 43 American children, one person is physically abused, particularly in the first week of life, are neglected by parents. Approximately, 500 American children in each age group will be victimized by unhealthy parenting behaviors41. The relationship between childhood traumas and increased risk of suicidal behavior has been seen in both general and clinical populations42. Childhood traumas are significantly associated with early onset of suicide attempts32. Unsafe attachment and childhood traumas are related to suicidal behavior43. In a research on people with substance abuse, it was found that the history of suicide in the family, as well as childhood and adolescent trauma, led to the prevalence of suicidal behaviors in adulthood24,30,31,41. Therefore, with the increasing rate of suicide in the world as well as in Iran, and given that suicide because of its social, economic and psychological consequences imposes abundant losses to society, studying the underlying factors in this regard in order to prevent the world crisis seems indispensable. Therefore, factors that can predict suicide behavior are very important. For this, the aim of this study was to determine the relationship between childhood traumas and stressors of a recent year with suicide attempt and general health in patients referred to Kashani Hospital in Shahrekord, Iran.

Materials and methods

The present study is a case-control one. This project was approved at the Ethics Committee of the Research and Technology Dept. of Shahrekord University of Medical Sciences. 156 subjects (in two groups of case and control) referred to Hospital by using convenience sampling method participated in this study. The case group included individuals who were hospitalized for attempted to suicide, and the control group were patients who were admitted for another reason in the general department of hospital. The participants were matched in age and gender.

In this study, standard questionnaires were used for data collection. They included demographic information, Childhood Trauma questionnaire (CTQ), General Health Questionnaire (GHQ), Holmes and Rahe Stress Scale. Childhood Traumatic Inventory (CTQ) with Cronbach's alpha between 0.79 and 0.9444,45, the mental health status questionnaire (GHQ) with Cronbach's alpha 0.90 (46, 47) and Holmes and Rahe Stress Scale with Cronbach's alpha of 0.7248. CTQ is a 28-item self-report measure which inquires about five types of maltreatment: 1) emotional abuse, 2) physical abuse, 3) sexual abuse, 4) emotional neglect, and 5) physical neglect. A five-point Likert score is used for scoring. For the never option, the number zero is considered. For the rarely option number 1, sometimes option number 2, often option number 3 and very often option number 4 is considered. For physical neglect and emotional neglect subscales. Scoring is reversed.

CTQ subscale scores are noted in Table 144,45.

Tabe 1: subscale scores of CTQ

Emotional abuse

Physical abuse

Sexual abuse

Emotional neglect

Physical neglect

Severity of abuse

≤8

≤7

≤5

≤9

≤7

None

12-9

9-8

7-6

14-10

9-8

Low

15-13

12-10

12-8

17-15

12-10

Moderate

≥16

≥13

≥13

≥18

≥13

Severe

GHQ-28 (28 item) is a psychometric screening tool that screen prevalent psychiatric disorders. This instrument covers four main areas: somatic symptoms, anxiety and insomnia, social dysfunction and severe depression and each domain have 7 questions.

In this scale using behavioral items with a 4-point scale indicating the following frequencies of experience: “not at all”, “no more than usual”, “rather more than usual” and “much more than usual”. The scoring system applied in this instrument is the Likert scale 0, 1, 2, 3. The minimum score for the 28 version is 0, and the maximum is 84. Higher GHQ-28 scores indicate higher levels of distress. Participants with total scores of 23 or below should be classified as non-psychiatric, while participants with scores > 24 may be classified as psychiatric46,47.

Holmes and Rahe Stress Scale: Thomas Holmes and Richard Rahe constructed a social readjustment rating scale after asking hundreds of persons from varying backgrounds to rank the relative degree of adjustment required by changing life events. Holmes and Rahe listed 43 life events associated with varying amounts of disruption and stress in average persons' lives and assigned each of them a certain number of units.

Interpretation of unites is as following:

150 unit or less: a relatively low amount of life change and a low susceptibility to stress-induced health breakdown

150 to 300 unit: 50% chance of health breakdown in the next 2 years

300 unit or more: 90% chance of health breakdown in the next 2 years, according to the Holmes-Rahe statistical prediction model48.

Inclusion criteria included age 18-65, lack of psychosis and physical illness, mental retardation, non-use of drugs or substances, and informed consent, and the exclusion criteria were non-cooperation and patients' death. After completing the questionnaires, the collected data were analyzed using SPSS software version 20 using Chi-square, T test, Mann-Whitney, Scheffe and variance analysis.

Results

The results showed that there was no significant difference between the two groups in terms of sex, education, marital status and place of residence (Table 2).

Table 2: Demographic characteristics of case and control groups

Variable

Group

Groups

P value

Control

Case (experiment)

Number

Percent

Number

Percent

Gender

Male

30

38.5

31

7.39

0.87

Female

48

61.5

47

3.60

0.56

Education

Illiterate

0

0

1

1.3

0.421

Elementary

9

11.5

11

14.1

Secondary

17

21.8

18

23.1

High School

30

38.5

26

33.3

Associate degree

0

0

2

2.6

Bachelor

15

19.2

18

23.1

Master

5

6.4

2

2.6

Ph.d

2

2.6

0

0

Marital status

Unmarried (single)

37

47.4

44

56.4

0.384

Married

30

38.5

20

25.6

Divorced

5

6.4

8

10.3

Widow

6

7.7

6

7.7

Location (Adress)

Shahrkord

41

51.3

50

64.1

0.25

Non-Shahrkord

36

48.8

28

35.9

The results of the study regarding the relationship rate of childhood trauma in two groups of case and control indicated that there was a significant difference in emotional negligence between the two groups (P <0.05). However, there is no significant difference between the two groups in terms of physical neglect, sexual abuse, physical abuse and emotional abuse (Table 3).

Table 3: Childhood traumas scores in case and control groups

Childhood traumas

Mean± Standard deviation

P-value

Control

Case

physical neglect

17.47±5.08

18.5±5.46

0.425

emotional neglect

14.32±5.58

16.33±5.7

0.012*

sexual abuse

22.5±4.02

21.41±4.2

0.124

physical abuse

19.66±3.63

18.7±4.71

0.429

emotional abuse

16.35±4.99

17.74±5.8

0.066

*: Indicates a significant difference at the level of p <0.05

The results also showed a significant difference between the two groups regarding general health (P <0.05), so that the case group had lower general health (Table 4).

Table 4: General health scores in two groups

Group

General Health

(mean ± standard deviation)

P-value

Case (Experiment)

45.47 ±    22.42

<0.05

Control

35.34±21.07

The results of the study indicate that there is a significant difference between the two groups of case and control in terms of general health components. So, in the case group, physical symptoms, anxiety, social function and depression were in a worse situation (Table 5).

Table 5: Comparison of general health components scores in case and control groups

General health components

Groups

mean ± standard deviation

p-value

Physical Symptoms

Control

1.2674±1.765

0.00*

Case

1.522±1.08

Anxiety

Control

1.2673±0.779

0.001*

Case

1.60±1.04

Social Function

Control

1.2839±0.776

0.00*

Case

1.6850±1.05

Depression

Control

1.2344±0.78

0.006*

Case

1.6868±1.08

*: Indicates a significant difference at the level of p <0.05

In table 6 we show that the comparison of the stressors in the two case and control groups was not statistically significant, so that the two groups experienced equal stressors during the past year.

Table 6: Scores of stressors in case and control groups

Group

Mean

SD

p-value

Control

173.88

103.85

0.701

Case (experiment)

180.20

103.56

According to Table 6, the components of general health among the case and control groups are significant based on repeated suicide (P <0.05).

Discussion

The results of the study showed that there are significant differences between childhood traumas in two groups. So that emotional negligence is most important. The importance of childhood traumas in suicidal ideation in adulthood in different countries has been reviewed. Afifi et al. reported that exposure to physical abuse, sexual abuse, or witnessed domestic violence during childhood increased by 16 to 50 percent the thoughts and behaviors of suicidal attempts49. Similarly, clinical studies report that childhood trauma is associated with suicidal attempts in adolescents with various psychiatric disorders20. The results of the study by Shams Alizadeh and colleagues showed that suicidal thoughts and suicide attempts are prevalent and factors such as previous history of suicide, education level, field of study, and residence have a direct and significant relationship with suicidal attempts2. The results of this study showed that there is a significant relationship between general health and spiritual health in the two groups. The results of other studies showed that the general health of people and the symptoms of depression were significantly associated with an increase in suicidal thoughts50. General health status and stress levels of students and university students are significantly related to suicidal ideation51. The results of this study, like the results of other studies, show well the relationship between general health and spiritual well-being with suicide attempt. There are many studies that report that about one in five people who commit suicide have contacted psychiatric clinics a month before committing suicide2. The results of the study by Wile et al showed that providing mental health services can reduce the suicide rate in the population, and studying this relationship can help prevent suicide in the future and improve the mental and spiritual conditions of patients52. According to Conwell et al., mental illness and spiritual anomalies are one of the most important risk factors for suicide53.

The results of Joiner et al. showed that general health in people committing suicide is much lower54. Regarding the fact that there was no difference between the last year`s stressors in the two groups. It can be concluded that high stressors in the presence of good general and mental health have little role in committing suicide, although the relationship between stressors and suicide attempts has been noted in various studies, it has even been pointed out that patients who are being treated in emergency department for suicide attempt they mention at least one of the stressors in their lives55,56.

Conclusion

Based on the results, it can be admitted that the role of various factors such as emotional neglect in childhood and general health in the attempt to suicide in different societies and individuals is different and in order to create solutions to prevent this phenomenon in the community, the role of all these factors must be carefully examined and steps taken to reduce these factors. Considering the importance of the role of the childhood, it seems to be necessary to provide parents with the necessary education for child-rearing and children's emotional education as well as paying attention to the spiritual and physical well-being of people of different ages and creating programs to improve the health status of people, it would be possible to greatly reduce suicide and its complications. Since in Iran traditional parenting is dominant in almost families it seems that classic and academic parenting training should be integrated in to the health and education systems.

Acknowledgment

We express our thanks to Research and Technology Deputy of the Shahrekord University of Medical Sciences, Shahrekord, Iran

References

  1. Cooper J, Kapur N, Webb R, Lawlor M, Guthrie E, Mackway-Jones K, et al. Suicide after deliberate self-harm: a 4-year cohort study. American Journal of Psychiatry. 2005;162(2):297-303.
  2. Malakouti SK, Davoudi F, Khalid S, Asl MA, Khan MM, Alirezaei N, et al. The Epidemiology of Suicide Behaviors among the Countries of the Eastern Mediterranean Region of WHO: a Systematic Review. Acta Medica Iranica. 2015;53(5):257-65.
  3. Sarokhani D, Parvareh M, Dehkordi AH, Sayehmiri K, Moghimbeigi A. Prevalence of depression among iranian elderly: systematic review and meta-analysis. Iranian journal of psychiatry. 2018;13(1):55.
  4. Assadi F. Psychological impact of chronic kidney disease among children and adolescents: Not rare and not benign. Journal of nephropathology. 2013;2(1):1.
  5. Huh Y, Kim SM, Lee JH, Nam GE. Associations between the type and number of chronic diseases and suicidal thoughts among Korean adults. Psychiatry Research. 2021;296:113694.
  6. Vasconcelos S. Hopelessness, suicide ideation, and depression in chronic kidney disease patients on hemodialysis or transplant recipients. CEP. 2015;4023:900
  7. Jhee JH, Lee E, Cha M-U, Lee M, Kim H, Park S, et al. Prevalence of depression and suicidal ideation increases proportionally with renal function decline, beginning from early stages of chronic kidney disease. Medicine. 2017;96(44).
  8. Organization WH. The world health report 2002: reducing risks, promoting healthy life: World Health Organization; 2002.
  9. Veisani Y, Delpisheh A, Moradi G, Hassanzadeh J, Sayehmiri K. Inequality in Addiction and Mental Disorders in 6818 Suicide Attempts: Determine of positive contribution of determinants by Decomposition Method. Iranian Journal of Public Health. 2017;46(6):796-803.
  10. Hawton K, Van Heeringen K. The international handbook of suicide and attempted suicide: John Wiley & Sons; 2000.
  11. Mofidi N, Ghazinour M, Salander-Renberg E, Richter J. Attitudes towards suicide among Kurdish people in Iran. Social psychiatry and psychiatric epidemiology. 2008;43(4):291-8.
  12. Dehkordi AH, Safavi P, Parvin N, Mosayebi B. Effect of methadone maintenance treatment of opioid-dependent fathers on the mental health and perceived family functioning of their children in Iran. Addiction is a treatable disease. 2016:9.
  13. Jalali A, Dehkordi AH, Mahvar T, Moradi M, Dinmohammadi M. Psychological needs of men under methadone maintenance treatment: A mixed method study. Heroin addiction and related clinical problems. 2015;17(1):23-31.
  14. Solati K, Hasanpour-Dehkordi A. Effectiveness of cognitive-behavioural stress management on self-efficacy and risk of relapse into symptoms of substance use disorders. Addiction is a treatable disease. 2017.
  15. Solati K, Hasanpour-Dehkordi A. Study of Association of Substance Use Disorders with Family Members’ Psychological Disorders. Journal of clinical and diagnostic research: JCDR. 2017;11(6):VC12.
  16. Xing X-Y, Tao F-B, Wan Y-H, Xing C, Qi X-Y, Hao J-H, et al. Family factors associated with suicide attempts among Chinese adolescent students: a national cross-sectional survey. Journal of Adolescent Health. 2010;46(6):592-9.
  17. Sawyer SM, Afifi RA, Bearinger LH, Blakemore S-J, Dick B, Ezeh AC, et al. Adolescence: a foundation for future health. The Lancet. 2012;379(9826):1630-40.
  18. Sadock BJ, Sadock VA. Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry: Lippincott Williams & Wilkins; 2011.
  19. Gratz KL, Latzman RD, Tull MT, Reynolds EK, Lejuez C. Exploring the association between emotional abuse and childhood borderline personality features: The moderating role of personality traits. Behavior Therapy. 2011;42(3):493-508.
  20. Milner JS, Thomsen CJ, Crouch JL, Rabenhorst MM, Martens PM, Dyslin CW, et al. Do trauma symptoms mediate the relationship between childhood physical abuse and adult child abuse risk? Child Abuse & Neglect. 2010;34(5):332-44.
  21. Powers AD, Thomas KM, Ressler KJ, Bradley B. The differential effects of child abuse and posttraumatic stress disorder on schizotypal personality disorder. Comprehensive psychiatry. 2011;52(4):438-45.
  22. Oviedo-Joekes E, Marchand K, Guh D, Marsh DC, Brissette S, Krausz M, et al. History of reported sexual or physical abuse among long-term heroin users and their response to substitution treatment. Addictive behaviors. 2011;36(1):55-60.
  23. Wingenfeld K, Schaffrath C, Rullkoetter N, Mensebach C, Schlosser N, Beblo T, et al. Associations of childhood trauma, trauma in adulthood and previous-year stress with psychopathology in patients with major depression and borderline personality disorder. Child Abuse & Neglect. 2011;35(8):647-54.
  24. Braquehais MD, Oquendo MA, Baca-García E, Sher L. Is impulsivity a link between childhood abuse and suicide? Comprehensive psychiatry. 2010;51(2):121-9.
  25. Ezeonwu BU, Nwafor I, Nnodim I, Ayodeji A, Ajaegbu O, Maduemem E, et al. Risk factors for chronic kidney disease in children attending pediatric outpatient clinic in federal medical center Asaba. Journal of Preventive Epidemiology. 2017;1(2).
  26. Fallahzadeh M-H, Fallahzadeh M-A. On the occasion of world kidney day 2016; renal disease in children. Acta Persica Pathophysiologica. 2016;1(1).
  27. Pakniyat A, Yousefichaijan P. Evaluation and management of children with acute kidney injury in emergency department. Journal of Nephropharmacology. 2015;4(2):83.
  28. Safaei-Asl A, Heydarzadeh A, Karimi A, Maleknejad S. NPJ. Journal of Nephropharmacology. 2017;6(2).
  29. Sebdani AM, Alamdary MP, Abdollahpour N. Depression among patients undergoing hemodialysis; a narrative review. Journal of Preventive Epidemiology. 2017;3(1).
  30. Elias B, Mignone J, Hall M, Hong SP, Hart L, Sareen J. Trauma and suicide behaviour histories among a Canadian indigenous population: an empirical exploration of the potential role of Canada's residential school system. Social science & medicine. 2012;74(10):1560-9.
  31. Roy A. Combination of family history of suicidal behavior and childhood trauma may represent correlate of increased suicide risk. Journal of Affective Disorders. 2011;130(1):205-8.
  32. Mandelli L, Carli V, Roy A, Serretti A, Sarchiapone M. The influence of childhood trauma on the onset and repetition of suicidal behavior: An investigation in a high risk sample of male prisoners. Journal of psychiatric research. 2011;45(6):742-7.
  33. Li N, Ahmed S, Zabin LS. Association between childhood sexual abuse and adverse psychological outcomes among youth in Taipei. Journal of Adolescent Health. 2012;50(3):S45-S51.
  34. Afsar Kazeroni P, Khazaei Z, Mousavi  M, Sohrabivafa  M, Adineh  H, Vali Esfahani  M, et al. .The prevalence of HIV positivity among female head of household in Shiraz Immunopathol Persa. 2017;3(2):e14.
  35. Amiri M. Diabetes mellitus type 2; an international challenge. Annals of Research in Dialysis. 2016;1(1).
  36. Beladi-Mousavi SS, Bashardoust B, Nasri H, Ahmadi A, Tolou-Ghamari Z, Hajian S, et al. The theme of the world diabetes day 2014; healthy living and diabetes; a nephrology viewpoint. Journal of Nephropharmacology. 2014;3(2):43.
  37. Kazeroni PA, Khazaei Z, Mousavi M, Khazaei S, Sohrabivafa M, Dehghani SL, et al. Prevalence of human immunodeficiency virus and tuberculosis among homeless individuals. Immunopathologia Persa. 2017;4(1).
  38. Shahreza FD. From oxidative stress to endothelial cell dysfunction. Journal of Preventive Epidemiology. 2016;1(1).
  39. Bücker J, Kapczinski F, Post R, Ceresér KM, Szobot C, Yatham LN, et al. Cognitive impairment in school-aged children with early trauma. Comprehensive Psychiatry. 2012;53(6):758-64.
  40. Branco BC, Inaba K, Barmparas G, Talving P, David J-S, Plurad D, et al. Sex-related differences in childhood and adolescent self-inflicted injuries: a National Trauma Databank review. Journal of pediatric surgery. 2010;45(4):796-800.
  41. Griffin ML, Amodeo M. Predicting long-term outcomes for women physically abused in childhood: Contribution of abuse severity versus family environment. Child abuse & neglect. 2010;34(10):724-33.
  42. Brodsky BS, Mann JJ, Stanley B, Tin A, Oquendo M, Birmaher B, et al. Familial transmission of suicidal behavior: factors mediating the relationship between childhood abuse and offspring suicide attempts. The Journal of clinical psychiatry. 2008;69(4):584.
  43. Grunebaum MF, Galfalvy HC, Mortenson LY, Burke AK, Oquendo MA, Mann JJ. Attachment and social adjustment: relationships to suicide attempt and major depressive episode in a prospective study. Journal of affective disorders. 2010;123(1):123-30.
  44. Garrusi B, Nakhaee N. Validity and reliability of a Persian version of the Childhood Trauma Questionnaire. Psychological reports. 2009;104(2):509-16.
  45. O’Connor DB, Green JA, Ferguson E, O’Carroll RE, O’Connor RC. Effects of childhood trauma on cortisol levels in suicide attempters and ideators. Psychoneuroendocrinology. 2017.
  46. Goldberg DP, Hillier VF. A scaled version of the General Health Questionnaire. Psychological medicine. 1979;9(1):139-45.
  47. Noorbala A, Mohammad K. The validation of general health questionnaire-28 as a psychiatric screening tool. Hakim Research Journal. 2009;11(4):47-53.
  48. Heydari A, Namjoo Z. Comparison of alexithymia, attachment styles and stress in men and women employees in Ahvaz. 2011.
  49. Afifi TO, Boman J, Fleisher W, Sareen J. The relationship between child abuse, parental divorce, and lifetime mental disorders and suicidality in a nationally representative adult sample. Child abuse & neglect. 2009;33(3):139-47.
  50. Poursharifi H, Habibi M, Zarani F, Ashouri A, Hefazi M, Hajebi A, et al. The Role of Depression, Stress, Happiness and Social Support in dentifying Suicidal Thoughts in Students. Iranian Journal of Psychiatry and Clinical Psychology. 2012;18(2):99-107.
  51. Zeinalzadeh AH, Viitasara E, Bahadori F, Sadeghi-Bazarghani H, Soares J, Mohammadi R, et al. Suicidal ideation and its correlates among high school students in Iran: a cross-sectional study. BMC psychiatry. 2017;17(1):147.
  52. While D, Bickley H, Roscoe A, Windfuhr K, Rahman S, Shaw J, et al. Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study. The Lancet. 2012;379(9820):1005-12.
  53. Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biological psychiatry. 2002;52(3):193-204.
  54. Joiner TE, Pfaff JJ, Acres JG. A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: reliability and validity data from the Australian National General Practice Youth Suicide Prevention Project. Behaviour research and therapy. 2002;40(4):471-81.
  55. Bolton JM, Cox BJ, Afifi TO, Enns MW, Bienvenu OJ, Sareen J. Anxiety disorders and risk for suicide attempts: findings from the Baltimore Epidemiologic Catchment area follow‐up study. Depression and Anxiety. 2008;25(6):477-81.
  56. Yoshimasu K, Kiyohara C, Miyashita K, Hygiene SRGotJSf. Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies. Environmental health and preventive medicine. 2008;13(5):243-56.