An assessment of suicide attempts by self-poisoning in the west of Iran

Clinico-epidemiological evaluation of pharmaceutical/non-pharmaceutical poisoning in a referral poisoning emergency in the Central part of Iran

The pattern of poisoning varies in different societies. In this study, we investigated the clinical-epidemiological features and outcomes of poisoned patients based on the substances involved, whether pharmaceutical or non- pharmaceutical toxins. This cross-sectional study involved a retrospective chart review of all poisoned patients who presented to the poisoning emergency hospital in the center of Iran between January 2015 and December 2019. We collected data on socio-demographics, the nature of the poisoning, and the outcomes. Backward stepwise binary regression analysis was conducted to predict the mortality. Throughout the study period, 5777 patients with acute poisoning met the inclusion criteria. Of these, 3524 cases (61%) were attributed to pharmaceutical, and 2253 cases (39%) were due to non-pharmaceutical poisoning. The majority of pharmaceutical poisonings (82.9%) were intentional, whereas non-pharmaceutical poisonings accounted for 46.2% of intentional exposures (P < 0.001). Patients with non-pharmaceutical poisoning were predominantly men, older in age, and had a history of addiction compared to those with pharmaceutical poisoning (P < 0.001). In binary logistic regression analysis, patients poisoned by non-pharmaceutical substances had a significantly higher risk of mortality [Odds ratio, 3.14; (95% CI 1.39-7.10); P = 0.006] compared to those poisoned by pharmaceutical substances (P < 0.001). The pattern of poisoning differs in terms of age and gender when comparing pharmaceutical to non-pharmaceutical poisoning. Patients poisoned by non-pharmaceutical may have a worse outcome compared to those poisoned by pharmaceutical substances.

A Clinical-Epidemiological Study on Beta-Blocker Poisonings Based on the Type of Drug Overdose

Background

Beta-blockers carry a high risk of potentially causing fatal poisoning if overdosed. We aimed to assess the clinical and epidemiological characteristics of patients with beta-blocker poisoning.

Methods

Patients were categorized based on the type of drug poisoning into propranolol, other beta-blockers, and the combination of beta-blocker groups, respectively. Demographic data, drug toxicity, and clinical, laboratory, and treatment information of different groups were compared.

Results

During the study period, 5086 poisoned patients were hospitalized, of whom 255 (5.1%) had beta-blocker poisoning. Most patients were women (80.8%), married (50.6%), with a history of psychiatric disorders (36.5%), previous suicide attempts (34.6%), and intentional type of exposure (95.3%). The mean ± SD age of the patients was 28.94 ± 11.08 years. Propranolol toxicity was the most common among different beta-blockers (84.4%). There was a significant difference in age, occupation, education level, and history of psychiatric diseases with respect to the type of beta-blocker poisoning (P < 0.05). We observed changes in the consciousness level and need for endotracheal intubation only in the third group (combination of beta-blockers). Only 1 (0.4%) patient had a fatal outcome in toxicity with the combination of beta-blockers.

Conclusion

Beta-blocker poisoning is not common in our poisoning referral center. Propranolol toxicity was most common among different beta-blockers. Although symptoms are not different among defined beta-blocker groups, more severe symptoms are observed in the combination of the beta-blocker group. Only one patient had a fatal outcome in the toxicity with the combination of the beta-blocker group. Therefore, poisoning circumstances have to investigate thoroughly to screen coexposure with combined drugs.

Time-series analysis of trends in the incidence rates of successful and attempted suicides in Thailand in 2013-2019 and their predictors

BACKGROUND

Suicide rates are of increasing concern worldwide. There are approximately 4000-5000 deaths by suicide each year in Thailand. This study examined trends in annual incidence rates and predictors of successful and attempted suicides in Thailand (2013-2019).

METHODS

Secondary data analysis was conducted on data from two national-level databases: The National Health Security Office and the National Death Certification Registry System. Time-related trends and predictors of successful and attempted suicides were calculated using joinpoint regression and multivariable logistic regression analyses, respectively.

RESULTS

Of all successful suicide cases from 2013 to 2019, about 80% involved men, with an average age of 45.37 (± 16.43) years. Predictors of successful suicide included male sex, older age, using highly lethal methods, and no prior psychiatric treatment. Among individuals admitted to hospitals following a suicide attempt from 2013- to 2019, the average age at first admission was 38.83 ± 22.47 years, with women more heavily represented than men. Only 2.3% of these patients received psychiatric treatment in the hospital. Predictors of attempted suicide included female sex; adolescent or adult; and mental, alcohol, or substance-related disorder(s). Age-standardized annual rates per 100,000 people showed that, through 2019, suicide incidence increased slightly, and attempts decreased.

CONCLUSIONS

There was a significantly increasing trend in successful suicide during the 7 years; the increase was more notable among men. The study highlights sex-related gaps in public health owing to an identified higher incidence of suicide among men, and a higher incidence of suicide attempts in women adolescents, emphasizing the need to consider sex-sensitive issues in individual as well as societal contexts.

Epidemiology of Suicide by Medication Overdose: A Population-based Study 2011-2019

BACKGROUNDS

The trend of suicide attempt by medication overdose has shown an increasing trend in recent years. The present study was conducted to investigate the epidemiology of suicide attempts and completed suicide by medication overdoses in Fars's province between 2011 and 2019.

METHODS

This cross-sectional study was performed on 40334 suicide attempts by medication overdose. First, fetal rate, and crude and aged-standardized mortality rate (ASR) were calculated. Then, χ² test was used to calculate the trend of rates of suicide attempt and completed suicide, also to explore differences between qualitative and outcome variables. Finally, logistic regression analysis was performed to identify factors associated with suicide outcome.

RESULTS

The mean age of the participants was 26.66 ± 11.03 years. The highest ASR for suicide attempt by medication overdose was observed in the age range of 15-24 years. The rate of completed suicide by medication overdose was estimated as 1.22%. The odds of completed suicide were 2.7 times higher in men than in women, 2.7 times higher in people with a family history of suicide, and 1.7 times higher in people with a previous history of suicide.

CONCLUSION

The results of our study may help health policymakers to effectively prevent recurrence of suicide attempts through establishing effective strategies for timely identification and appropriate intervention among high-risk individuals with previous history of suicide.

Age Changes and Suicidal Activity in Iran Over the Past Decade: A Systematic Review and Meta-Analysis

This review study fills an important gap by aiming to determine the age changes in attempted and completed suicide in Iran during the past decade. A systematic review of related articles in international and Iranian databases from January 2008 to January 2020 was first conducted and relevant studies were extracted based on established criteria. Results showed that the mean age of suicide in Iran is 29.8 (range 27.7 - 31.8) years old for men and 27.4 (range 25.8 - 28.9) for women (P < 0.0001). The youngest and oldest populations of completed suicide belong to eastern and central regions of the country respectively. Findings imply the critical importance of increasing awareness through educational programs and public health campaigns to increase awareness and reduce suicidal behavior in Iran.

The mortality rate from self-harm in Iran

BACKGROUND

Self-harm-related death is one of the most unfortunate, tragic, and regrettable types of death owing to injuries with a variety of socio-economic and cultural causes. The study aimed to determine the trend in the mortality of self-harm by sex and age at national and provincial levels in Iran over a period of 26 years.

METHODS

The Iran Death Registration System (DRS), cemetery databanks in Tehran and Esfahan, and the national population and housing censuses of Iran were used for this study. Using a growth model, the population was estimated in the age groups. Incompleteness, misalignment, and misclassification in the DRS were all considered and addressed accordingly. We used a spatio-temporal and Gaussian process regression model to estimate mortality rates in children and adults.

RESULTS

Over the study period, 67,670 deaths were estimated owing to self-harm across the country. The overall age-standardized mortality rate decreased from 4.32 per 100,000 (95% unit interface (UI): 3.25-5.75) to 2.78 (2.15-3.59) per 100,000 between 1990 and 2015, a reduction of approximately 35.65%. The M/F ratio was 2.03:1 with an annual percent change of -2.38% and -1.37% for women and men, respectively. The annual self-harm mortality rate was higher among individuals aged 15-24 years, as well as it was more in men during the study period.

CONCLUSION

Mortality from self-harm has declined over the study period in Iran. Higher rates in men and in population aged 15-24 years, with considerable variation by province, were the distinguishing features of self-harm. Iran needs to improve monitoring through a comprehensive multisectoral strategy; and most importantly, provide timely, effective and low-cost preventive interventions.

Size Estimation of Under-Reported Suicides and Suicide Attempts Using Network Scale up Method

Objective:

To estimate (under reporting) UR of SDS (Suicide deaths) and SAS (suicide attempts) in Kermanshah Province which is among provinces with high suicide rate in Iran.

Methods:

For estimating the size of UR suicide death registers, all cases of SAS and suicide deaths were retrieved from forensic medicine and health centers. Then, using network scale up method, a sample of 500 cases, aged 18 to 65 years, were randomly selected from the general population on the basis of age - sex proportion. To find the 95% confidence interval, bootstrap technique was used.

Results:

 The average coverage of SDS was 58.4%, the lowest and highest coverage rate of SDS were attributed to self-immolation (34.2%) and hanging (81.2%), respectively. The coverage rate of SAS for self-immolation and deliberate self-poisoning were 82.4% and 77.2%, respectively. Size estimation of SAS by NSU method revealed that deliberate self-poisoning with medication (61.7%), poisoning with toxins and chemicals (20.6%), and self-immolation (7.7%) were the most frequent methods of SAS.

Conclusion:

Given the low coverage of suicide registers, all causes of death, especially deaths classified as accident or deaths with undetermined category, are required to be accurately registered. Investigations of causes of death, correction of wrong codes, as well as interviews with survivors to give them assurance can reduce the rate of suicide denial and result in increased accuracy of death register coverage.

Trend of fatal poisoning at national and provincial levels in Iran from 1990 to 2015

OBJECTIVES

Comprehensive and up-to-date data on fatal injury trends are critical to identify challenges and plan priority setting. This study provides a comprehensive assessment of poisoning mortality trends across Iran.

STUDY DESIGN

The data were gathered from various resources, including death registration systems, cemetery databases of Tehran and Esfahan, the Demographic and Health Survey of 2000, and three rounds of national population and housing censuses.

METHODS

After addressing incompleteness for child and adult death data separately and using a spatio-temporal model and Gaussian process regression, the level and trend of child and adult mortality were estimated. For estimating cause-specific mortality, the cause fraction was calculated and applied to the level and trend of death.

RESULTS

From 1990 to 2015, 40,586 deaths due to poisoning were estimated across the country. The poisoning-related age-standardized death rate per 100,000 was estimated to have changed from 3.08 (95% uncertainty interval [UI]: 2.32-4.11) in 1990 to 0.96 (95% UI: 0.73-1.25) in 2015, and the male/female ratio was 1.35 during 25 years of study with an annual percentage change of -5.4% and -4.0% for women and men, respectively. The annual mortality rate was higher among children younger than 5 years and the elderly population (≥70 years) in the study period.

CONCLUSIONS

This study showed that mortality from poisoning declined in Iran over the period from 1990 to 2015 and varied by province. Understanding the reasons for the differences of poisoning mortality by province will help in developing and implementing measures to reduce this burden in Iran.

How much self-poisoning attempts are visible in Iran?

BACKGROUND

Stigma of suicide attempt (SA) results in not asking friends and relatives for help. Others' awareness of an individual's SA sometimes can solve his/her problems and reduce rates of SA. This study is intended to examine the degree of SA visibility through deliberate self-poisoning (DSP), which is the most common method of SA in Iran.

METHODS

In order to study visibility, all individuals who had attempted to suicide by DSP and had been referred to the western Iran poisoning center during April-June, 2016 were entered to the study. A female and a male interviewer experienced in role-playing were recruited to interview clients, each with clients of their own gender, in order to increase compliance and information accuracy. Multivariate Poisson Regression was used to identify visibility determinants.

RESULTS

Among 100 subjects interviewed, 10 denied SA. Regardless of those denying SA, self-poisoning visibility factor (SVF) was 26.6% (21.7-31.5) which decreased to 23.9% (19.7-28.1) after considering those individuals who denied SA. The highest values of SVF were observed in subjects poisoned by toxins, alcohol and illegal drugs, respectively. In the multivariate model, the value of SVF increased with an increase in age (IRR=1.03, 95% CI: 1.02-1.04), having history of SA (IRR=1.18, 95% CI: 1.07-1.30), and being married (IRR=1.70, 95% CI: 1.05-1.29).

CONCLUSIONS

Lower values of SVF of DSP indicate that individuals committing suicide do not ask others for help and saying their SA intents. The higher the degree of visibility, the lower the rates of committing and repeating SAs. To increase the visibility of SA, therefore, the one way is to prevent and reduce SA repetition.

Epidemiological study of suicide by physical methods between 1993 and 2013 in Ilam province, Iran

BACKGROUND

Suicide by aggressive physical methods such as firearms, hanging, and jumping is well known; however, different factors may influence a person while selecting a particular method. The aim of this study was to investigate the epidemiological factors involved in the selection and use of different physical methods for suicide over a long-term period in Ilam province, Iran.

METHODS

The present study was conducted retrospectively between 1993 and 2013 using recorded data from a comprehensive system for registration of suicide attempts in Ilam University of Medical Sciences. The epidemiological characteristics included person, time and place variables, and the outcomes of the suicide attempts. The chi square, univariate and multivariate logistic regression models were used for data analysis.

RESULTS

Totally, 1516 suicide attempts were evaluated (the annual incidence rate: 19/100,000 individuals). The most commonly used suicide method in females (88.4%) and males (38.9%) was self-immolation. Furthermore, the annual incidence rate among males and females was within the age group of 15-24 years (24.6 and 47.8/100,000 individuals). The risk of death by suicide in the age group of 55-64 years was 2.93 compared with the age group of 10-14 years (OR = 2.93; 95% CI = 0.64-13.54, P = 0.168).

CONCLUSION

This study revealed that self-immolation was the most selected physical method of suicide and had the highest incidence rate, and inflicted the survivors with severe physical and mental complications. In order to reduce the use of physical methods, especially self-immolation, life skills training becomes more important than ever.

Estimation of the rate and number of underreported deliberate self-poisoning attempts in western Iran in 2015

OBJECTIVES

Rates of attempted deliberate self-poisoning (DSP) are subject to undercounting, underreporting, and denial of the suicide attempt. In this study, we estimated the rate of underreported DSP, which is the most common method of attempted suicide in Iran.

METHODS

We estimated the rate and number of unaccounted individuals who attempted DSP in western Iran in 2015 using a truncated count model. In this method, the number of people who attempted DSP but were not referred to any health care centers, n₀, was calculated through integrating hospital and forensic data. The crude and age-adjusted rates of attempted DSP were estimated directly using the average population size of the city of Kermanshah and the World Health Organization (WHO) world standard population with and without accounting for underreporting. The Monte Carlo method was used to determine the confidence level.

RESULTS

The recorded number of people who attempted DSP was estimated by different methods to be in the range of 46.6 to 53.2% of the actual number of individuals who attempted DSP. The rate of underreported cases was higher among women than men and decreased as age increased. The rate of underreported cases decreased as the potency and intensity of toxic factors increased. The highest underreporting rates of 69.9, 51.2, and 21.5% were observed when oil and detergents (International Classification of Diseases, 10th revision [ICD-10] code: X66), medications (ICD-10 code: X60-X64), and agricultural toxins (ICD-10 codes: X68, X69) were used for poisoning, respectively. Crude rates, with and without accounting for underreporting, were estimated by the mixture method as 167.5 per 100,000 persons and 331.7 per 100,000 persons, respectively, which decreased to 129.8 per 100,000 persons and 253.1 per 100,000 persons after adjusting for age on the basis of the WHO world standard population.

CONCLUSIONS

Nearly half of individuals who attempted DSP were not referred to a hospital for treatment or denied the suicide attempt for political or sociocultural reasons. Individuals with no access to counseling services are at a higher risk for repeated suicide attempts and fatal suicides.

Exploring Complexity of Deliberate Self-Poisoning through Network Analysis

The purpose of this research was to examine the complexity of circumstances that result in deliberate self-poisoning cases. For the purposes of this paper, the cases were patients that presented for care and were admitted to the specialty hospital in Northwest of Iran. The research examined the problems preceding deliberate self-poisoning and the interrelations among them by applying network analysis methods. The network was scored for degrees of centrality and betweenness centrality. Structural analysis of network also was conducted using block modelling. The results showed that family conflicts had the highest score for degree of centrality among women, while the highest score for degree of centrality among men belonged to those dealing with drug addiction. Analysis for degree of betweenness centrality revealed that drug addiction had the highest score among men, whereas the highest score for women on betweenness centrality was related to physical illness. Structural analysis of the network showed differences in role that various problems played in intentional self-poisoning. The findings from this research can be used by public health authorities to create prevention programs that address the problems leading to deliberate self-poisoning.

Epidemiological survey of intentional poisoning suicide during 1993-2013 in Ilam Province, Iran

BACKGROUND

Suicide is an important social tragic phenomenon which occurs by different tools or methods in different communities. Considering deliberate poisoning as a common and important method in Ilam province for suicide, the present study was launched to epidemiologically assess committing suicide in Ilam province, Iran, based on intentional poisoning.

METHODS

By a retrospective study, all the recorded data associated with intentional poisoning suicide in Ilam Province during 1993-2013 were analyzed. All the demographic variables and the suicides' outcomes were analyzed using the Chi-Square test, and the univariate and multivariate logistic regression models.

RESULTS

Totally, 6794 cases of suicide (annual incidence rate of 87.28/ 100, 000) associated with poisoning were evaluated. The incidence rate of suicide attempts was 84.63/ 100, 000 (94.51 in female and 74.98 in male) and the incidence rate of completed suicide was 2.17/ 100, 000 (1.94 in female and 2.40 in male). Also, the highest rates of attempted and completed suicide (annual incidence rate of 172.42 and 4.14, respectively) were attributed to the age group of 15-24 year.

CONCLUSION

Females had a greater tendency to commit suicide by poisoning, and the lower level of education, the age group of 15-24 years and single individuals were more associated with suicide using poisonings. The incidence of attempted suicide in females and completed suicide in males was higher in this method. Considering the high rate of suicide by poisoning, further attention and supervision on the sale and reserve of drugs and poisons is necessary. Meanwhile, it seems that due to momentary emotions during the pubertal stage, the risk of committing suicide is increased especially among unemployed individuals; therefore, performing an extensive psychotherapy intervention is needed in the societies with younger populations.

Survey on Hypothermia and Hyperthermia in Poisoned Patients in a Unique Referral Hospital, Tehran, Iran

Background

Body temperature is a critical criterion of health. Drugs and a variety of poisons can affect body temperature in poisoned patients, causing hyperthermia and hyperpyrexia.

Objectives

Our previous study’s findings in patients poisoned with organophosphate led us to the goal of this study: obtaining the initial tympanic temperature in patients poisoned by a variety of toxins.

Materials and Methods

A cross-sectional study reviewed the records of poisoned patients who were admitted to the toxicological intensive care unit (TICU) at Loghman Hakim hospital poison center (LHHPC) from February 2014 to February 2015. The data collected included gender, age, type of poisoning, the season during which poisoning occurred, vital signs, initial tympanic temperature (first four hours), presence of seizures, white blood cell (WBC) count, creatinine phosphokinase (CPK), length of stay and patient outcome. We determined the mean (SD) for normally distributed continuous variables, the median and interquartile range for non-normally distributed continuous variables, and the absolute and relative frequency (%) for categorical variables. All were determined using SPSS version 16.

Results

Data were collected from 310 eligible patients. The mean patient age was 32.65 (with a standard deviation of 14.40). Of the patients in the study, 183 (59%) were male. Intentional poisoning in an attempted suicide was documented in 253 (81.6%) patients. The most prevalent poisoning agent was aluminum phosphate (18.70%), followed by methadone (10%) and opium (10%). Seventy percent of the patients (n = 217) were diagnosed and classified with fever or hyperthermia. A temperature ≥ 40°C was detected in just three cases. The highest mean temperature was found in patients poisoned with amphetamine, organophosphate and tramadol. Patients with alcohol and phenobarbital poisoning were included in the sample, but these patients were not diagnosed with hypothermia. WBC ≥ 10,000 cells/mL and CPK ≥ 975 IU/L were recorded in 57.7% and 13.2% of subjects, respectively.

Conclusions

Body temperature changes in human poisonings are a matter in need of special attention. A literature review did not reveal any controversy over hypothermia, but poisoning cases exhibit a variety of patterns of fever and hyperthermia. If there are no limits to the diagnosis of fever and hyperthermia, all cases with a poor prognosis which fail to respond to treatment could be categorized as drug-induced hyperthermia. Therefore, a different approach is needed for poisoning cases.