Anxiety and Suicidality Risk in Primary Care in General Population 111
Citation: Anxiety and Suicidality Risk in Primary Care in General Population. American Research Journal of Nursing. 2017; 3(1): 1-9.
Copyright This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: Suicide is among the ten most common causes of death for all ages. Anxiety is a major risk factor
for suicidal behavior in adolescents.
Aim: The main aim of this study was to examine anxiety and suicidality risk in patients in municipality of
Heraklion in Crete.
Methodology: The sample of the study consisted of 203 individuals tested in the regular clinics of the
University Hospital of Heraklion and in Health Center of Moires in 2016. For the data collection were used
two questionnaires. The first involved the Scale of Stress Spielberger (Trait and State Anxiety) consisting of
40 graded scale and the Scale of suicidality Risk (RASS), consisting of 12 questions classified in a 4-point scale.
They followed univariate correlations and evaluated indicators Odds Ratio of people with high vs. low grade
RASS scale and also for the characteristics and Anxiety scores Spielberger by multiple regression analyses. The
statistical analyses were performed using IBM SPSS 23.0 program.
Results: With higher risk suicidality were older individuals (r = 0.201, p <0.05), which are separated and live
alone (r = 0.143, p <0.05) and / or lower educational level (r = -0.245, p <0.05). Moreover, people with low
family income were found with a significantly higher anxiety levels (r = 0.194, p <0.05), state anxiety (r = 0,174,
p <0.05) and trait anxiety (r = 0.191, p <0.05) as those with a lower level of education (r = -0.278, p <0,05).
From the assessment of the indices odds ratio was significantly increased risk of suicidal behavior RASS by 16%
(OR: 1,16, 95% CI: 1.08 to 1.24) as varied increasing their state anxiety. Nine subjects (4.4%) reported having
attempted suicide at least once.
Conclusions: The suicidality seems to be influenced by existing conditions such as increasing age, the life
situation or the low educational level and the state anxiety can be considered an important factor in suicidal
Keywords: suicidality, state anxiety, trait anxiety
The suicidality seems to be influenced by existing conditions such as increasing age, the life situation
or the low educational level.
The state anxiety can be considered an important factor in suicidal behavior
People with low family income were found with a significantly higher anxiety levels, as those with a
lower level of education.
From the assessment of the indices odds ratio was significantly increased risk of suicidal behavior
RASS by 16% as varied increasing their state anxiety
In many countries suicide is a major public health problem with ever-increasing trends. Suicide includes any
behavior caused by the person himself and is carried out with the intent or expectation to end his / her life and
involves passive acts caused by it or energetic .
Two main categories of suicidal behavior, suicide attacks, and complete suicides have been described in which
the person`s actions result in his death. One person may belong to these two categories [2,3,4].
Suicide is one of the most common causes of death for all ages. The factors that are mainly related to the high
risk of suicide are biological factors, social-demographic factors, physical health problems and psychiatric
morbidity. Risk factors such as race, age, marital status and religion-related suicides play an important role in
An adequate and documented assessment of the risk of suicide in an individual is not yet feasible. Correspondingly,
the number of suicides in a given time period in a country is very difficult. Separation between suicide from
killing by an accident or criminal act is difficult when there is no evidence (note, mental illness, previous
attempts, warning) proving that killing is a criminal act, an accident or suicide .
Stress is the unpleasant emotional state that involves fear, feelings of tension or even horror in response to
a source whose source is to a large extent unrecognizable or unknown. Anxiety is a common reaction that to
some extent occurs in most people in the form of excessive response to mild stress-causing events . Moreover,
stressful life events play an important role in suicide .
When the person is in anxiety it is possible to experience some symptoms, which are categorized into
psychological and physical symptoms. Psychotic symptoms include impotence, anxiety, feeling of indefinite fear
and anxiety, anxiety, distraction, difficulty in concentrating, and a sense of reduced perception. In the physical
symptoms belongs the problems of chest pain, dyspnoea, choking, knot feeling, stiffness, palpitations, anorexia,
nausea, insomnia, fainting, kinetic anxiety, trembling, weakness, dizziness, sweating, frequency, cold hands,
drooping tendency, abdominal pain, muscle tension headache and dry mouth .
Spielberger was the one who talked about the theory of anxiety in which he approached anxiety as trait anxiety,
as a result of a situation and state anxiety as a characteristic of the personality. Trait anxiety is related to the
subjective emotional state characterized by nervousness and tension. State anxiety is related to the person`s
predisposition to perceiving specific situations as threatening and reacting with stress to them disproportionate
to the intensity or magnitude of the actual risk .
Stress is a major risk factor for suicidal behavior in teenagers and supports that doctors should consider the
disease to evaluate and treat adults with suicidal behavior. Finally, Hill and colleagues argue that stress is a
major risk factor for suicide-related behaviors in children and adolescents. There is limited evidence that the
disease is an independent prognostic factor for suicidal behaviors in younger ages .
A few studies have been done to examine the relationship between anxiety and suicide behaviour in Greece
during period of economic crisis. Further research should be conducted on the issue as there is limited
The main aim of this study was to examine the relationship between suicidality risk and the existence of state
and trait anxiety in the general population in municipality of Heraklion in Crete during the period of
The survey was conducted in a 3-month period (November 2016 - January 2017) in Heraklion of Crete. It is
as descriptive study. The selection of the sample was done randomly Our random selection of subjects from
primary care included all the patients that visited the regular clinics of the University Hospital of Heraklion
and the Health Center of Moires All registered members were 203 people. Included criteria were a) age over
18 years b) the information is provided only by the participant and c) no to have history of psychiatric illness.
Three questionnaires were used to collect demographic information, information about suicides using the Risk
Assessment Suicidality Scale Scale (RASS). Collection that concerns anxiety was performed using the Scale of
Stress Spielberger (Trait and State Anxiety).
The study questionnaire
The first contains 6 multiple choice questions and attempts to capture the demographic characteristics of the
participants. Also, for the data collection were used two questionnaires. The first involved the Scale of Stress
Spielberger (Trait and State Anxiety) consisting of 40 graded scale and the Scale of Suicidality Risk (RASS),
consisting of 12 questions classified in a 4-point scale. RASS is a self-report tool of suicidal risk behaviors which
contains items relevant to intention, life, and history of suicide attempts rated on a 0–3 Likert-type scale (not
at all to very much ).
They followed univariate correlations and evaluated indicators Odds Ratio of people with high vs. low grade
RASS scale and also for the characteristics and Anxiety scores Spielberger by multiple regression analyses.
Followed by univariate correlations, Chi Square and X2
markers were evaluated as well as using T Test.
An ethical approval was provided by the 7th Health Region of Crete and the Ethical Committee of the Technological
and Educational Institute of Crete. Participants’ anonymity was secured and an informed consent was provided
The statistical analyses were performed using IBM SPSS 23.0 program. With the x2 test analysis were analyzed
the distributions of the demographic characteristics of the patients (age, education level, gender) In addition,
we used the average method where necessary (quantitative variables), the Chi Square test to find correlations
between the variables, as well as the P-P plot reliability test (probability–probability plot or percent–percent
A total of 203 patients were enrolled in the study from the regular clinics of the University Hospital of Heraklion
and in Health Center of Moires. Table 1 shows the characteristics of the respondents. Most of them were male
(53,2%) aged 18-29 years (30,5%) aged 30-44 years (26,6) and (27,1%) aged 45-59. Finally, over the age of 60
are only the 15.8% of the respondents. Regarding the marital status, we notice that 46.3% are unmarried and
38.9% are married.
Furthermore, only 7.9% and 4.4% of the respondents are in dissociation or widowhood respectively. Finally,
2.5% said he lives alone. As far as the education of the participants is concerned, we observe that 11.3% are
graduates of primary school and 55.1% are graduates of secondary education. Finally, 25.1% are graduates of
higher education and only the 7.4% had a postgraduate or doctorate degrees. The 46.3% of the respondents
are self-employed, 16.7% are civil servants and 10.3% are retired. In terms of personal income, 34.5% said their
individual income was more than 4500 € opposed to 65%). Moreover, 9500 € exceeds 60.6% of respondents
The second part of the questionnaire used the Risk Assessment Suicidality Scale (RASS). The first question
concerns the fear of the respondents about death and is formulated with the phrase "Are you afraid that you
are going to die?" With 86.7% of the respondents responded negatively to the choice (not at all). While positive
(quite and very much) answered the 13.3%. The question of whether "you think it`s a great thing you are alive
now" is positive with the selection "enough" and "too much" the 77.8% and negatively "no" or "little" the 22,
2% of respondents (Table 3).
The indication that no one is worth living has had the 11.8% stating "enough " and "too much". The answer to
the question whether "You think it`s a great thing you`re alive" answered positively with the choice "enough" and
"too much" 77.8% and negatively with the choice "no" or "little" the 11.8% of the respondents. The indication
that one is not worth living has had the 11.8% stating enough and too much. He thinks of doing evil to himself
only the 1% of the respondents. To the question of whether they often think of committing suicide, if they found
the opportunity, the 99% answered negatively. Respondents to the question of whether they think to end their
lives, 93.6% answered a little. He plans to commit suicide but will not do it the 4.9% (Table 3).
Tired of their lives declare the 21.7%, while they do not agree with this view the 40.9%, a little agree with this
the 37.4% and quite the 16.3%. He has hurt himself more than one time the 9.9% and never the 90.1% of the
respondents. By computing the sum of the answers to the questionnaire, we observe that the total sum <=
175/340 has the 61.6% of the participants (Table 3).
As we can see from the table of correlations, there is a significant relationship between gender and the degree of
predisposition or risk of suicide. Women appear to be less prone than men. This observation is confirmed with
a high statistical accuracy as the Chi Square indicator shows. Moreover, with statistical accuracy is confirmed
that there is a positive dependence between age and the level of risk. More prone seems to be the younger ages
with participants between 18- 44 gather higher rates (Table 4).
The third part of the questionnaire used the STAI I-II scale to measure the disease in the population. This
questionnaire is used to measure anxiety and the scale separates the disease as a condition (condition A) from
the disease as a personality trait (A-Trait). In STAI I (A-State) measures the average of the participants were
44.5 while the median 44 indicates the absence of the effect of the extreme values. Furthermore, the average
value of the observations describing the disease as a personality trait is 41.7 while the average 41. The average
of anxiety as a condition averages 43.63 for the self-employed with a variation of 7.8 and 45.29` for the public
servant (Table 5).
It is noteworthy that there is no dependence between the family situation and the momentum towards suicide
(Figure1).. The same absence of dependence is also observed between the existence of children or not. Due to
the value of the ChiSquareSig2 index sided = 0.329, there is no statistically significant dependence between the
torque-dangers of suicide and the educational level (Table 6).. It is logical that the high values of the variable of
fear for death appear in people with a high propensity to suicide. A high price and a high degree of agreement
with this view also entails a high degree of risk in the final / overall score. Also, as expected, those who have been
pleased with their lives and enjoy the way they spend time have less risk of suicide. It is also expected that the
dependency between the risk and the tendency for suicide will be in the people that in the past have attempted
to do bad to themselves as well as to the people who feel tired of their lives at this time by demonstrating in
this way Some of the most important factors that affect human intent as well as confirming some important
indicators. Moreover, the profession, the financial situation, and individual or family income are independent of
the degree of fatigue from life.
By conducting test testing of two independent samples associated with age 18-29 and 45-59, we assume that the
average value of the resistance index as a personality trait is equal, while the alternative is different. Since the
sig value is less than 0.05 due to the value of sig 2 tail > 0.05, we accept the zero hypothesis of the equivalence
of the two independent samples. Finally, statistically significant dependencies appear between the mean of the
disease as a characteristic of the personality and the suicide risk scale. Thus, the high values of one also imply
high values of the other index that indicate the existence of a positive correlation.
It is worth to notice that the value of the state anxiety is completely independent of demographic factors. Thus, the
degree of experiencing the anxiety, either state or trait, is not affected by the marital status, sex or occupational
status of respondents according to the Crosstabs Test and the Chi Square index. The only statistically significant
dependence is observed between the anxiety as a temporary / general condition and the less stressed and
anxious in the tertiary education graduates. The observation is confirmed by Chi square <0. Non-high family
income was found with significantly higher levels of anxiety.
The results of the survey showed relatively high rates of anxiety indicators both as a condition and as a
personality. More specifically, the average price was 44.5 and 41.7 compared to 37.34 set in an earlier survey.
According to the National Study of Morbidity and Risk Factors (EMME), which took place in 2014, the Medical
School in collaboration with all medical schools of Greek Universities and the Panteion University in a random
sample of 5,000 people, 18 years old and over , It was found that the proportion of people with anxiety symptoms
was 24%, which is worrying Which is alarmingly high .
In the present study, non-high family income was found with significantly higher levels of anxiety (r = 0.194, p
<0.05), state (r = 0.174, p <0.05) and trait (r = 0.191, p <0 , 05) as well as those with a lower level of education
(r = -0.278, p <0.05). According to Moussuli (2016) the high levels of anxiety are related to various sociodemographic
indicators such as low levels of education and low family income .
From the Odds Ratio was found a significant increase risk of suicide (RASS) 16% (OR: 1.16, 95% CI: 1.08-1.24)
as their state anxiety increased. Thus, high values of one also result in high values of the other index, revealing
the existence of a positive correlation. A study had found that anxiety is a major risk factor for suicidal behavior
in adolescents and children, and they believe that physicians should get into account anxiety for the evaluation
and treatment of adolescents with suicidal behavior . According to Nock et al, anxiety is a significantly
predict subsequent suicide attempts .
There is limited evidence that the disease is an independent predictor for suicidal behaviors. Studies have been
made and examine the relationship between illness and suicidal behavior .
At a higher risk of suicide were found older people (r = 0.201, p <0.05), who are in a dissociation and living
alone (r = 0.143, p <0.05) and / or lower educational level (r = -0.245 , P & lt; 0.05). According to a study, suicide
rates increase with age, especially among men, and married women have the lowest rates of suicide. Extremely
high suicidal signs were observed in widowed men aged 25-34 . Another study carried out in 1967 showed
that autotonicity rates are high in divorced and unmarried couples compared to married .
In addition, full independence appears to exist between the suicide risk indicator, the trait and state anxiety, the
family or personal income and professional status. Studies demonstrating that there is a significant dependence
between the suicide risk index, the trait and state anxiety, the family or personal income and occupational
status have not been made before.
The results of the present study, especially when examined in relation to the theoretical background and the
results of previous research found in the literature, show that anxiety can, as an etiological factor of suicide,
perhaps be an over-simplification of the subject. Suicide appears to be affected by existing conditions such as
age, living or low educational level, and permanent anxiety can be considered an important factor in suicidal
In addition, further research should be conducted on the issue as there is limited evidence that the disease
is an independent prognostic factor for suicidal behaviors, and few studies have been done to examine the
relationship between anxiety and suicide behavior
There is no doubt that further exploration of the subject will broaden the understanding of the theoretical
relationships between suicide and anxiety. In order to gain a fuller understanding, interventions are needed in
order to adequately manage the problems associated with anxiety and suicidal ideation as a whole. In addition,
the evaluation of combined interventions such as psychological therapies, group psychotherapies combined
with traditional therapeutic interventions are essential. The economic crisis is a great opportunity to protect
services targeted at vulnerable populations, improve access to the mental health system, support the welfare
state and promote interventions such as the reintegration of the unemployed and people with psychiatric
problems, high risk. The training of primary health care physicians, the detection and treatment of depression
and other common. Finally, the training of nurses and social workers working in Primary Care Units is considered
very important for the detection of incidents with suicidal behavior with the use of tested tools
There is a prospect of continuing research through a pan-Hellenic program aimed at detecting suicidal behavior,
depression and anxiety with the participation of community nurses in Primary Care Units and schools with
school nurses as well as interim interventions with the creation of team psychotherapy teams. Finally evaluate
the effects of psychotherapy on these incidents.
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