Suicide and Associated Risk Factors Among College Students

Background and aims: Despite the growing epidemic of suicide among college students, the associated risk factors have not been properly understood in developing countries. This study was conducted to estimate the prevalence of suicide ideation and attempt and associated risk factors among university students. Methods: We performed this cross-sectional study in the Hamadan University of Medical Sciences from January to May, 2016, and invited university students to participate voluntarily in the study. The outcomes of interest were suicide ideation and attempt. The exposures of interest were behavioral risk factors, including having girlfriends/boyfriends, emotional breakdown (also known as mental breakdown), illegitimate heterosexual and/or homosexual intercourse, cigarette smoking, drug abuse, psychiatric disorders, and social media. Results: Of 1254 participants, 146 (11.7%) had suicidal ideation during the past year and 63 (5.0%) had attempted suicide at least once in the past year. After adjusting the odds ratio (OR) (95% CI) for age and sex, it was found that suicide ideation was significantly associated with emotional breakdown 2.33 (1.64, 3.31), heterosexual intercourse 2.71 (1.77, 4.15), homosexual intercourse 3.21 (1.97, 5.25), cigarette smoking 4.03 (2.65, 6.11), drug abuse 12.09 (7.97, 18.35), psychiatric disorders 12.48 (7.59, 20.53), no interest in the discipline 2.08 (1.40, 3.07), and despair about the future 2.18 (1.49, 3.19). There was no significant association between suicide ideation and using social media 1.13 (0.65, 1.96). Conclusion: This study provided beneficial information about the association between suicidal ideation and attempted suicide and some behavioral risk factors among university students and emphasized the importance of these modifiable risk factors which if neglected, may severely impair the students’ function.


Introduction
Suicide is the second leading cause of death in 15-29-year-olds 1 and one of the greatest sources of premature death. 2 Suicide is estimated to account for 1.4% of total mortality and 15% of injury mortality of the world in .These figures seem to underestimate the problem, because for each death due to suicide, there are almost 10 to 40 attempted suicides. 4Furthermore, many people who have suicide ideation and plan, never seek services. 5uicide is a multifactorial phenomenon which is associated with several psychological, social, biological, and cultural factors. 6,7Psychiatric disorders 8,9 and highrisk behaviors such as harmful use of alcohol, 10 drug abuse, 11 and even cigarette smoking 12 are among the major contributing risk factors for suicide.4][15][16][17][18][19][20] It is estimated that almost 19.4% of the Iranian university students are smokers, 3.9% use illegal drugs, and 10.1% use alcohol. 21espite the growing epidemic of suicide among university students and its residual effects, 22,23 the risk factors of suicide among university students have not been properly investigated particularly in developing countries.Unless reliable information about the burden and causes of suicide behaviors is collected, it is difficult or even impossible to design effective intervention strategies and carry out preventive measures.The present study was carried out to estimate the prevalence and associated risk factors of suicide ideation and attempt among university students.

Methods
We conducted this cross-sectional study from January to May 2016.We invited the students of the university to participate voluntarily in the study.In order to increase the generalizability of the results, we performed a proportional random sampling.For this purpose, we divided the university into colleges (strata) and then, we took random samples from each stratum.We just enrolled students who had passed at least one semester and excluded the newcomers.
We invited 1338 eligible university students; 45 subjects refused to fill out questionnaires, 30 did not return questionnaires, and 9 were excluded from the analysis because they did not complete the questionnaires.The analysis was based on data from the remaining 1254 participants.The acceptance rate was 94%.The mean (SD) age of the participants was 22.54 (3.34) with a range of 18 to 49 years, including 492 (39.2%) males and 762 (60.8%) females.
The outcomes of interest were suicide ideation and attempt.Suicidal ideation was defined as serious thought about committing suicide during the past year.Suicide attempt was defined as actually attempting suicide during the past year.The exposures of interest were behavioral risk factors, including having boyfriends/ girlfriends, emotional breakdown (also known as mental breakdown), illegitimate heterosexual and/ or homosexual intercourse, cigarette smoking, drug abuse including narcotic and/or psychotropic drugs, psychiatric disorders based on GHQ-28 questionnaire, and using social media.
The participants filled out an anonymous selfadministered questionnaire.The questionnaire included demographic characteristics, personal information, behavioral risk factors, and the Persian version of the GHQ-28 questionnaire which was developed by Goldberg and Hillier in 1979 as a screening tool for detecting psychiatric disorders 24 and was translated into Persian by Noorbala et al in 2009. 25e used the chi-square test for the analysis of categorical variables and the simple and multiple logistic regression analysis to measure the association between suicide ideation and attempt and the behavioral risk factors.All statistical analyses were performed at a significance level of 0.05, using Stata software, version 11 (StataCorp, College Station, TX, USA).
The prevalence of behavioral risk factors is given in

Discussion
We indicated that suicidal ideation was significantly associated with several behavioral factors, including having girlfriends/boyfriends, emotional breakdown, heterosexual intercourse, homosexual intercourse, Poorolajal et al cigarette smoking, drug abuse, psychiatric disorders, no interest in the discipline, and despair about the future.
On the basis of our results, university students who had a friend of the opposite sex or had illegitimate sexual contact with the same or opposite sex were at higher risk of suicide ideation and attempt.Evidence has shown a strong association between sexual assault and suicide risk in both males and females. 26Mood disorder and suicide risk are more common among young people who have suffered sexual violence. 27urthermore, adolescents and young adults who are identified as lesbian, gay, or bisexual are at increased risk of suicide than heterosexual youths. 28,29Indeed, these subjects are associated with higher risk of mood or anxiety disorders 30 which are major risk factors for suicide. 8,9e showed that drug abuse increased the risk of According to our findings, there was a significant association between smoking and suicide.We indicated that suicide was more common among smokers or the prevalence of smoking habits was higher among suicidal individuals.That means smoking is associated with suicide, but it does not mean smoking necessarily causes suicide, because it is not clear whether smoking causes suicidal behaviors through a biological pathway of smoking itself or whether there is collinearity between smoking and other psychological disorders and behavioral risk factors such as substance and alcohol use disorders. 8,10,11,31However, a meta-analysis conducted in 2016, including 63 studies with 8,063,634 participants, reported a significant association (OR; 95% CI) between smoking and suicide ideation 2.05 (1.53, 2.58), suicide plan 2.36 (1.69, 3.02), suicide attempt 2.84 (1.49, 4.19), and fatal suicide 1.83 (1.64, 2.02). 12his study had a few limitations.The questionnaire that we used in this study included a number of sensitive questions.Answers to questions about sexual activities rely heavily on self-reported data.People usually do not answer to such questions correctly. 32onsidering this issue and the rejection rate of 6%, it seems that our results underestimated the prevalence of high-risk behaviors among the university students.The real prevalence of behavioral risk factors is estimated to be higher than what we reported in this paper.Furthermore, the results of this cross-sectional study just reported an association between suicide and behavioral risk factors.However, the association does not necessarily imply a cause-and-effect relationship because exposures and outcomes were determined at the same time and the observed association may be confounded by other variables.Despite these limitations, this study provided useful information about the prevalence and potential risk factors of suicide among university students in a developing country.Such information may be useful for planning effective intervention strategies and implementing preventive measures.However, behavioral risk factors are closely related with sociocultural situation.Therefore, the results of this study may not be generalized to other countries such as American and European countries with different sociocultural situations.Therefore, these countries may require to investigate the prevalence and associated risk factors of suicide on their own university students.

Conclusion
This study provided beneficial information about the prevalence of suicide, psychiatric disorders and behavioral risk factors among university students.Our findings highlighted the association between suicide and some behavioral risk factors and emphasized the importance of these modifiable and preventable risk factors, which if neglected, may severely impair the students' function and influence their subsequent development and productive lives.Thus, university students may benefit from interventions that target these risk factors.

Ethical Approval
The Ethics Committee of the Hamadan University of Medical Sciences approved the study.

Table 1 .
Characteristics of the College Students With and Without Suicide Ideation and Attempt During the Past Year

Table 2 .
Association Between Suicide Ideation and High-Risk Behaviors Abbreviations: AOR, adjusted odds ratio; UOR, unadjusted odds ratio.a Adjusted for age and sex.