The cost-effectiveness of banning highly hazardous pesticides to prevent suicides due to pesticide self-ingestion across 14 countries: an economic modelling study

Restriction of access to means used for suicide

One of the most effective public health measures to prevent suicide is the restriction of access to means used in suicidal acts. This approach can be especially effective if a method is common and readily accessible. Suicide methods vary widely, and there have been several examples where means restriction has been applied, often with considerable success. Factors contributing to availability of suicide methods can include access to physical means as well as cognitive awareness of methods. In this paper, which is the second in a Series on a public health approach to suicide prevention, we focus primarily on examples of restricting access to physical means of suicide, such as pesticides, firearms, and medication. We also discuss restricting the cognitive availability of means through attention to media and other representations of suicide methods. There are challenges associated with restricting access to means, including resistance to measures required to change the availability of some methods (which might, in part, be commercially determined) and method substitution, whereby one suicide method is replaced by another. Nevertheless, means restriction must be an integral part of all national and local suicide prevention strategies.

Forecasting the impact of means restriction on the suicide mortality rate in the Region of the Americas: an ecological modeling study

Background

The suicide mortality rate has been increasing in Region of the Americas, despite decreasing in all other World Health Organization (WHO) regions. Means restriction is an effective evidence-based intervention for suicide prevention. The objective of the current study was to estimate the impact of implementing national-level means restriction policies (i.e., firearm and pesticide restrictions) on the suicide mortality rate in the Region of the Americas.

Methods

In this ecological modeling study, two counterfactual scenarios were investigated using sex-specific suicide mortality data from the WHO Global Health Estimates database for 2000 to 2019. Forecasted sex-specific age-standardized suicide mortality rates were then estimated for each country for 2020 to 2030. Counterfactual scenario 1 involved modeling the impact of a firearm or pesticide restriction implemented in 2020 for those countries where the respective means accounted for 40% or more of all suicides for at least one sex in 2019, while in counterfactual scenario 2 this threshold was reduced to 20% or more.

Findings

It was estimated that if a firearm or pesticide restriction had been implemented in 2020 in those countries where the respective means accounted for 40% or more of all suicides for at least one sex in 2019, by 2030 the male and female suicide mortality rate in the Region of the Americas would be 20.5% (from 14.5 [95% Confidence Interval [CI]: 14.1, 15.0] per 100,000 males to 11.5 [95% CI: 11.1, 12.0] per 100,000 males) and 11.1% (from 4.5 [95% CI: 4.4, 4.7] per 100,000 females to 4.0 [95% CI: 3.9, 4.2] per 100,000 females) lower than the rate if no such restrictions were implemented, respectively. When the threshold was reduced to 20% or more, minimal additional gains in terms of number of suicides avoided and suicide mortality rate reduction would be achieved.

Interpretation

The implementation of a firearm or pesticide restriction policy in countries where the respective means account for a large proportion of suicides (e.g., at least 40%) could aid the Region of the Americas in achieving the WHO target of a one third reduction in the suicide mortality rate by 2030.

Funding

This work received no funding.

"Ad hoc policy decisions" in the news: Media framing analysis of a pesticide import ban in Sri Lanka

Modern agriculture relies on pesticides to maximise outputs. While many highly hazardous pesticides (HHPs) are banned in places like the European Union due to concerns about harm to the environment and human health, their use continues in many low- and middle-income counties (LMICs). Pesticide suicide is a public health problem unique to countries where HHPs are used, and Sri Lanka has successfully implemented several HHP bans as part of a suicide prevention strategy. On 27 April 2021, the Sri Lankan government announced an imminent import ban of all fertilizers and pesticides which was later revoked in November 2021. The aim of this article was to explore the media framing of the import ban as it pertained to pesticides. Guided by Entman's typology of frame functions, we analysed newspaper articles from nine Sri Lankan newspapers (N = 102) between 20 April to 31 October 2021. Overall, most framings were supportive of the ban, captured by framings that articulated the ban through a health, environment, and organic farming narrative. Framings that foregrounded farmer or industry livelihoods and the pesticide market were primarily adopted to express opposition to the ban. The presence of frames opposing the ban within media articles increased over time during the study period. There was a greater proportion of opposing frames in private newspapers compared to government (78% vs 22%). Many of the articles analysed described the widespread impact of the ban, but only 11% of articles represented the voices of policy end users. This study adds understanding to the ways communication via outlets like mainstream newspapers may shape public support or opposition to pesticide bans in a LMIC. Mass media is an under-recognised factor in policy implementation and this study may inform planning to implement pesticide bans in other countries.

The Cost-Effectiveness of Psychosocial Interventions Following Self-Harm in Australia

Background: Psychosocial interventions following self-harm in adults, in particular cognitive behavioral therapy (CBT), can be effective in lowering the risk of repeated self-harm. Aims: To evaluate the cost-effectiveness of CBT for reducing repeated self-harm in the Australian context. Method: The current study adopted the accessing cost-effectiveness (ACE) approach using return-on-investment (ROI) analysis. Uncertainty and sensitivity analyses (Sas) tested the robustness of the model outputs to changes in three assumptions: general practitioner referral pathway (SA1), private setting intervention delivery (SA2), and training costs (SA3). Results: The intervention produced cost savings of A$ 46M (95% UI -223.7 to 73.3) and A$ 18.3M (95% UI -86.2 to 24.6), subject to the effect of intervention lasting 2- or 1-year follow-up. The ROI ratio reduced to 5.22 in SA1 (95% UI -10.1 to 27.9), 2.5 in SA2 (95% UI -4.8 to 13.3), and 5.1 in SA3 (95% UI -9.8 to 27.8). Limitations: We assumed that the effectiveness would reduce 50% within 5 years in the base case, and we used Australian data and a partial social perspective. Conclusions: The current study demonstrated cost-effectiveness of CBT for adults who have self-harmed with the return-on-investment ratio of A$ 2.3 to $6.0 for every A$ 1 invested.

Cost-effectiveness analysis of insecticide ban aimed at preventing Parkinson's disease in Central California

BACKGROUND

Our study assessed whether banning specific insecticides to reduce the PD burden in three Central California (CA) counties is cost-effective.

METHOD

We applied a cost-effectiveness analysis using a cohort-based Markov model to estimate the impact and costs of banning seven insecticides that were previously associated with PD in these counties as well as mixture exposures to some of these pesticides. We relied for our estimations on the cohort of 65- and 66-year-olds living in these counties who were unaffected by PD at baseline in 2020 and projected their incidence, costs, and reduction in quality-adjusted-life-years (QALY) loss due to developing PD over a 20-year period. We included a shiny app for modeling different scenarios (https://sherlockli.shinyapps.io/pesticide_pd_economics_part_2/).

RESULTS

According to our scenarios, banning insecticides to reduce the occurrence of PD in three Central CA counties was cost-effective relative to not banning insecticides. In the worst-case scenario of exposure to a single pesticide, methomyl, versus none would result in an estimated 205 (95 % CI: 75, 348) additional PD cases or 12 % (95 % CI: 4 %, 20 %) increase in PD cases over a 20-year period based on residential proximity to pesticide applications. The increase in PD cases due to methomyl would increase health-related costs by $72.0 million (95 % CI: $5.5 million, $187.4 million). Each additional PD patient due to methomyl exposure would incur $109,327 (95 % CI, $5554, $347,757) in costs per QALY loss due to PD. Exposure to methomyl based on workplace proximity to pesticide applications generated similar estimates. The highest PD burden and associated costs would be incurred from exposure to multiple pesticides simultaneously.

CONCLUSION

Our study provides an assessment of the cost-effectiveness of banning specific insecticides to reduce PD burden in terms of health-related QALYs and related costs. This information may help policymakers and stakeholders to make decisions concerning the regulation of pesticides.

Dienediamine: A safe surrogate for the herbicide paraquat

Paraquat (PQ) has been used as an herbicide worldwide because of its potent activity against weeds. However, it is highly toxic to humans. The very high fatality of PQ poisoning is due to its inherent toxicity and the lack of any effective treatment. Consequently, developing a non-toxic herbicide with comparable efficacy to PQ will contribute to global food security and help prevent PQ-related fatalities. Herein, we report a new herbicide called dienediamine, which was discovered from how to intervene the redox cycle of PQ, an inherent toxicity nature. Dienediamine, the "reduced" form of PQ with no function as an electron transfer agent, was shown to be non-toxic through comprehensive in vivo and in vitro experiments at molar concentrations equivalent to PQ's absolute lethal dose. Remarkably, dienediamine can undergo conversion to PQ under natural sunlight and ambient air conditions, exhibiting herbicidal activities that are comparable to those of PQ. The conversion of dienediamine to PQ, which is toxic to chloroplasts, is the key mechanism underlying its potent herbicidal activity. Our study discovers that dienediamine is a safe and superior alternative to PQ, possessing significant potential for application in sustainable agriculture globally.

Banning highly hazardous pesticides saves the lives of young people, particularly females, in low- and middle-income countries

Pesticide self-poisoning is a public health problem mostly affecting low- and middle-income countries. In Sri Lanka, India and China suicide rates have reduced among young people, particularly females, following highly hazardous pesticides (HHP) bans. This success story requires attention to encourage more research on differential effects of HHP bans.

Organophosphorus and carbamate pesticides: Molecular toxicology and laboratory testing

Population and food requirements are increasing daily throughout the world. To fulfil these requirements application of pesticides is also increasing. Organophosphorous (OP) and Organocarbamate (OC) compounds are widely used pesticides. These pesticides are used for suicidal purposes too. Both inhibit Acetylcholinesterase (AChE) and cholinergic symptoms are mainly used for the diagnosis of pesticide poisoning. Although the symptoms of the intoxication of OP and OC are similar, recent research has described different targets for OP and OC pesticides. Researchers believe the distinction of OP/OC poisoning will be beneficial for the management of pesticide exposure. OP compounds produce adducts with several proteins. There is a new generation of OP compounds like glyphosate that do not inhibit AChE. Therefore, it's high time to develop biomarkers that can distinguish OP poisoning from OC poisoning.

Impact of pesticide regulations on mortality from suicide by pesticide in China: an interrupted time series analysis

Background

Pesticide bans and regulatory restrictions have been shown to be effective strategies for preventing suicide in several countries. Suicide and suicide by pesticides have decreased significantly in China over the past two decades. However, whether the reduction was associated with pesticide regulation is unknown.

Methods

The monthly data on suicide and suicide by pesticide from 2006 to 2018 were obtained from China's Disease Surveillance Point (DSP) system. Information on China's pesticide regulations since 1970 was obtained from Pesticide Action Network International (PAN International), Joint Meeting on Pesticide Management Highly Hazardous Pesticides (JMPM HHP) lists, the website of the Ministry of Agriculture of China, Pesticide Information Network of China, and the Wan Fang database. Change point detection and policy analysis were combined to identify the time of any trend change breakpoint of suicide and suicide by pesticide. Interrupted time series analysis was used to investigate the pre- and post-breakpoint trends of monthly standardized rates in suicide and suicide by pesticide.

Results

The standardized pesticide suicide rate decreased by 60.5% from 6.50 in 2006 to 2.56 per 100,000 in 2018. Larger declines were evident among people in urban areas (67.3%), female individuals (63.5%), and people aged 15-44 years (68.1%). The effect of policies banning highly hazardous organophosphorus pesticides (HHOP) [rate ratio (RR) = 0.993, 95% CIs (0.991-0.994)] in December 2008 and stopping domestic sales and use of paraquat aqueous solution (RR = 0.992, 95% CIs: 0.990-0.994) in July 2016 were more pronounced than regulating the paraquat-related products (RR = 1.003, 95% CIs: 1.002-1.004) in April 2012.

Conclusion

Declines in suicide by pesticide in China occurred contemporaneously with regulatory bans and restrictions implemented on several pesticides, particularly in urban areas, among female individuals, and the relatively low age profile. These findings indicate the potential influence of these bans on trends of suicide by pesticides.

Cross-country analysis of national mental health investment case studies in sub-Saharan Africa and Central, South and South-East Asia

Introduction

Despite the increasing interest in and political commitment to mental health service development in many regions of the world, there remains a very low level of financial commitment and corresponding investment. Assessment of the projected costs and benefits of scaling up the delivery of effective mental health interventions can help to promote, inform and guide greater investment in public mental health.

Methods

A series of national mental health investment case studies were carried out (in Bangladesh, Kenya, Nepal, Philippines, Uganda, Uzbekistan and Zimbabwe), using standardized guidance developed by WHO and UNDP and implemented by a multi-disciplinary team. Intervention costs and the monetized value of improved health and production were computed in national currency units and, for comparison, US dollars. Benefit-cost ratios were derived.

Findings

Across seven countries, the economic burden of mental health conditions was estimated at between 0.5%-1.0% of Gross Domestic Product. Delivery of an evidence-based package of mental health interventions was estimated to cost US$ 0.40-2.40 per capita per year, depending on the country and its scale-up period. For most conditions and country contexts there was a return of >1 for each dollar or unit of local currency invested (range: 0.0-10.6 to 1) when productivity gains alone are included, and >2 (range: 0.4-30.3 to 1) when the intrinsic economic value of health is also considered. There was considerable variation in benefit-cost ratios between intervention areas, with population-based preventive measures and treatment of common mental, neurological and conditions showing the most attractive returns when all assessed benefits are taken into account.

Discussion and Conclusion

Performing a mental health investment case can provide national-level decision makers with new and contextualized information on the outlays and returns that can be expected from renewed local efforts to enhance access to quality mental health services. Economic evidence from seven low- and middle-income countries indicates that the economic burden of mental health conditions is high, the investment costs are low and the potential returns are substantial.

Surveillance of pesticide poisoning in an East and a West Malaysian hospital: characteristics of pesticide poisoning and the early impact of a national Paraquat ban

BACKGROUND

Previous studies have shown that pesticide bans were associated with reduced fatal pesticide self-poisoning cases in high, and low-and-middle-income countries. We aimed to investigate the characteristics of pesticide poisoning patients admitted to two Malaysian hospitals and the early impact of the national paraquat ban implemented on 1st January 2020 in a culturally heterogenous South-East-Asian upper-middle-income setting.

METHODS

Data were collected from an East (Bintulu) and a West (Ipoh) Malaysian hospital medical records in 2015-2021 and 2018-2021, respectively. Logistic regression analyses were conducted to investigate the association of aspects such as socio-demographic and clinical characteristics, paraquat ban with the types of pesticides involved (paraquat versus non-paraquat versus unknown) ,and the outcomes (fatal versus non-fatal).

RESULTS

From the study sample of 212 pesticide poisoning patients aged 15 years or above, the majority were self-poisoning cases (75.5%) with a disproportionate over-representation of Indian ethnic minority (44.8%). Most pesticide poisoning cases had socio-environmental stressors (62.30%). The commonest stressors were domestic interpersonal conflicts (61.36%). 42.15% of pesticide poisoning survivors had a psychiatric diagnosis. Paraquat poisoning accounted for 31.6% of all patients and 66.7% of fatalities. Case fatality was positively associated with male gender, current suicidal intent, and paraquat poisoning. After the paraquat ban, the proportion of pesticide poisoning cases using paraquat decreased from 35.8 to 24.0%, and the overall case-fatality dropped slightly from 21.2 to 17.3%.

CONCLUSIONS

Socio-environmental stressors in specific domestic interpersonal conflicts, seemed more prominent in pesticide poisoning compared to psychiatric diagnosis. Paraquat accounted for the majority of pesticide-associated deaths occurring in hospitals in the study areas. There was preliminary evidence that the 2020 paraquat ban led to a fall in case fatality from pesticide poisoning.

Conceptualising the commercial determinants of suicide: broadening the lens on suicide and self-harm prevention

Suicide is preventable, yet, in many settings, robust suicide prevention strategies have not been implemented. Although a commercial determinants of health lens is increasingly being applied to industries important to the field of suicide prevention, the interplay between the vested interests of commercial actors and suicide has received little attention. There is a need to shift attention to the causes of the causes, directing more focus to the ways that commercial determinants influence suicide and shape suicide prevention strategies. Such a shift in perspective, with an evidence base and precedents to draw upon, has transformative potential for research and policy agendas dedicated to understanding and addressing upstream modifiable determinants of suicide and self-harm. We propose a framework intended to help guide efforts to conceptualise, research, and address the commercial determinants of suicide and their inequitable distribution. We hope these ideas and lines of inquiry help to catalyse connections between disciplines and open further debate and discussion as to how to take such an agenda forward.

Suicides by pesticide ingestion in Pakistan and the impact of pesticide regulation

INTRODUCTION

Suicide is a major public health problem in Pakistan, accounting to approximately 19,331 deaths every year. Many are due to consumption of acutely toxic pesticides; however, there is a lack of national suicide data, limiting knowledge and potential for intervention. In this paper, we aimed to review the literature on pesticide self-poisoning in Pakistan to identify the most problematic pesticides in relation to national pesticide regulations.

METHODS

Information on the currently registered and banned pesticides was obtained from Ministry of National Food Security and Research while data on pesticide import and use was extracted from FAOSTAT. We searched the following sources for articles and research papers on poisoning in Pakistan: Cumulative Index to Nursing and Allied Health (CINAHL), Google Scholar, Applied Social Sciences Index and Abstracts (ASSIA), Excerpta Medica (EMBASE), National Library of Medicine's MEDLINE (PUBMED), PS102YCHINFO and Pakmedinet.com using the search terms 'self-poisoning', 'deliberate self-harm', 'suicide', 'methods and means of suicide', 'organophosphate', 'wheat pill', 'aluminium phosphide', 'acute poisoning', OR 'pesticides', AND 'Pakistan'.

RESULTS

As of May 2021, 382 pesticide active ingredients (substances) were registered in Pakistan, of which five were WHO hazard class Ia (extremely hazardous) and 17 WHO hazard class Ib (highly hazardous). Twenty-six pesticides, four formulations, and seven non-registered pesticides had been banned, of which two were WHO class Ia and five Ib. We identified 106 hospital-level studies of poisoning conducted in Pakistan, of which 23 did not mention self-poisoning cases and one reported no suicidal poisoning cases. We found no community or forensic medicine studies. Of 52,323 poisoning cases identified in these papers, 24,546 [47%] were due to pesticides. The most commonly identified pesticide classes were organophosphorus (OP) insecticides (13,816 cases, 56%) and the fumigant aluminium phosphide (3 g 56% tablets, often termed 'wheat pills'; 686 cases, 2.7%). Few studies identified the particular pesticides involved or the resulting case fatality.

CONCLUSION

We found pesticide poisoning to be a major cause of poisoning in Pakistan, with OP insecticides and the fumigant aluminium phosphide the main pesticides identified. Withdrawal of Class I pesticides (as proposed to occur nationally in 2022) and high concentration aluminium phosphide tablets should rapidly reduce suicidal deaths by reducing the case fatality for low-intention poisoning cases. National cause of death data and forensic toxicology laboratory data identifying the pesticides responsible for deaths will be important to assess impacts of the proposed national ban.

Direct Thermal Growth of Gold Nanopearls on 3D Interweaved Hydrophobic Fibers as Ultrasensitive Portable SERS Substrates for Clinical Applications

Surface-enhanced Raman spectroscopy (SERS)-based biosensors have attracted much attention for their label-free detection, ultrahigh sensitivity, and unique molecular fingerprinting. In this study, a wafer-scale, ultrasensitive, highly uniform, paper-based, portable SERS detection platform featuring abundant and dense gold nanopearls with narrow gap distances, are prepared and deposited directly onto ultralow-surface-energy fluorosilane-modified cellulose fibers through simple thermal evaporation by delicately manipulating the atom diffusion behavior. The as-designed paper-based SERS substrate exhibits an extremely high Raman enhancement factor (3.9 × 10¹¹ ), detectability at sub-femtomolar concentrations (single-molecule level) and great signal reproductivity (relative standard deviation: 3.97%), even when operated with a portable 785-nm Raman spectrometer. This system is used for fingerprinting identification of 12 diverse analytes, including clinical medicines (cefazolin, chloramphenicol, levetiracetam, nicotine), pesticides (thiram, paraquat, carbaryl, chlorpyrifos), environmental carcinogens (benzo[a]pyrene, benzo[g,h,i]perylene), and illegal drugs (methamphetamine, mephedrone). The lowest detection concentrations reach the sub-ppb level, highlighted by a low of 16.2 ppq for nicotine. This system appears suitable for clinical applications in, for example, i) therapeutic drug monitoring for individualized medication adjustment and ii) ultra-early diagnosis for pesticide intoxication. Accordingly, such scalable, portable and ultrasensitive fibrous SERS substrates open up new opportunities for practical on-site detection in biofluid analysis, point-of-care diagnostics and precision medicine.

Pesticide exposure and poisoning in Brazil: Outcome severity, clinical manifestations and management of cases reported to a poison control center

This work aimed to identify variables associated with increased risk of outcome severity as well as to describe clinical manifestations/symptoms and management of pesticide-related cases reported to a poison center in Brazil. An increased risk of more severe outcomes was observed when exposures occurred in rural areas, involved suicide attempts and moderately to extremely hazardous pesticides. Clinical manifestations with higher frequencies included vomiting, nausea, sialorrhea, headache, miosis and sweating. From the treatment initially applied to the patient, 51.91% encompassed gastric lavage, but this procedure was only recommended in 20.01% of cases by the CIATox. Identifying risk factors associated with poor outcome, describing clinical manifestations, and contrasting initial treatment measures adopted against those recommended by the Poison Center can help determine diagnosis, prognosis and ensure appropriate clinical interventions are used in cases of pesticide poisoning.

Exploring the phenomenon of suicidal behaviour (SB): An explanatory, mixed-method study in rural Pakistan

BACKGROUND

Despite scientific literature and media reports of rising cases of suicide and attempted suicide in different parts of Pakistan, the extent of this problem remains unknown, particularly from outside the main urban centres of the country.

AIMS

To report data on Suicidal Behaviour (SB) from Malakand Division, a rural and marginalised part of Khyber Pakhtunkhwa (KPK) province, explore aetiological factors and propose preventive strategies.

METHODS

This study followed an explanatory, mixed-method study design. The first part quantitative [QUANT] comprised of police reports on suicidal behaviour, from 2001 till first 8 months of 2018. Detailed analysis of only data from 2013 was undertaken, as data prior to 2013 contained insufficient information. The second part that is, qualitative (QUAL) consisted of in-depth interviews with relevant stakeholders. A mixed method of inductive and deductive analytical approach was used.

RESULTS

From 2013 until the first quarter of 2018, the police recorded 1,645 attempts of both males and females of which 144 (8.75%) resulted in fatalities. Suicide attempts rose by 83.4% over the 5 years and 8 months. Approximately, 43.3% of the attempts were attributed to 'depression'. Domestic abuse was reported in 49.6% of cases. Of the total victims, 1,049 (63.7%) were females, whereas 60.1% were married. Ingestion of the organophosphates poison (pesticide) was reported in 53.2% (n = 999) of suicide attempts. In more than 90% of the non-fatal suicide attempts, victims were booked under punitive laws. Poor socio-economic status, inter-personal stressors, violence against women and mental illnesses were the major causes of suicidal behaviour in Malakand [QUAL]. Investment in human development, strengthening of the healthcare system, de-stigmatisation of mental illnesses and women empowerment could possibly prevent suicidal behaviour in Malakand [QUAL].

CONCLUSION

SB in Malakand Division is steadily increasing. The increase is more evident in vulnerable populations such as women and the younger population. 'Psychosocial stressors' and 'depression' were the main causes of suicidal behaviour. A broad-based, proactive, multi-sectorial approach is needed to prevent SB in the region.

Interventions to Reduce Pesticide Exposure from the Agricultural Sector in Africa: A Workshop Report

Despite the fact that several cases of unsafe pesticide use among farmers in different parts of Africa have been documented, there is limited evidence regarding which specific interventions are effective in reducing pesticide exposure and associated risks to human health and ecology. The overall goal of the African Pesticide Intervention Project (APsent) study is to better understand ongoing research and public health activities related to interventions in Africa through the implementation of suitable target-specific situations or use contexts. A systematic review of the scientific literature on pesticide intervention studies with a focus on Africa was conducted. This was followed by a qualitative survey among stakeholders involved in pesticide research or management in the African region to learn about barriers to and promoters of successful interventions. The project was concluded with an international workshop in November 2021, where a broad range of topics relevant to occupational and environmental health risks were discussed such as acute poisoning, street pesticides, switching to alternatives, or disposal of empty pesticide containers. Key areas of improvement identified were training on pesticide usage techniques, research on the effectiveness of interventions targeted at exposure reduction and/or behavioral changes, awareness raising, implementation of adequate policies, and enforcement of regulations and processes.

Modelling in economic evaluation of mental health prevention: current status and quality of studies

BACKGROUND

The present study aimed to identify and critically appraise the quality of model-based economic evaluation studies in mental health prevention.

METHODS

A systematic search was performed on MEDLINE, EMBASE, EconLit, PsycINFO, and Web of Science. Two reviewers independently screened for eligible records using predefined criteria and extracted data using a pre-piloted data extraction form. The 61-item Philips Checklist was used to critically appraise the studies. Systematic review registration number: CRD42020184519.

RESULTS

Forty-nine studies were eligible to be included. Thirty studies (61.2%) were published in 2015-2021. Forty-seven studies were conducted for higher-income countries. There were mainly cost-utility analyses (n = 31) with the dominant primary outcome of quality-adjusted life year. The most common model was Markov (n = 26). Most of the studies were conducted from a societal or health care perspective (n = 37). Only ten models used a 50-year time horizon (n = 2) or lifetime horizon (n = 8). A wide range of mental health prevention strategies was evaluated with the dominance of selective/indicate strategy and focusing on common mental health problems (e.g., depression, suicide). The percentage of the Philip checkilst's criteria fulfilled by included studies was 69.3% on average and ranged from 43.3 to 90%. Among three domains of the Philip checklist, criteria on the model structure were fulfilled the most (72.1% on average, ranging from 50.0% to 91.7%), followed by the data domain (69.5% on average, ranging from 28.9% to 94.0%) and the consistency domain (54.6% on average, ranging from 20.0% to 100%). The practice of identification of 'relevant' evidence to inform model structure and inputs was inadequately performed. The model validation practice was rarely reported.

CONCLUSIONS

There is an increasing number of model-based economic evaluations of mental health prevention available to decision-makers, but evidence has been limited to the higher-income countries and the short-term horizon. Despite a high level of heterogeneity in study scope and model structure among included studies, almost all mental health prevention interventions were either cost-saving or cost-effective. Future models should make efforts to conduct in the low-resource context setting, expand the time horizon, improve the evidence identification to inform model structure and inputs, and promote the practice of model validation.

Exogenous pesticide poisoning in the state of Espírito Santo, Brazil, 2007-2016: spatial distribution and temporal trend in the incidence rate and case fatality ratio of notified cases

OBJECTIVE

To describe the spatial distribution of pesticide poisoning cases and analyze the temporal trend in the incidence rate and case fatality ratio of this event in the state of Espírito Santo, Brazil.

METHODS

This was a time series study of confirmed cases of pesticide poisoning registered on the Notifiable Health Conditions Information System (SINAN) between 2007 and 2016. Incidence rates were presented in thematic maps. Scatter plots were used to show the incidence and case fatality ratio of cases.

RESULTS

There was an increasing incidence rate of poisoning in the period regarding the total number of cases, by sex and age group - except for those aged 70 years and over. There was a decreasing case fatality ratio until 2012, with a subsequent increase. Eight municipalities presented the highest notification rates (30 to 46 new cases/100,000 inhabitants).

CONCLUSION

There was an increase in the incidence of notifications in the period. There was a decrease in case fatality ratio until 2012, subsequently followed by an increase.

Direct Costs of Healthcare among Patients with Deliberate Self-harm: A Pilot Study from a Tertiary Care Hospital in South India

Background

Deliberate self-harm (DSH) in developing nations has a significant impact on health and economic conditions of patients and families.

Materials and methods

This retrospective study aims to study the cost of hospitalization and the factors affecting the cost of medical care. Adult patients with a diagnosis of DSH were included.

Results

A total of 107 patients were included with the most common type of poison consumed being pesticides (35.5%) followed by a tablet overdose (31.8%). There was a male preponderance with a mean (SD) age of 30.04 (9.03) years. The median cost of admission was ₹13,690 (USD 195.57); DSH with pesticide increased the cost of care by 67% as compared to non-pesticides. Other factors which increased the cost were need for intensive care, ventilation, use of vasopressors, and development of ventilator-associated pneumonia (VAP).

Conclusions

Pesticide-based poisoning is the most frequent cause of DSH. Among different types of DSH, pesticide poisoning is associated with a higher direct cost of hospitalization.

How to cite this article

Barnabas R, Yadav B, Jayakaran J, Gunasekaran K, Johnson J, Pichamuthu K, et al. Direct Costs of Healthcare among Patients with Deliberate Self-harm: A Pilot Study from a Tertiary Care Hospital in South India. Indian J Crit Care Med 2022;26(7):836-838.

Quantitative methods for climate change and mental health research: current trends and future directions

The quantitative literature on climate change and mental health is growing rapidly. However, the methodological quality of the evidence is heterogeneous, and there is scope for methodological improvement and innovation. The first section of this Personal View provides a snapshot of current methodological trends and issues in the quantitative literature on climate change and mental health, drawing on literature collected through a previous scoping review. The second part of this Personal View outlines opportunities for methodological innovation concerning the assessment of the relationship between climate change and mental health. We then highlight possible methodological innovations in intervention research and in the measurement of climate change and mental health-related variables. This section draws upon methods from public mental health, environmental epidemiology, and other fields. The objective is not to provide a detailed description of different methodological techniques, but rather to highlight opportunities to use diverse methods, collaborate across disciplines, and inspire methodological innovation. The reader will be referred to practical guidance on different methods when available. We hope this Personal View will constitute a roadmap and launching pad for methodological innovation for researchers interested in investigating a rapidly growing area of research.

Characteristics and patterns of individuals who have self-harmed: a retrospective descriptive study from Karachi, Pakistan

BACKGROUND

Self-Harm (SH) is a major global public health problem under-researched in Pakistan due to religious and legal implications. This study aims to identify the characteristics and patterns among patients with SH and factors associated with the intent to die.

METHOD

This retrospective descriptive study where SH cases presented to private tertiary care teaching hospital in Karachi, Pakistan, from January 2013 to December 2017 were extracted from HIMS records. Details related to demography, history, associated factors, access to methods used, and intent to die were collected on a structured proforma and analysed using STATA version 14.  RESULTS: A total of 350 cases were analysed. More than half of the reported cases were in the age group 20-39 years. Though only one-fourth of the SH cases had a past psychiatric history, it was found to be significantly (P-value < 0.05) associated with intent to die. Notably, 81% of the cases do not have a history of SH. Drug overdose (61.6%) and insecticides (36.6%) were the two most common methods used. Depression was identified in nearly half of the cases. The most common reason for attempting SH was inter-personal relationship issues (54.3%).

CONCLUSION

This paper provides recent data on the characteristics and patterns associated with the intent to die of individuals who have self-harmed. In most cases of SH, past psychiatric history was not evident. Current psychiatric diagnosis and young adults were favoured in this study. The data from this study has limited representation for all demographic representation of SH cases from Pakistan as being from a single private hospital. There is a need for further research on SH in Pakistan.

Impact of large-scale, government legislated and funded organic farming training on pesticide use in Andhra Pradesh, India: a cross-sectional study

BACKGROUND

The use of pesticides in agriculture has been associated with the destruction of biodiversity and damage to human health. A marked reduction in pesticide use is urgently required globally, but whether this can be achieved rapidly and at scale is unclear. We aimed to assess whether government-legislated and funded organic farming training in Andhra Pradesh, India, reduced pesticide use by farmers and sales of pesticides by pesticide retailers.

METHODS

We did a cross-sectional survey between Aug 11 and Nov 26, 2020, among farmers and pesticide retailers in Kurnool District of Andhra Pradesh (India). We assessed the impact of the Andhra Pradesh Community Managed Natural Farming (APCNF) programme, which aims to transition 100% of the agricultural land of Andhra Pradesh (population approximately 49 million, 6 million of whom are farmers) to organic farming practices by 2030. We did cross-sectional phone interview surveys of farmers and face-to-face surveys of pesticide retailers. We used multivariable Poisson regression models to estimate relative risks (RRs) and logistic regression models to estimate odds ratios (ORs).

FINDINGS

962 farmers were invited to participate, of whom 894 (93%) consented (709 conventional farmers and 149 APCNF farmers). 47 pesticide retailers were invited to participate, of whom 38 (81%) consented. APCNF farmers had practised APCNF for a median of 2 years (IQR 1-3). APCNF farmers were less likely to use pesticides than conventional farmers (adjusted RR 0·65 [95% CI 0·57-0·75]), although pesticide use remained high among both APCNF and conventional farmers (73 [49%] of 148 APCNF farmers vs 695 [99%] of 700 conventional farmers; p<0·0001). APCNF farmers had lower pesticide expenditures than conventional farmers (median US$0 [IQR 0-170] for APCNF farmers vs $175 [91-281] for conventional farmers; p=0·0001). Increased frequency of meeting with agricultural extension workers was associated with reduced pesticide use among ACPNF farmers. Seven (18%) of 38 retailers reported a decrease in sales of pesticides in the past 4 years; no difference in the odds of reporting a decrease in pesticide sales in the past 4 years was identified between APCNF retailers and conventional retailers (OR 0·95 [95% CI 0·58-1·57]).

INTERPRETATION

Despite a major government drive for organic agriculture, about half of APCNF farmers continued to use pesticides and no impact on pesticide sales at local retailers was observed. A combination of policy instruments (eg, bans on highly hazardous pesticides), not solely training for farmers, might be needed to eliminate pesticide use in agriculture.

FUNDING

Scottish Funding Council and UK Research and Innovation.

Association Between Means Restriction of Poison and Method-Specific Suicide Rates

Question

Findings

Meaning

Importance

Objective

Evidence Review

Findings

Conclusions and Relevance

An Exploration of the Labor, Financial, and Economic Factors Related to Suicide in the Republic of Kazakhstan

The Republic of Kazakhstan has one of the world’s highest suicide rates. A detailed study of the risk factors for suicide in that country is therefore important. We investigated country-wide statistics related to labor, financial, and economic factors and whether any of these factors contribute to the risk of suicide in Kazakhstan. Using the 20 year period from 2000 to 2019, we examined the annual suicide rates overall (all citizens) and for males and females in Kazakhstan, annual unemployment rates, annual rates of increase in the country’s consumer price index, annual total exports, and annual total imports. We then calculated the correlations between the suicide rates and these four items. We also performed a multiple regression analysis of the relationship between the suicide rate and those four items. The results of these analyses indicated that the unemployment rate was the correlation coefficient most highly correlated with the suicide rate; unemployment was significantly related to suicide and should be targeted as a risk factor in suicide prevention interventions in Kazakhstan. With this in mind, organizations, government agencies, and professionals in relevant fields need to devise and implement suicide prevention measures.

Case fatality of agricultural pesticides after self-poisoning in Sri Lanka: a prospective cohort study

BACKGROUND

Pesticide poisoning is among the most common means of suicide globally, but can be prevented with regulation of the most hazardous agents. We aimed to compare the lethality of pesticides ingested by our cohort, seek evidence on variation between human and regulatory animal toxicity, and establish change over time in the case fatality of individual pesticides in Sri Lanka.

METHODS

We examined the case fatality of agricultural pesticides in a prospective cohort in nine hospitals serving rural populations in Sri Lanka. We included all patients (>11 years) who had presented to a South Asian Clinical Toxicology Research Collaboration study hospital during the study period. Patients were enrolled by clinical research assistants and were regularly reviewed. Identification of the ingested pesticide was generally on the basis of history or positive identification of the container, supported by nested blood analysis.

FINDINGS

From March 31, 2002, to Dec 31, 2019, 34 902 patients (median age 29 years [IQR 21-40]; 23 060 [66·1%] male) presented with a possible or known pesticide self-poisoning. We identified 23 139 specific pesticides that were ingested. Poisoning was fatal in 2299 (6·6%) patients. Case fatality varied greatly from 0·0% (several substances) to 41·8% (paraquat). The three most toxic agents (ie, paraquat, dimethoate, and fenthion) were banned between 2008 and 2011. Since 2013, the five agents causing the most deaths (ie, profenofos, propanil, fenobucarb, carbosulfan, and quinalphos) had a case fatality of 7·2-8·6%. A steady decline was seen in overall case fatality of pesticide poisoning (10·5% for 2002-06 to 3·7% for 2013-19), largely attributable to pesticide bans. A modest fall in case fatality for non-banned pesticides was also seen.

INTERPRETATION

Declines seen in case fatalities of poisonings with non-banned pesticides suggest that medical management improved over time. The human data for acute toxicity of pesticides should drive hazard classifications and regulation. We believe that a global benchmark for registration of pesticides should include a less than 5% case fatality after self-poisoning, which could prevent many deaths and have a substantial effect on global suicide rates.

FUNDING

The Wellcome Trust and the National Health and Medical Research Council of Australia.

TRANSLATIONS

For the Sinhala and Tamil translations of the abstract see Supplementary Materials section.