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Suicidal Ideation, Suicide Attempt and Associated Factors in Thai Patients with Acutely Treated Depressive Disorder

Article Information

Mayteewat Chiddaycha, Peeraphon Lueboonthavatchai*

Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

*Corresponding Author: Peeraphon Lueboonthavatchai, Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand

Received: 27 February 2022; Accepted: 07 March 2022; Published: 15 March 2022

Citation: Mayteewat Chiddaycha, Peeraphon Lueboonthavatchai. Suicidal Ideation, Suicide Attempt and Associated Factors in Thai Patients with Acutely Treated Depressive Disorder. Journal of Psychiatry and Psychiatric Disorders 6 (2022): 047-060.

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Abstract

Background: The suicide rate in Thailand has increased over the last ten years. Most of the people who died from suicide were depressed, and social problems were thought to be an important crisis for them.

Aim: The aim of this study was to examine the prevalence of suicidal ideation, suicide attempt and associated sociodemographic, clinical, and social factors in Thai patients with acutely treated depressive disorders.

Methods: A sample of 178 patients with depressive disorders who were treated within the six-month period of being diagnosed or of a recurrent episode were recruited from a tertiary hospital. Multinomial logistic regression was used to determine the associated factors of suicidal ideation and suicide attempt.

Results: Most of the subjects were single (80.9%), female (68%), and in early adulthood. The prevalence of suicidality, suicidal ideation, and suicide attempt within one month were 76.4%, 62.4% and 35.4%, respectively. Associated factors of suicidal ideation compared with those with absence of suicidality were unemployment (OR 4.30; 95% CI 1.16 – 15.92) and family relationship (OR 0.93; 95%CI 0.86 – 0.99). Compared with the suicidal ideators, the suicide attempters were more likely to have more severe depression (OR 1.07; 95%CI 1.02 – 1.12), use benzodiazepines (OR 2.71; 95%CI 1.05 – 7.03) and have interpersonal deficits (OR 3.85; 95%CI 1.03 – 14.45).

Conclusions: Determinants of suicidal ideation and suicide attempt varies among population. Knowledge of these associated factors may raise awareness of suicide prevention during the early phase of treatment of depression in Thai patients.

Keywords

Demographic factor; Depressive disorder; Family relations; Interpersonal relations; Suicide; Suicidal ideation; Suicide attempt

Demographic factor articles; Depressive disorder articles; Family relations articles; Interpersonal relations articles; Suicide articles; Suicidal ideation articles; Suicide attempt articles

Article Details

Abbreviations

BDI-II; Beck Depression Inventory II; SSRIs; Selective serotonin reuptake inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors

1. Introduction

Suicide is considered a problem not only for individuals but also for family, society, and public health. According to a report from the World Health Organization (WHO) [1], there were an estimated 7.39 hundred thousand suicide deaths worldwide in 2016. In Thailand, the completed suicide rate in 2015 was 6.47 per a hundred thousand, and there has also been an increase in this trend over the last ten years [2]. Persons who have a risk of suicide generally have genetic vulnerability, diagnosed mental illness, social isolation, and impulsiveness [3]. Psychosocial stressors are also found to be associated with suicide, for example, perceived social support, life stress events and poor family communication [4, 5].

Among psychiatric disorders, depressive disorder has received a lot of attention because of its long-term disability. WHO reports that depression is the leading cause of disability and by the year 2030, unipolar depressive disorder is projected to reach first place in the ranking of Disability-Adjusted Life Years (DALYs) [6]. Past studies have shown various levels of prevalence of suicidality in patients with depressive disorders, ranging from 32% to 62% [7-9] depending on the various sites and samples’ characteristics. Reports from psychological autopsies demonstrate that more than half of suicidal individuals have depression [10] and indicate that 44% of completed suicides are individuals who underwent psychiatric or psychosomatic treatment within a month prior to suicide [11]. This reminds health care professionals to be aware of patients’ suicide risk, even during treatment. The median duration of the depressive episodes found in the previous research ranged from one month to six months [12-14]. This could be an essential period when there is a need to be focused on assessing suicide risk and to provide intensive intervention to prevent suicidal behaviors. There is limited data regarding the suicidality of patients with depressive disorders who are currently in acute treatment. Past studies included depressed patients in various phases of treatment, such as remission and recovery, which may affect their suicidality rate.

Past studies have tried to identify factors that would distinguish the groups of people with suicidal ideation and those with suicide attempt. Younger age, female sex, unemployment, severe depression, alcohol use disorder, borderline personality disorder, childhood trauma and recent stressful life events were found to be associated with suicide attempt among suicidal ideators [15-18]. In Thailand, these factors have not been investigated and they might be different from other countries’ regarding divergent sociocultural context. The aim of this study was to examine the prevalence of suicidal ideation, suicide attempt and the associated demographic, clinical and social factors in Thai patients with acutely treated depressive disorders, which may help us to better understand the situation of suicide in this population and to improve the quality of care, which may lead to more effective suicide prevention for patients.

2. Methods

2.1 Study design and setting

This cross-sectional descriptive study was carried out from November 2017 to April 2018. All of 178 participants were recruited from the in- and outpatient psychiatric clinic of King Chulalongkorn Memorial Hospital, a tertiary hospital in Bangkok, Thailand. This study was approved by the Ethics Committee, the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University.

2.2 Participants

Regarding the median duration of the depressive episodes found in the previous research [12-14], patients who were treated within the initial six-month period were classed as ‘acutely treated’. The inclusion criteria were 1) age 18 years and older, 2) was diagnosed with a “major depressive disorder” (MDD) or “persistent depressive disorder” (using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) and 3) was treated within the six-month period of being diagnosed or of a recurrent episode. The patients were excluded from the study if they were diagnosed as having a “bipolar disorder” or “dementia”. Psychotic disorders including schizo-phrenia, schizoaffective disorder and delusional disorder were also excluded.

2.3 Sample size and sampling

With the suicidality rate from the previous study of 62% [9], a level of precision taken as 7.5% and the 10% allowance for non-response, the calculated sample size was 178. All consecutive patients who met the study criteria were asked to participate in the study until the sample size was met.

2.4 Assessment

After the patients were informed of the objectives and methods of the study, they were asked to complete the demographic questionnaire. The clinical and treatment history in patients’ medical records were reviewed. Their suicidality was assessed using semi-structured interviews according to the suicidality module of the Mini International Neuropsychiatric Interview (MINI) Thai version which had good inter-rater reliability (Cohen’s kappa = 0.86) ,good sensitivity (0.96) and specificity (0.91) compared with a psychiatrist’s interview [19].

The suicidal ideation, suicidal plans, attempted suicide during the past month and any past suicide attempts were asked about. The total scores categorized patients’ current suicide risks into absent (0), low (1-8), moderate (9-16) and high risk (17 or higher). Patients’ suicidality was presented when the score was higher than zero. The presence of any levels of suicide risk were reported to the doctors, and thus the appropriate interventions were given to the patients. Finally, depressive severity and social factors were evaluated by self-report questionnaires as follows.

1) The Beck Depression Inventory-II (BDI-II) Thai version, a widely used questionnaire for assessment of the severity of depression, was developed from its original version in English [20] and consists of 21 questions with a total score of 63. The severities of depression were categorized into minimal (0-13), mild (14-19), moderate (20-28) and severe depression (29-63). The test showed good internal consistency (Cronbach’s alpha coefficient, α = 0.91) and the Spearman’s correlation coefficient, which indicated the relationship between the score obtained from this BDI-II and the Hamilton Rating Scale for Depression, was 0.71.

2) The Thai Interpersonal Questionnaire [21] was developed from the interpersonal psychotherapy manual [22] to assess four interpersonal problem areas (grief or complicated bereavement, interpersonal role disputes, role transitions, and interpersonal deficits). The questionnaire showed good internal consistency in each subscale (α = 0.79-0.96). High scores indicate presents of interpersonal problems.

3) The Social Support Questionnaire [23] was developed from Schaefer’s concept of social support [24]. This 16-item instrument examines three subscales of social supports: emotional, informational, and tangible or material support. High scores indicate good social supports. The questionnaire had good internal consistency in each subscale (α = 0.87-0.91).

4) The Family Relationship and Functioning Questionnaire was developed by Lueboonthavatchai [23] and has been tested for validity and reliability (α = 0.93). The questionnaire consists of seven questions, and a higher total score indicates good family relationships and functioning.

2.5 Statistical analysis

The data were analyzed using STATA 16 (John Wiley & Sons, Inc.). The prevalence of suicidality, including suicidal ideation and suicide attempt was presented in proportion and percentage. Three groups of depressed patients, 1) with absence of suicidality, 2) with suicidal ideation, and 3) with suicide attempt were compared on various factors by chi-square test, Fisher’s exact test, ANOVA or Kruskal-Wallis test as appropriate. Significant factors from the univariate analysis were entered into a multinomial logistic regression model for identifying the potential predictors of suicidal ideation and suicide attempt. A p-value of less than 0.05 was considered statistically significant.

3. Results

3.1 Characteristics of participants

There were 178 participants, aged 18 - 63 years in the study. From the total, 77 of them (43.3%) were in the age range of 21 - 30 years. Most of the patients were female (68%), single (80.9%), Buddhist (83.7%), had at least bachelor’s degree (61.2%) and were unemployed (60.7%). The most common occupations were employee (20.8%), personal business (11.2) and government official (6.2%). A percentage of 53.9% of the participants had at least one medical illness, of which the three most common were allergy (31.5%), gastrointestinal disease (12.9%) and migraine (7.3%), respectively. Some of them (35.6%) had a history of substance use within one year, of which alcohol (33.1%) and smoking (13.5%) were the most common. In terms of clinical characteristics, the majority of the patients were in the outpatient clinic (92.7%), diagnosed with a major depressive disorder (86.5%) or with severe depression (50.6%). The median number of medications they received was two (ranging from one to four), and most of them receive antidepressants (98.9%) and benzodiazepines (68.0%) (Table 1). The mean and median scores from each questionnaire for the assessment of social factors are shown in Table 1.

Demographic, clinical, and social characteristics

n or mean or median

% or ±SD or IQR

Sex

Female

121

68.0

Male

57

32.0

Age (years) (min 18, max 63)

24

21 ,35

Marital status

Single

144

80.9

Married

30

16.9

Widowed or divorced

4

2.2

Religion

Buddhism

149

83.7

Islam

6

3.4

Christianity

4

2.2

No religion

19

10.7

Occupations

Student

80

44.9

Employed

70

39.3

Unemployed

28

15.7

Education

Primary school

10

5.6

High school

59

33.2

Bachelor and higher

109

61.2

Medical comorbidity

96

53.9

Allergic rhinitis

56

31.5

Gastrointestinal disease

22

12.4

Migraine

13

7.3

Musculoskeletal disease

10

5.6

Respiratory disease

10

5.6

Dyslipidemia

8

4.5

Hypertension

8

4.5

Diabetes mellitus

4

2.3

History of substance use within one year

64

35.6

Alcohol

59

33.2

Smoking

24

13.5

Illicit substances

11

6.2

Family history of suicide

24

13.5

Setting of treatment

Outpatient

165

92.7

Inpatient

13

7.3

Diagnosis

Major depressive disorder

154

86.5

First episode

126

70.8

Recurrent episode

28

15.7

Persistent depressive disorder (dysthymia)

17

9.6

Double depression

7

3.9

Depressive severity (BDI-II) (min 1, max 53)

29

17, 37

Minimal depression

9

5.1

Mild depression

22

12.4

Moderate depression

57

32.0

Severe depression

90

50.6

BDI-II not include suicidality (min 1, max 52)

26

16, 35

Received psychotropic medication

Antidepressants (e.g., SSRIs, SNRIs)

176

98.9

Benzodiazepines

121

68.0

Antipsychotics

31

17.4

Anticonvulsants

7

3.9

Others

6

3.4

Duration of treatment (months)

< 1

44

24.7

1 - 2

47

26.4

> 2 - 6

87

48.9

Median (weeks)

8

4, 20

Interpersonal problem areas

Grief or complicated bereavement (0-12)

6

0, 9

Interpersonal role disputes (0-15)

9

5, 10

Role transitions (0-9)

3

0, 6

Interpersonal deficits (0-12)

6

3, 7

Social support

Overall (16-80)

53.4

± 11.4

Emotional (7-35)

24.1

± 5.6

Informational (4-20)

12.5

± 3.7

Tangible or material (5-25)

16.8

± 4.6

Family relationships and functioning (5-35)

22.8

± 6.7

Table 1: Demographic data, clinical characteristics, and social factors of participants.

3.2 Prevalence of suicidality

The prevalence of suicidal ideation, suicide attempt within one month and lifetime suicide attempt were 62.4%, 35.4% and 41.0%, respectively. Suicidality was presented in the majority of the patients (76.4%), and 83 patients (46.6%) were classed as having high suicide risk (Table 2).

Suicidality in the past month

n

%

Thought of death

115

64.6

Suicidal ideation

111

62.4

Suicidal plan

52

29.2

Non-suicidal self-injury

59

33.1

Suicide attempt

63

35.4

Lifetime suicide attempt

73

41.0

Current suicide risk

Absent risk

42

23.6

Low risk

32

18.0

Moderate risk

21

11.8

High risk

83

46.6

Table 2 : Suicidality.

3.3 Demographic, clinical, and social factors associated with suicidal ideation and suicide attempt in the univariate analysis

The associated demographic and clinical factors of suicidality were age (p < 0.01), marital status (p < 0.05), occupation (p < 0.05), severity of depression (p < 0.01), and receiving benzodiazepines (p < 0.01). Regarding the social factors, it was found that interpersonal role disputes (p < 0.01), interpersonal deficits (p < 0.01), overall social supports (p < 0.01), emotional social support (p < 0.01), informational social support (p < 0.05), and family relationships and functioning (p < 0.01) were associated with suicidal ideation and suicide attempt in the univariate analysis. (Table 3).

Factors

Absence of suicidality

(n= 67)

Suicidal ideation

(n= 48)

Suicide attempt

(n= 63)

p-value

n or mean or median

% or ±SD or IQR

n or mean or median

% or ±SD or IQR

n or mean or median

% or ±SD or IQR

Age

29

23,45

22.5

20,27.5

22

20,32

<0.001*

Male Sex

24

35.8

15

31.3

18

28.6

0.670

Single / divorced /widowed

50

74.6

44

91.7

54

85.7

0.046*

Religion

0.176

Buddhism

60

89.55

37

77.08

52

82.54

Others

4

5.97

2

4.17

4

6.35

No religion

3

4.48

9

18.75

7

11.11

Occupation

0.011*

Student

10

14.9

10

20.8

8

12.7

Employed

36

53.7

11

22.9

23

36.5

Unemployed

21

31.4

27

56.3

32

50.8

Education

0.083

Primary school

8

11.9

19

2.1

1

1.6

High school

19

28.4

15

31.2

25

39.7

Bachelor

40

59.7

32

66.7

37

58.7

Family history of suicide

6

9.0

8

16.7

10

15.9

0.355

Medical comorbidity

40

59.7

22

45.8

34

54.0

0.339

Substance use

19

28.4

17

35.4

28

44.4

0.161

Alcohol

17

25.4

17

35.4

25

39.7

0.207

Smoking

8

11.9

5

10.4

11

17.5

0.572

Recurrent episode

9

13.4

8

16.7

11

17.5

0.802

BDI-II not include suicidality

18

7,27

28

19.5,36

34

28,40

<0.001*

Medications

Antidepressants

66

98.5

48

100.0

62

98.4

1.000

Benzodiazepines

39

58.2

30

62.5

52

82.5

0.006*

Antipsychotics

8

11.9

6

12.5

17

27.0

0.060

Interpersonal problems

Grief or complicated bereavement

6

0,9

6

0,9

7

0,8

0.995

Interpersonal role disputes

7

0,10

9

7,11

9

8,11

0.003*

Role transitions

0

0,5

4

0,6

5

0,7

0.070

Interpersonal deficits

4

1,6

6

4,8

6

4,8

<0.001*

Social support

Overall

57.0

±11.1

51.4

±11.6

50.9

±10.6

0.004*

Emotional

25.9

±5.3

22.9

±5.7

23.1

±5.4

0.002*

Informational

13.5

±3.7

11.9

±3.8

11.9

±3.5

0.026*

Tangible or material

17.7

±4.8

16.6

±4.7

15.9

±4.1

0.065

Family relationships and functioning

25.5

±6.5

21.1

±6.2

21.2

±6.3

<0.001*

Note: * p<0.05 Abbreviations: BDI-II, Beck Depression Inventory II

Table 3: Factors associated with suicidal ideation and suicide attempt.

3.4 Multivariable analysis

After performing the univariate analysis, statistically significant factors (p < 0.05) were entered into the multinomial logistic regression analysis. Compared with patients without suicidality, those with suicidal ideation tended to be unemployed (OR 4.30; 95% CI 1.16 – 15.92) and have poor family relationship and functioning (OR 0.93; 95% CI 0.86 – 0.99). (Table 4). Patients with suicide attempt were found to have more severity of depressive symptoms (OR 1.07; 95%CI 1.02 – 1.12), receive benzodiazepines (OR 2.71; 95% CI 1.05 – 7.03), and have interpersonal deficits (OR 3.85; 95% CI 1.03 – 14.45) compared with those who have suicidal ideation without suicide attempt. (Table 5).

Factors

Absence of suicidality vs Suicidal ideators

Adjusted OR

95% CI

p-value

lower

upper

Male sex

0.72

0.28

1.89

0.506

Age

0.96

0.90

1.01

0.113

Single / divorced / widowed

2.04

0.46

9.09

0.350

Employed (base)

1.00

-

-

-

Unemployed

4.30

1.16

15.92

0.029*

Student

0.45

0.10

2.03

0.300

BDI-II scores, not include suicidality

1.04

0.99

1.08

0.094

Benzodiazepines use

1.62

0.63

4.17

0.313

Social support

0.97

0.93

1.02

0.225

Family relationships and functioning

0.93

0.86

0.99

0.045*

Interpersonal role disputes

1.37

0.36

5.16

0.644

Interpersonal deficits

1.10

0.31

3.89

0.878

Note: *p < 0.05, reference group Abbreviations: OR, odds ratio; BDI-II, Beck Depression Inventory II

Table 4: Multinomial logistic regression analysis between the absent suicidality group and the suicide ideation group.

Factors

Suicidal ideators vs Suicide attempters

Adjusted ORs

95% CI

p-value

lower

upper

Male sex

1.11

0.44

2.79

0.827

Age

0.98

0.92

1.04

0.414

Single / divorced / widowed

0.46

0.10

2.09

0.313

Employed (base)

1.00

-

-

-

Unemployed

0.30

0.08

1.06

0.062

Student

1.50

0.38

5.97

0.566

BDI-II scores, not include suicidality

1.07

1.02

1.12

0.005*

Benzodiazepines use

2.71

1.05

7.03

0.040*

Social support

1.00

0.96

1.04

0.956

Family relationships and functioning

1.02

0.95

1.09

0.550

Interpersonal role disputes

1.21

0.29

5.09

0.798

Interpersonal deficits

3.85

1.03

14.45

0.046*

Note: *p < 0.05, reference group Abbreviations: OR, odds ratio; BDI-II, Beck Depression Inventory II

Table 5: Multinomial logistic regression analysis between the suicide ideation group and the suicide attempt group.

4. Discussion

Based on the demographic data, most of the patients in this study were single, female, in early adulthood, educated, Buddhist, and unemployed. With regard to the clinical characteristics, most of the patients were diagnosed as having first episode MDD with severe depression, had a median treatment duration of eight weeks, and received a number of medications. A total of 76.4% of the participants in this study were shown to present suicidality, which is higher than past reports in Thailand and other countries. One study found a 62.3% rate of suicidality [9], whereas another one found only 32.1% of suicidality [7] in Thai MDD patients. A study in Europe [8] found only 46.67% of suicidality in MDD patients. Prevalence of suicidal ideation (62.4%) and suicide attempt within a month (35.4%) that were found were higher than past studies in Asia. Rates of suicidal ideation reported in China [25, 26] and Singapore [27] ranged from 49 - 55% among MDD patients and a recent meta-analysis showed a 24% one-month prevalence of Chinese MDD patients having suicide attempts [28]. The variation of the prevalence may be influenced by the different tools using to evaluate suicidality. The variety of inclusion criteria is another important factor.

Earlier mentioned studies recruited patients in various phases of illness including active, remission and recovery leading to less severe symptoms of depression, which was probably the reason for having lower rates of suicidality. This study included patients who were treated within the six-month period of being diagnosed or of a recurrent episode, which was considered as an active episode of depression [12-14]. For this reason, patients were currently suffering from an active illness, which may have led to a higher severity of depression and resulted in the higher suicidality rate.

Regarding the sociodemographic data, unemployment was found to be a significant factor associated with suicidal ideation in the current study as well as previous studies. [29] Not only employment status, but also employment protection legislation and economic recession period have been reported to be associated with suicide [30, 31]. Therefore, government support for employment and financial assistance should be an important part of helping to reduce suicide especially during the economic crisis.

Higher severity of depression was a potential predictor of suicide attempt among suicidal ideators in this current study. Consistent findings were reported in previous studies. [15, 16], One study, conducted in India, showed increased agitation and paranoid symptoms among attempters whereas hypochondriasis and general somatic symptoms were more often present in non-attempters [32]. Depressive symptoms which can distinguish between suicidal ideators and suicide attempters should be further investigated and might be beneficial in clinical practice.

The interesting finding in terms of the associated clinical characteristics was that of benzodiazepines use which was more prevalent in patients with suicide attempt compared with those with suicidal ideation. Benzodiazepine use may be the consequence of severe depression because benzodiazepines are anxiolytics that are prescribed for relief of several symptoms, including insomnia. Recent studies reported that somatic symptoms such as insomnia are associated with suicide [33, 34]. In addition, receiving benzodiazepines may be associated with increased aggression [35] and may result in disinhibition [36], which may be the factors that contribute to suicidal behavior. While several observational studies found association between benzodiazepines use and suicidal behavior, some did not [37]. Since the causality of benzodiazepines and suicidal behavior has not been clearly understood, suicide risk in patients who were prescribed benzodiazepines should be adequately monitored.

Regarding the remarkable social factors, poor family relationships and functioning were associated with suicidal ideation. This shows that family issues are the social problems that need to be focused on. In a previous study, poor family communication was associated with a history of suicide attempts in depressive disorder patients [5]. Consistent data was found in research on adolescents, in which perceptions of family functioning were associated with suicidal ideation and suicide attempts [38].

Moreover, Interpersonal deficits, such as lack of social skills, loneliness, or paucity of attachments which had been previously proved to be associated with depression [39], was found to be the important issue for the suicidal attempters in this study. According to the Interpersonal Theory of Suicide proposed by Joiner [40], thwarted belongingness is one of the determinants leading to suicidal behaviors. The results of our study emphasized the importance of social connectedness and suicide. Therefore, the problems of interpersonal relationships, for example, an argument with their family members, close friends, colleagues, partners, or feeling detached from others should be appropriately intervened.

According to the results of the present study, suicidality is common among depressive disorder patients, especially in the initial six-month period of treatment. Depressive severity and various factors including family and interpersonal problems should be assessed, particularly in early adulthood patients, when these issues are crucial. Adequate treatment of depression should be prompt, and early intervention in family and interpersonal problems may be helpful in reducing the risk of suicide.

There were several limitations in this study. First, due to the descriptive design, the associations identified did not indicate a causal relationship. Second, the samples were collected from only one hospital in Thailand, which may result in the findings not being representative of all depressive disorder patients. The influence of different sociocultural characteristics should also be considered. Lastly, other factors that may affect suicidality, such as psychiatric comorbidity and personality disorders, were not evaluated. Further investigation should be conducted in order to determine when the suicidality may decrease during the course of treatment and what types of interventions that will help to reduce the suicidality can be applied.

5. Conclusions

The prevalence of suicidality in patients in the first six-month period of treatment for depressive disorders was 76.4%. Unemployment and poor family relationship were associated with suicidal ideation. Among those with suicidal ideation, higher severity of depression, interpersonal deficits and benzodiazepines use were found to be associated with suicide attempt. Adequate treatment of depression, monitoring suicide risk, assessment of family and interpersonal problems in conjunction with proper psychosocial interventions are recommended to prevent suicidal behaviors in patients with depressive disorder.

Declaration of Conflicting Interests

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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