Prevention of self-immolation by community-based intervention

Situation Analysis of Suicide and Self-Harm in the WHO Eastern Mediterranean Region

OBJECTIVE

An estimated 41,000 lives are lost to suicide each year in World Health Organization Eastern Mediterranean Region Office (WHO EMRO) countries. The objective of this study was to conduct a situation analysis for suicide and self-harm in the WHO EMRO region.

METHODS

Data on suicide were obtained from the WHO Global Health Estimates for the years 2000-2019. Information on risk groups efforts to prevent self-harm and suicide in the EMRO region were retrieved through scientific studies, grey literature, and public websites.

RESULTS

During 2000-2019, the age-standardized suicide rate was 6.7 per 100,000 inhabitants, albeit there are concerns regarding data quality. Self-harm and suicide remain criminal acts in more than half of the countries. Few countries have a national plan for prevention of suicide. Toxic agents, such as pesticides and black henna, are easily available and frequently used for suicide in some areas, as are firearms and self-immolation. Successful prevention measures include means restriction and psychosocial interventions after self-harm.

CONCLUSION

Many WHO EMRO countries remain underserved in terms of mental health care. Decriminalization of suicide and means restriction might be further promoted. Online-based tools for mental health literacy and psychosocial therapy are other options to explore.

Attempted Suicide by Burning: A Cross-sectional Analysis at a Regional Burn Center in Germany

Attempted suicide by self-immolation or burning constitutes an uncommon form of attempted suicide in high income countries, presenting substantial challenges to burn units. The aim of this study was to analyze the epidemiologic characteristics and outcomes in intensive care burn patients treated for attempted suicide by burning. For this purpose, we examined intensive care burn patients admitted to a single major burn unit between March 2007 and December 2020. Demographic, clinical, epidemiological, and mortality data were collected and analyzed. Major psychiatric comorbidities were evaluated according to ICD-9 and ICD-10 classifications. A total of 1325 intensive care unit burn patients were included. Suicide by burning was attempted in 45 cases (3.4%). Attempted suicide victims presented with significantly higher burn severity, reflected by higher abbreviated burn severity index scores, and larger TBSA affected. Burned TBSA ≥30% and inhalation injuries were observed more frequently in suicidal patients. These patients also experienced prolonged hospital and intensive care unit length of stay, required surgical interventions and mechanical ventilation more frequently, and had significantly longer periods on ventilation, causing an overall higher mortality rate (24.4%). Psychiatric comorbidities were present in 75.6% of patients who attempted suicide. Despite the low prevalence, burn severity and mortality are considerably high in patients who attempted suicide by burning, presenting a significant challenge for healthcare providers. The majority of patients had a history of psychiatric disorder, highlighting the importance of identifying patients at high-risk who may profit from increased psychiatric intervention.

Suicide attempts and deaths by self-immolation: A population-based study in Fars (Iran), 2011-2019

Background: Self-immolation is a leading public health challenge with a relatively high mortality, especially in some low- and middle-income countries. This study aimed to investigate epidemiological factors of attempts and completed suicide by self-immolation during 2011-2019 in Fars province (Iran). Materials and methods: This retrospective cross-sectional study included 506 cases of attempted self-immolation suicide during 2011-2019 in Fars province (Iran). Demographic characteristics and suicide information were collected from the Fars Suicide Surveillance System. The first fatality rate and age-standardized mortality rates were calculated. Then, chi-square tests were performed to evaluate suicide trends and examine differences between qualitative variables and outcomes. Logistic regression was used to identify factors associated with self-immolation death. Result: The mean age of study participants was 32.11 ± 14.04 years. The highest age-standardized rates of attempt and completed self-immolation suicide were seen in the age group 25-34 years. The fatality rate of suicide by self-immolation was 61.89%, and the risk of death was around three times higher in people with a history of suicide attempts compared to those who had no history of suicide attempts. However, a family history of suicide attempts was shown to be a protective factor against completed self-immolation suicide. Conclusion: The rate of self-immolation is higher in women and young adults. The results of our study can assist health policy-makers to design comprehensive plans and determine the necessary strategies aimed at identifying vulnerable people, then preventing self-immolation suicide.

Systematic review of suicide prevention studies with data on youth and young adults living in low-income and middle-income countries

OBJECTIVES

This review aimed to provide a summary of peer-reviewed, published literature on suicide preventive interventions with data on youth and young adults in low-income and middle-income countries (LMIC).

DESIGN

A systematic review was conducted using electronic databases of PubMed/MEDLINE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center and The Campbell Collaboration databases for English-language articles published between 1 January 1990 and 15 February 2022.

ELIGIBILITY CRITERIA

Interventions of interest could include behavioural, community, clinical/medical or policy studies, or any combination of these, so long as the studies had at least one outcome of interest and at least one control group or control period. Outcomes included suicide ideation, suicide attempt and suicide. Interventions must have been conducted in an LMIC. Studies with individuals ages 0-25 in the sample were included. Articles describing data on individuals over age 25 could be included if individuals ages 0-25 were part of the sample.

RESULTS

A total of 44 eligible studies were identified, representing a broad range of universal, selective and indicated interventions. Most studies assessed interventions designed to address lethal means or mental health. Most studies were conducted in lower-middle-income or upper-middle-income countries, with the largest proportion in Asia. Assessment of outcomes across studies was heterogeneous and there were few large-scale investigations tailored specifically for youth.

CONCLUSIONS

Most of the published, peer-reviewed suicide intervention research from LMIC is concentrated in a few countries. While geographical coverage to date has been limited, strategies and samples in included studies were diverse, representing populations in clinical, educational and community settings. While current findings hold promise, this review identified a need for large-scale studies designed specifically for youth.

Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43-79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Factors Associated With Self-Burning Among Women in Reproductive Age of Ilam: A Case-Control Study in a Western Part of Iran

OBJECTIVE

Self-burning is one way that some people choose to commit suicide, and it has been seen in many nations. This problem is considered as an uncommon method in developed countries and a common method of suicide in developing countries. The present study aimed to identify the factors associated with self-burning among Iranian women in reproductive age.

METHOD

This case-control study was conducted among 228 (57 cases and 171 controls) women in reproductive age from the Imam Khomeini Hospital of Ilam. A self-report questionnaire was used to determine factors associated with self-burning, including job status, domestic violence, mental health status, education levels, smoking and alcohol use, forced marriage, socioeconomic status, drug history, and family history of self-burning. Data analysis was performed using simple and multiple logistic regression to control the effects of possible confounders.

RESULTS

There was a significant positive association between self-burning and being unemployed and a housewife. Also, the presence of self-burning was increasingly associated with high domestic violence and having history of forced marriage and decreasingly associated with post-diploma education level and a high socioeconomic level.

CONCLUSION

It is recommended that health and social policy makers pay attention to the social and economic aspects that cause self-burning in women to prevent this problem.

Burn injury prevention in low- and middle- income countries: scoping systematic review

BACKGROUND

Burn injuries are a leading cause of morbidity and disability, with the burden of disease being disproportionately higher in low- and middle-income countries (LMIC). Burn prevention programmes have led to significant reductions in the incidence of burns in high-income countries. However, a previous systematic review published in 2015 highlighted that implementation and evaluation of similar programmes has been limited in LMIC. The objective of this scoping review and narrative synthesis was to summarise and understand the initiatives that have been carried out to reduce burn injuries in LMIC and their effectiveness.

METHODS

We aimed to identify publications that described studies of effectiveness of burn prevention interventions applied to any population within a LMIC and measured burn incidence or burns-related outcomes. Suitable publications were identified from three sources. Firstly, data was extracted from manuscripts identified in the systematic review published by Rybarczyk et al. We then performed a search for manuscripts on burn prevention interventions published between January 2015 and September 2020. Finally, we extracted data from two systematic reviews where burn evidence was not the primary outcome, which were identified by senior authors. A quality assessment and narrative synthesis of included manuscripts were performed.

RESULTS

In total, 24 manuscripts were identified and categorized according to intervention type. The majority of manuscripts (n = 16) described education-based interventions. Four manuscripts focused on environmental modification interventions and four adopted a mixed-methods approach. All of the education-based initiatives demonstrated improvements in knowledge relating to burn safety or first aid, however few measured the impact of their intervention on burn incidence. Four manuscripts described population-based educational interventions and noted reductions in burn incidence. Only one of the four manuscripts describing environmental modification interventions reported burns as a primary outcome measure, noting a reduction in burn incidence. All mixed-method interventions demonstrated some positive improvements in either burn incidence or burns-related safety practices.

CONCLUSION

There is a lack of published literature describing large-scale burn prevention programmes in LMIC that can demonstrate sustained reductions in burn incidence. Population-level, collaborative projects are necessary to drive forward burn prevention through specific environmental or legislative changes and supplementary educational programmes.

Development of a pre-hospital emergencies protocol for the management of suicidal patients in Iran

Background

Suicide is a painful consequence of many psychiatric disorders and one of the most frequent psychiatric emergencies. Generally, pre-hospital technician is the first person in the treatment chain who attends the situation; hence, his/her sound clinical judgment and professional behavior can play an important role in preventing or stopping the suicide process. We tried to develop a concise, evidence-based, and step-by-step guide for dealing with a suicidal patient, which could be quickly reviewed by technicians before confronting a suicide situation.

Method

We reviewed the literature for suicide management plans and protocols, to extract the evidence-based interventions and instructions for dealing with a suicide situation. Then, we discussed the extracted material in an expert panel, and developed the initial version of the protocol considering the local socio-cultural issues and available facilities. Subsequently, we reviewed the protocol in a meeting with pre-hospital technicians and emergency physicians, to receive their feedback and address any possible executive problems. Finally, we revised the protocol to its final version considering the feedbacks.

Results

The basic principles of dealing with a suicidal patient are similar to other psychiatric emergencies and include: Patient Safety; Patient evaluation and diagnosis; and Patient (behavioral and pharmacological) management. However, specific considerations should be taken into account and special arrangements are necessary for suicidal patients. Whether the patient has attempted suicide or not, would guide the management to one of the two major paths. In addition, the needs of the family should be considered.

Conclusion

A locally adapted protocol considering existing facilities in the emergency system and cultural issues in Iranian society is provided for pre-hospital emergency technicians.

Children's fear in traffic and its association with pedestrian decisions

INTRODUCTION

Research on risk for child pedestrian injury risk focuses primarily on cognitive risk factors, but emotional states such as fear may also be relevant to injury risk. The current study examined children's perception of fear in various traffic situations and the relationship between fear perception and pedestrian decisions.

METHOD

150 children aged 6-12-years old made pedestrian decisions using a table-top road model. Their perceived fear in the pedestrian context was assessed.

RESULTS

Children reported greater emotional fear when they faced quicker traffic, shorter distances from approaching traffic, and red rather than green traffic signals. Children who were more fearful made safer pedestrian decisions in more challenging traffic situations. However, when the least risky traffic situation was presented, fear was associated with more errors in children's pedestrian decisions: fearful children failed to cross the street when they could have done so safely. Perception of fear did not vary by child age, although safe pedestrian decisions were more common among the older children.

CONCLUSIONS

Children's emotional fear may predict risk-taking in traffic. When traffic situations are challenging to cross within, fear may appropriately create safer decisions. However, when the traffic situation is less risky, feelings of fear could lead to excessive caution and inefficiency. Practical applications: Child pedestrian safety interventions may benefit by incorporating activities that introduce realistic fear of traffic risks into broader safety lessons.

Drivers and consequences of self-immolation in parts of Iran, Iraq and Uzbekistan: A systematic review of qualitative evidence

OBJECTIVES

The prevalence of self-immolation is significantly higher in some Middle Eastern and Central Asian Islamic countries than in Western countries. Self-immolation typically occurs among females and can be either an attempt at suicide or an act of protest. This systematic review examined the drivers and consequences of self-immolation in Asian Islamic countries from the perspective of those affected by it, including survivors, family and health care staff in order to understand its higher prevalence in these countries.

METHOD

A systematic review of qualitative studies was conducted in June 2018, using five electronic databases: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, Scopus and PsycINFO. Of the 236 papers identified, seven met the inclusion criteria. Authors independently rated the reporting of included qualitative studies and thematic analysis was used to analyse the data.

RESULTS

The drivers of self-immolation included marital and familial conflict, male-dominated culture, mental health disorders and economic and social factors. Survivors chose self-immolation in order to express their sense of a lack of control and mostly utilised this method due to its accessibility. The consequences of self-immolation were social isolation, regret, and physical and psychological impacts.

CONCLUSIONS

The reasons for self-immolation, its prevalence and the demographics of those who choose this means vary significantly between Asian Islamic and Western countries. This review confirmed the impact of culture, tradition, and societal structures and relationships on people's decisions to self-immolate. Education about the consequences of self-immolation may reduce the use of this method.

Socioeconomic Inequality in Self-immolation, between Genders; Oaxaca-Blinder Decomposition, Results of Registration-Based Suicide Data

Objective:

To assess the important socio-demographic inequalities in self-immolation in between genders.

Methods:

A cross-sectional study, 2011 to 2016, was conducted. A total of 540 completed suicides were recruited to the study. Data were collected by systematic registration suicide data (SRSD) and Legal Medicine Organization (LMO). The concentration index (CI) was used to determine the inequality. The inequality line was decomposed to find out the main sources of inequality in self-immolation between genders by Oaxaca-Blinder approach.

Results:

The mean ratio of self-immolation was 21.8% among completed suicides. The decreasing trend was found in self-immolations during 2011-2016 (z = -2.07, p = 0.039), the mean rate in six years, was 2.98 per 100.000 populations. Unemployment −.043 (−.07, −0.01), married subject’s −.016 (−.03, −0.00) and low educational level −.005 (−.01, −0.00) were the main inequality source in females compared to males.

Conclusion:

Our results suggest that despite the incidence decreasing in self-immolation within 6 years of study period, the inequality was detected in self-immolation. The main socio-demographics in inequalities were lower educational level, married persons and unemployment that prevention programs should be more concentrated in females to a decrease of inequality in self-immolation.

Exploring barriers and challenges in protecting residential fire-related injuries: a qualitative study

Background:

Building fires can be a great threat to the safety of residents, and can lead to economic and social damage. Exploring the views of stakeholders is a great source for understanding the factors that affect fires. The purpose of this study was to explore stakeholders’ experiences of unintentional fire-related injuries in residential buildings in Iran.

Methods:

This qualitative study was carried out using grounded theory. The study was conducted in Iran, in 2017. The study participants consisted of 25 people including stakeholders who had practical experience/or were knowledgeable in the field of preventing and fighting building fires. Purposeful and theoretical sampling were used for data collection. Data were analyzed based on constant comparative analysis and according to recommendations by Strauss and Corbin.

Results:

"Lack of a comprehensive approach to prevention of fire-related injury" emerged as a core variable which impacted on residents' safety against fires. The findings were classified into four groups of challenges related to the structure of building, socio-economic challenge, residents of the building and rescue services.

Conclusions:

Based on participants` experiences, unintentional fire-related injuries in residential buildings are affected by cultural context and economic, social and geographical factors. Improving the safety against unintentional fire-related injuries in residential buildings requires multidisciplinary operations including both change and improvement of the building construction and change in the beliefs and practices of residents to increase safety against fires.

Self-immolation in Iran: Systematic Review and Meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of self-immolation epidemiology and characteristics in Iran.

METHODS

This was a systematic review and meta-analysis study. PubMed, Scopus, Web of science and Science Direct were searched for English literature and SID and Magiran for Persian in the time period of 2000 to 2016. The retrieved studies were screened and reviewed then quality assessed. Random Effect model was applied for meta-analysis. The qualitative data were analyzed by content analysis method.

RESULTS

After literature screening, 39 studies included in the analysis. Women were subject to self-immolation more than men. The rate of self-immolation estimated to be 4.5 cases in every 100,000 populations and it was the reason of 16% of hospitalized burns. The average length of hospital stay calculated to be 12.24 (95% CI: 8.85-15.59) days. The total burnt surface area was 65.3% (95% CI: 56.71-73.89). Death due to self-immolation was 62.1%. The major risk factors of self-immolation were having mental health issues, family problems and characteristics and problems in relation/communication with spouses.

CONCLUSION

Despite the low rate of self-immolation in Iran, it comprises one sixth of the hospitalized burns. The mortality rate of self-immolation also is high and this highlights the importance of providing special care. Psychological consultations and mental health screening in the primary health care would help to prevent the self-immolation.

What Works in Youth Suicide Prevention? A Systematic Review and Meta-Analysis

BACKGROUND

Young people require specific attention when it comes to suicide prevention, however efforts need to be based on robust evidence.

METHODS

We conducted a systematic review and meta-analysis of all studies examining the impact of interventions that were specifically designed to reduce suicide-related behavior in young people.

FINDINGS

Ninety-nine studies were identified, of which 52 were conducted in clinical settings, 31 in educational or workplace settings, and 15 in community settings. Around half were randomized controlled trials. Large scale interventions delivered in both clinical and educational settings appear to reduce self-harm and suicidal ideation post-intervention, and to a lesser extent at follow-up. In community settings, multi-faceted, place-based approaches seem to have an impact. Study quality was limited.

INTERPRETATION

Overall whilst the number and range of studies is encouraging, gaps exist. Few studies were conducted in low-middle income countries or with demographic populations known to be at increased risk. Similarly, there was a lack of studies conducted in primary care, universities and workplaces. However, we identified that specific youth suicide-prevention interventions can reduce self-harm and suicidal ideation; these types of intervention need testing in high-quality studies.

From Querulous to Suicidal: Self-immolation in Public Places as a Symbolic Response to the Feeling of Injustice

Aim: This paper sheds light on the context that leads some querulous patients to self-immolate in front of, or into, public buildings (e.g., tribunals, city halls, and employment agencies). Method: The author defines paranoid querulousness. A psychoanalytic perspective, but also a judicial and a psychiatric point of view, over querulous claimants is presented. The links between political or social claims and self-immolation are studied. The expression of suicidal thoughts voiced by four querulous subjects is analyzed. Eight examples of self-immolation are presented. Results: The querulous subjects' self-aggressive behaviors seem to be caused by a loss of hope to obtain compensation for a prejudice they allegedly suffered. Querulous individuals tend to self-immolate in front of, or into, public buildings when no answer is given to their claims. These gestures may be both a consequence of some personal distress and triggered by a difficult social or professional context. Discussion: Five sets of assumptions derived from Freudian and Lacanian psychoanalytic theories are advanced. The status of the object over which the querulous claimants wish to assert their rights is clarified. The meaning of self-aggressive gestures is outlined by making reference to the concepts of instinct for mastery, symbolic other, chain of signifiers, masochism, pleasure principle, and reality principle. Conclusion: Prevention of self-immolation could involve that members of the legal professions, social workers, civil servants, and mental health professionals in contact with querulous subjects openly show their will to listen to these claimants' voice: self-aggressive gestures might be avoided by supporting the querulous person's hope to obtain compensation for the prejudice allegedly suffered.

Cause-specific mortality among women of reproductive age: Results from a population-based study in an Iranian community

PURPOSE OF STUDY

This study was conducted to evaluate the levels, patterns, and causes of mortality among women of reproductive age in Northwestern Iran.

METHODS

Deaths were determined for females resident in West Azerbaijan Province of Iran and who died between March 2013 to February 2014 using reproductive age mortality survey (RAMOS). Causes of death were ascertained by verbal autopsy (VA) and classified based on the International Classification of Diseases, tenth revision (ICD-10). Overall and cause-specific mortality rates (MRs) per 100,000 women with 95% confidence intervals were calculated.

RESULTS

A total of 510 deaths were detected, and VA interviews were conducted with the relatives of the deceased Cases; overall MR was 56.59 per 100,000 women (95% CI: 56.49-56.69). The highest MR was observed in suicide cases (MR=10.21per 100,000women, 95% CI: 10.15-10.27), accounting for 18% of all deaths. The most common method of suicide was self-inflicted burns (45.6%), followed by deaths due to breast cancer (MR=4.22per 100,000women, 95% CI: 4.18-4.26), which accounted for the most cancer-related mortality. All-cause mortality was associated with age, area of residence, marital status, level of education, and ethnic (religious) status relationship (P<0.001).

CONCLUSION

Suicide, especially self-immolation, was the main cause of death among women of reproductive age, and both suicides and breast cancer are major public health problems for this group of women.

Technology-enhanced suicide prevention interventions: A systematic review

Objective

Suicide prevention is a high priority. Scalable and sustainable interventions for suicide prevention are needed to set the stage for population-level impact. This systematic review explores how technology-enhanced interventions target suicide risk and protective factors, using the Centers for Disease Control and Prevention (CDC, 2015) Risk and Protective Factors Ecological Model.

Methods

Information databases (PsycINFO, PubMed and CINAHL) were systematically searched and records including technology-enhanced interventions for suicide prevention ( n = 3764) were reviewed. Records with varying technologies and diverse methodologies were integrated into the search.

Results

Review of the records resulted in the inclusion of 16 studies that utilized technology-enhanced interventions to address determinants of suicidal behaviour. This includes the use of standalone or, in most cases, adjunct technology-enhanced interventions for suicide prevention delivered by mobile phone application, text message, telephone, computer, web, CD-ROM and video.

Conclusion

Intervention effectiveness was variable, but several technology-enhanced interventions have demonstrated effectiveness in reducing suicidal ideation and mental health co-morbidities. Large-scale research and evaluation initiatives are needed to evaluate the costs and long-term population-level impact of these interventions.

Overview evidence on interventions for population suicide with an eye to identifying best-supported strategies for LMICs

Globally, over 800 000 people died by suicide in 2012 and there are indications that for each adult who died of suicide there were likely to be many more attempting suicide. There are many millions of people every year who are affected by suicide and suicide attempts, taking into consideration the family members, friends, work colleagues and communities, who are bereaved by suicide. In the WHO Mental Health Action Plan 2013-2020, Member States committed themselves to work towards the global target of reducing the suicide rate in countries by 10% by 2020. Hence, the first-ever WHO report on suicide prevention, Preventing suicide: a global imperative, published in September 2014, is a timely call to take action using effective evidence-based interventions. Their relevance for low- and middle-income countries is discussed in this paper, highlighting restricting access to means, responsible media reporting, introducing mental health and alcohol policies, early identification and treatment, training of health workers, and follow-up care and community support following a suicide attempt.

Paediatric suicidal burns: A growing concern

An alarming rise in rates of paediatric population committing self-immolation acts is a growing social and medical problem. In recent times there seems to be a rising concern in paediatric population. A study was conducted at a government tertiary care burn centre over 5 years in paediatric age group of <18 years who had committed self-immolation. Demographic data, aetiology, burn severity, associated illnesses, treatment and outcomes of the patients were collected with preventive strategies. Of total 89 patients, 12 patients were below 12 years (children) and 77 between 12-18 years (adolescent) with female preponderance. Majority belonged to lower middle and upper lower class families. Most had deep partial thickness burns. Psychiatric and personality disorder were found in 24.03% and 31.46% patients respectively. Kerosene was the main agent chosen to inflict injury. The average length of hospital stay was 19.8 days. The crude mortality rate observed was 38.2%. With cultural and socio-economic changes children and adolescents are exposed to increased levels of stress and peer pressure leaving them vulnerable. A multidisciplinary care involving medical, psychological and social support is required. Identifying children at risk and proper counselling and support can form an important strategy at prevention rather than cure.

What factors play a role in preventing self-immolation? Results from a case-control study in Iran

Background:

To investigate factors related to prevention of self-immolation in west of Iran.

Methods:

In a case-control study, 30 consecutive cases of deliberate self-inflicted burns admitted to the regional burn center (Imam Khomeini hospital in Kermanshah province, Iran) were compared with controls selected from the community and matched by sex, age, district-county of residence, and rural vs urban living environment. The following characteristics relevant to preventing self-immolation were collected from all cases and controls: main domestic fuel used in the household, awareness about complications of burn injuries, and use of counseling services.

Results:

Descriptive analyses revealed that kerosene was the main domestic fuel in the household for 83% of cases. Not surprisingly, the main means of self-immolation in 93% of the patients was kerosene, with other fuels such as petrol and domestic gas used in remaining cases. The majority of cases and controls were aware of the potential complications of burn injuries. Use of counseling services was more common in controls.

Conclusions:

All three aspects of preventing self-immolation – having kerosene and other fuels in the home, being aware of the complications of burn injuries, and using counseling services were present in both the cases and controls. This suggests a large portion of residents in rural Iran are potential self-immolation victims. Increasing preventive strategies may reduce risk of suicide by self-immolation.

The effect of parent and peer attachment on suicidality: the mediation effect of self-control and anomie

We explore the influence of psycho-social factors including the attachment to parent and peer, self-control, and anomie on suicidality. Research questionnaires were distributed among 336 students of Shahid Chamran University of Ahvaz in Iran. The results demonstrated that mother and peer attachments had an indirect effect on suicidality via self-control and anomie, and self-control had a direct effect on suicidality and an indirect effect via anomie. Self-control and anomie had the most efficient role in the model with a large effect size. Findings are discussed theoretically and with regards to the socio-cultural sphere of Iranian society.

Evaluation of Demographic and Clinical Characteristics of Patients who Attempted Suicide by Self-Inflicted Burn Using Catalyzer

Our aim was to assess demographic and clinical characteristics of patients treated at our units who attempted suicide by self-incineration, and to compare the results of burns with or without catalyzer use. Twenty patients who attempted suicide by self-incineration were examined in terms of clinical and demographic characteristics. Average age of the study population was 35 years (range 13-85 years). Average percentage of total body surface area burn was 53% (9%-100%). Six (30%) patients used gasoline and 5 (25%) used paint thinner in order to catalyze burning. Of these 11 patients who used a catalyzer, 5 (45.4%) had inhalation injury and 7 (63.6%) died. Among 9 patients who did not use any catalyzer, 1 (11.1%) had inhalation injury and 4 (44.4%) died. In general, inhalation injury was diagnosed in 6 patients (30%) while 11 (55%) patients died. A high morbidity and mortality rate was found in patients who used a catalyzer.

Self-immolation and its adverse life-events risk factors: results from an Iranian population

Background:

Despite considerable loss of life by deliberate self-burning in low and middle-income countries, few scholars have examined psychiatric factors such as adverse life events that may be related to self-immolation.

Methods:

This case-control study investigated adverse life-events as risk factors for self-immolation patients admitted to a burn center serving the western region of Iran. Variables investigated included the following adverse life-events: unplanned pregnancy, infertility, homelessness, financial hardship, problems with friends, intimate relationship break-up , school or university failure, anxiety about school/university performance, problems at work, personal history of suicide attempts, family history of suicide attempts, individual history of mental disorders, and malignant disease.

Results:

Financial hardship (OR=3.35, 95% CI=1.19-9.90), intimate relationship break-up (OR=5.45, 95% CI=1.20-11.99), and personal history of suicide attempts (OR=7.00, 95% CI=1.38-35.48) were associated with increased risk of self-immolation.

Conclusions:

This study suggests that financial hardship, intimate relationship break-ups, and personal history of suicide attempts are risk factors for self-immolation. Other variables studied did not play a role as individually protective or risk factors for self-immolation.

Further study is needed to substantiate findings of this study and direct research toward tailoring culturally sensitive, empirically-supported interventions for prevention of self-immolation.

A case-control study of psychosocial risk and protective factors of self-immolation in Iran

Self-immolation is the third leading cause of years of life lost (YLL) among women in Iran. The aim of this study is to investigate self-immolation-related risk and protective factors in the western region of Iran, a province with the highest prevalent of self-immolation in the country. Using a case-control design, we compared 151 cases of self-immolation attempters who were admitted to a burn center in Kermanshah with 302-matched control group from the same community/locality between March 21st, 2009, and March 20th, 2012. We conducted descriptive, bivariate, and multivariate analysis to examine the associations of self-immolation with demographic and familial risk factors, adverse life events, mental disorders, as well as potential protective factors. According to our findings, the highest percentage of self-immolation was in the 16-25 year-old age group (60%) and in females (76%). Of the potential risk factors in the study, major depression, adjustment disorders, individual history of suicide attempts and opium dependence, were statistically significant predictors of self-immolation. Suggestions for translating the local picture of self-immolation portrayed by our findings, into meaningful prevention strategies that have a good fit with the social and interpersonal context within which self-immolation takes place are discussed.

Development of suicidality within socioeconomic context: mediation effect of parental control and anomie

Despite some scientific research on suicide as one of the most serious social and mental health problems in Iran, there is still lack of research on the effective structural and socio-familial factors contributing to the issue in Iran. The purpose of this study is to investigate some of the effective variables conditioning suicidality while also establishing a synthetic model. Three hundred-fifty university students (165 males, 185 females) were randomly chosen from Shahid Chamran University, Ahvaz, Iran. The participants were asked to complete a package of self-report questionnaires including subjective socioeconomic status (SES), feeling of anomie, perceived parental control, and suicidality. The results show that all correlations among variables are significant. For testing the theoretical model, results of standardized regression coefficients suggest that SES has direct effect on suicidality and indirect effect via anomie and parental control. In addition, parental control has direct effects on suicidality and indirect effect via anomie as well. The findings confirm the expected paths hypothesized among variables which are consistent with the theories of Durkheim, Merton, Kohn, and Agnew. It implies that the development of suicidality takes place within socioeconomic context through the influence of parental control and feeling of anomie.

Epidemiology of self-immolation

One might categorize the method of committing suicide into fatal and non-fatal methods. One of the less recognized fatal methods of suicide is self-immolation or self-burn. In this article, a fresh look at the epidemiology of self-immolation around the world is taken. Furthermore, the case fatality rate and the prevention of suicides using self-immolation method are also discussed.

Characteristics of hospitalized patients following suicide attempt in hamadan district, iran

OBJECTIVES

Limited research has been undertaken on suicide in developing countries. This paper aims to investigate characteristics of suicide attempts in Hamadan district of Iran.

METHODS

A prospective study was conducted in all university hospitals in the Hamadan district of Iran and patients admitted for attempted suicides were included. All cases were assessed by psychiatrists and visited by two trained interns of Medicine.

RESULTS

The incidence rate per 100,000 persons of attempted suicides was 228.6 for males and 263.1 for females; moreover, 344.9 for rural areas and 222.7 for urban areas. The suicide attempt was the highest in the 15 to 24 age category for both sexes and regions.

CONCLUSIONS

Suicide is a complex, long-term outcome that requires multifaceted theoretical constructs for the appropriate study of its antecedents. Findings of this study along with other studies in Iran revealed that unemployed men, housewives, and rural women, high-school students, and those with a low level of education were at higher risk of suicidal behaviors.

Epidemiology of burns throughout the World. Part II: intentional burns in adults

A significant number of burns and deaths from fire are intentionally wrought. Rates of intentional burns are unevenly distributed throughout the world; India has a particularly high rate in young women whereas in Europe rates are higher in men in mid-life. Data from hospitalized burn patients worldwide reveal incidence rates for assault by fire and scalds ranging from 3% to 10%. The average proportion of the body surface area burned in an assault by fire or scalds is approximately 20%. In different parts of the world, attempted burning of others or oneself can be attributed to different motives. Circumstances under which assaults occur fall largely into the categories of interpersonal conflict, including spousal abuse, elder abuse, or interactions over contentious business transactions. Contributing social factors to assaults by burning include drug and alcohol abuse, non-constructive use of leisure time, non-participation in religious and community activities, unstable relationships, and extramarital affairs. Although the incidence of self-mutilation and suicide attempts by burning are relatively low, deliberate self-harm carries a significant risk of death, with an overall mortality rate of 65% worldwide. In those who resort to self-immolation, circumstantial themes reflect domestic discord, family dysfunction, and the social ramifications of unemployment. Preventing injurious burn-related violence requires a multifaceted approach, including legislation and enforcement, education, and advocacy. Better standardized assessment tools are needed to screen for risks of abuse and for psychiatric disorders in perpetrators.

Suicide clusters: introducing a novel type of categorization

A suicide cluster within a given community may be defined as a group of suicides or suicide attempts, or both, that happen closer together in time and space than would generally be expected. However, since the perception of clustering may itself be a risk factor for suicide, suicide clusters differ almost from all other event clusters. The aim of this article, therefore, is to discuss the unique pattern of suicide cluster and introduce a novel type of categorization taking into account varieties of studies, which investigate suicide clusters within diverse settings. This article concludes with challenging areas in suicide cluster studies and emphasizing that each community must deal rapidly and appropriately with any perceived suicide clusters.

Suicide by burning: epidemiological and clinical profiles

Self-immolation constitutes a rare form of suicide in developed countries, though it accounts for unique injury characteristics in the burn intensive care unit. The aim of this study was to present the epidemiological and clinical features of patients burned during a suicidal attempt seen in a North Rhine-Westphalia burn intensive care unit (BICU). To address this aim, we undertook a 21-year retrospective study involving patients with thermal injuries admitted to the largest burn unit in Germany. A total of 125 suicide-related burn victims were identified in the study period (9.4%). Comparing the self-immolation group with the rest burn patient cohort, suicide victims were more likely to be single and to act under the influence of alcohol. The suicidal group had a larger extent of burns, higher incidence of inhalation injury, required more surgical procedures, catecholamines, blood transfusions, and a longer BICU stay. Their clinical course was complicated by prolonged intubation period, higher rate of multiple drug-resistant bacteria acquisition and sepsis, leading to a higher mortality rate. Although the proportion of self-immolation victims among all burned patients is not high, the markedly higher severity of their burns and their poorer quality of outcomes makes them an important clinical subgroup for further study.

Suicide among young Middle Eastern Muslim females

BACKGROUND

Recent epidemiological studies highlight that within Muslim-dominated Middle Eastern countries suicide rates are high or are increasing among young females. This paper discusses the most important reasons behind this trend.

METHODS

The literature review started using the PubMed (http://www.ncbi.nlm.nih.gov) search engine, applying four keywords: suicide, young females, Middle East, and Muslim. The search strategy was complemented by hand-searching selected journals or by looking at the reference list of the retrieved papers.

RESULTS

All retrieved papers confirm a higher rate of suicide or attempted suicide among young Muslim females in the Middle East. Furthermore, the method chosen for suicide, psychiatric disorders, marriage, and masculine role are among the most important interrelated reasons that increase the likelihood of a young female being a victim of suicide.

CONCLUSIONS

Higher suicide rates among young Middle Eastern Muslim females must be considered an important issue, and their root causes should be dealt with properly and without delay.

The role of marital status, literacy, and urbanity in suicidal behavior by burns in the province of Khorasan, Iran

A prospective study of all suicidal behaviors by burns requiring hospitalization was conducted in the province of Khorasan, Iran, from March 21, 2005 to March 20, 2006, to examine marital status, urbanity and literacy among these patients. Data were obtained through interviews during the course of hospitalization. A total of 130 patients with suicidal behavior by burns were identified (incidence rate of 2.9 per 100,000). Females had a higher rate of suicidal behavior by burns than males (4.2 vs. 1.6 per 100,000, P < 0.001). The rate of suicidal behavior by burns was higher among single persons than married persons (4.3 vs. 3.5 per 100,000). The rate of suicidal behavior by burns among the rural population was slightly higher than the urban population (3.2 vs. 2.7 per 100,000). The high rate of suicidal behavior by burns among young, married women in Khorasan is a social tragedy.

The base rates and factors associated with reported access to firearms in psychiatric inpatients

OBJECTIVE

The aim of this study was to define whether specific patient demographic groups, diagnoses or other factors are associated with psychiatric inpatients reporting firearms access.

METHODS

A retrospective medical records review study was conducted using information on access to firearms from electronic medical records for all patients 16 years and older admitted between July 2007 and May 2008 at the Mayo Clinic Psychiatric Hospital in Rochester, MN. Data were obtained only on patients providing authorization for record review. Data were analyzed using univariate and multivariate logistic regression analyses accounting for gender, diagnostic groups, comorbid substance use, history of suicide attempts and family history of suicide/suicide attempts.

RESULTS

Seventy-four percent (1169/1580) of patients provided research authorization. The ratio of men to women was identical in both research and nonresearch authorization groups. There were 14.6% of inpatients who reported firearms access. In univariate analysis, men were more likely (P<.0001) to report access than women, and a history of previous suicide attempt(s) was associated with decreased access (P=.02). Multiple logistic regression analyses controlling for other factors found females and patients with history of previous suicide attempt(s) less likely to report access, while patients with a family history of suicide or suicide attempts reported increased firearms access. Diagnostic groups were not associated with access on univariate or multiple logistic regression analyses.

CONCLUSIONS

Men and inpatients with a family history of suicide/suicide attempts were more likely to report firearms access. Clinicians should develop standardized systems of identification of firearms access and provide guidance on removal.

Psychiatric disorders (Axis I and Axis II) and self-immolation: a case-control study from Iran

The objective of this study was to investigate preexisting psychiatric disorders in self-immolation patients. In a case-control study, 30 consecutive cases of deliberate self-inflicted burns, admitted to the regional burn center, were compared with 30 controls. Mental disorders were assessed via detailed clinical interview. Descriptive data revealed that 67% of self-immolation patients had adjustment disorder (all female), 10% drug and alcohol abuse/dependence (all male), 7% dysthymia, 3% major depression, 3% anorexia nervosa, 3% primary insomnia, 7% borderline personality disorder (50% male), 7% depressive personality disorder (100% female), and 3% antisocial personality disorder. In bivariate comparisons, adjustment disorders emerged as related to risk of self-immolation (odds ratio = 13.00). This study suggests that adjustment disorder is a risk factor for self-immolation. As a result, it has been suggested that increasing education about problem-solving approaches, and coping skills for females and at-risk groups are appropriate prevention programs and strategies in Iranian communities.

Epidemiology of burn injuries II: psychiatric and behavioural perspectives

Modern technological advances have decreased the incidence and severity of burn injuries, and medical care improvements of burn injuries have significantly increased survival rates, particularly in developed countries. Still, fire-related burn injuries are responsible for 300,000 deaths and 10 million disability-adjusted life years lost annually worldwide. The extent to which psychiatric and behavioural factors contribute to the incidence and outcomes of these tragedies has not been systematically documented, and the available data is often insufficient to reach definitive conclusions. Accordingly, this article reviews the evidence of psychiatric and behavioural risk factors and prevention opportunities for burn injuries worldwide. Psychiatric prevalence rates and risk factors for burn injuries, prevalence and risks associated with 'intentional' burn injuries (self-immolation, assault, and child maltreatment), and prevention activities targeting the general population and those with known psychiatric and behavioural risk factors are discussed. These issues are substantially interwoven with many co-occurring risk factors. While success in teasing apart the roles and contributions of these factors rests upon improving the methodology employed in future research, the nature of this entanglement increases the likelihood that successful interventions in one problem area will reap benefits in others.

Suicidal behavior by burns in the province of Fars, Iran

BACKGROUND

While suicide by burns is a relatively uncommon form of suicide in developed countries, it is one of the most common methods of suicide in the Middle East region including Iran.

AIMS

To describe epidemiologic characteristics of suicidal behaviors by burns in the province of Fars, Iran.

METHODS

A prospective population-based study of all suicidal behaviors by burns requiring hospitalization was conducted in the province of Fars, Iran, from March 21, 2005 to March 20, 2006. Data were obtained from patients, family members, and/or significant others through interviews during the course of hospitalization.

RESULTS

A total of 125 patients with suicidal behavior by burns requiring hospitalization were identified during the study period, representing an overall incidence rate of 4.3 per 100,000 (95% Confidence Interval [CI]: 3.6-5.1). Females (6.2 per 100,000) had a higher rate of suicidal behavior by burns than males (2.4 per 100,000; p < .001). The age-specific rate of suicidal behavior by burns peaked at age 20-29 years (10.1 per 100,000). The rate of suicidal behavior by burns was higher among single (7.2 per 100,000) vs. married persons (4.2 per 100,000; p = 0.03). Single males aged 20-39 years and young married women aged 15-29 years were at greatest risk of suicidal behavior by burns. The most common precipitating factor (74.4%) for suicidal behavior was a quarrel with a family member, a relative, and/or a friend.

CONCLUSIONS

The high rate of suicidal behavior by burns among young/married women in Fars is of concern. Social, cultural, and economic factors may contribute to suicidal behavior and need to be addressed through education, support, and commitment.

Prevalence of suicide thoughts, plans and attempts in a community sample from Karaj, Iran

Aim of this study was to evaluate the prevalence of suicide ideation and behavior in a community sample of an Iranian city, Karaj. Study sample consisted of 2,300 subjects, chosen randomly from the community. The WHO/SUPRE-MISS survey questionnaire, used in this study. Lifetime prevalence for suicide thoughts, plans and attempts were 12.7, 6.2 and 3.3%, respectively and for the previous year they were 5.7, 2.9 and 1%, respectively. Although it is not possible to generalize the results to the country, but in some area of Iran, the prevalence of suicide ideation, plan and attempt appeared to be similar to that of many developed countries.