Relationship of the high proportion of suicidal acts involving ingestion of pesticides to the low male-to-female ratio of suicide rates in China

Declining suicide rates in China (1990-2017): Gender and age specific analyses

BACKGROUND

In China suicide rates have been declining for about three decades. Patterns of suicide for women and men across the lifespan over time however have not been systematically documented.

METHODS

Official suicide mortality data (from 1990 to 2017) available via China CDC were used to examine suicide patterns by gender and age in each of the 33 provincial-level regions. Suicide data were aggregated by five years, except for the year of 2017. The bar graphs were used to descriptive the change tread of the suicide rate.

RESULTS

In the past three decades, the decline in female suicide rates was greater than that in the male rates, with the overall male to female (M/F) ratio changing from 0.88 in 1996 to 1.56 in 2017. The overall suicide rate of male was 8.82 and female was 5.65 per 100,000 persons in 2017. However the decline of suicide rates for people aged 70 and older was the greatest declination (33.73/per 100,000 persons) among all the age groups in China.

CONCLUSION

Overall suicide rates have declined over the three decades in China, particularly among females and individuals age 70+ years. Suicide rates continue to be higher among individuals aged 50 and older (particularly among men), and this population should continue to the focus for prevention.

Case fatality of repeated suicidal acts among suicide attempters in rural China: a retrospective cohort study

Background

Individuals presenting to hospital due to suicide attempt are at high risk for repeated suicidal act, yet there are meager data on the extent to which repeated suicidal acts result in death.

Methods

This retrospective cohort study was based on a general hospital self-harm register system in a rural county in China. Identified individuals who attempted suicide were contacted and followed up for up to 8 years. Main outcomes over follow-up were: 1) suicide death, 2) nonlethal suicide attempt, and 3) suicidal acts including suicide death and nonlethal attempt. Incidence densities, correlates, and case fatality of repeated suicidal acts were estimated.

Findings

A total of 1086 individuals (two-thirds females, mean age 40.6 years) with a suicide attempt presenting to hospital (index attempt) were identified and followed up, with most of the index attempts by pesticide ingestion (79%). Over follow-up, there were 116 suicidal acts carried out by 108 individuals (69 females, 39 males), including 34 suicide deaths (21 females, 13 males), yielding a high case-fatality of 29.3%. During follow-up, suicide death rates were also high overall and in the first year of follow-up (846.7 and 1787.2 per 100,000 person years). Over follow-up, pesticide was the most common method (47/116) of repeated suicidal act and yielded a higher case-fatality than other methods (46.8% vs 17.4%, χ2 = 11.68, P < 0.001). The incidence densities of repeated suicidal acts and nonlethal attempts were low compared to rates reported in previous literature.

Interpretation

Incidence densities of repeated suicidal acts in a rural China cohort were low compared to previous studies. However, rates of suicide deaths over follow-up were high, a result driven by the high case-fatality of suicidal acts and attributable to the common use of pesticides. Reducing suicidal acts with pesticides is a key target for suicide prevention in rural China.

Funding

Beijing Municipal High Rank Public Health Researcher Training Program, Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support, and Beijing Hospitals Authority's Ascent Plan.

A Qualitative Study on the Psychological Experience of Emergency Department Medical Staff Caring for Patients with Suicide Attempts in Northeastern Sichuan

The purpose of this study was to explore the psychological experiences of emergency department staff in northeastern Sichuan when treating patients with suicide attempts and to provide a theoretical basis for developing appropriate clinical interventions and improving mental health services for suicidal patients. Sixteen emergency department staff members who met recruitment requirements at two hospitals in Nanchong, China, were interviewed using Colizzi descriptive phenomenological analysis. The interviews were in-depth and semi-structured. The qualitative analysis of this study revealed three main themes: (1) aspects of the emotional experience that may be detrimental to helping people in crisis (e.g., sympathy and regret, confusion and bewilderment, worry and stress); (2) aspects of the cognitive experience (e.g., inability to deal with patients' psychological issues and having new perspective on the medical profession); and (3) raising awareness of mental health services. Future reform efforts should consider training medical staff in suicide prevention knowledge and communication skills, using a compassion-centered approach to alleviate the suffering of patients who attempt suicide, using the Safety Screening Scale (PSS-3), providing counselors for patients, developing family-focused interventions, and involving family members in suicide risk prevention and treatment.

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.

Predictive value of suicidal risk assessment using data from China's largest suicide prevention hotline

BACKGROUND

Suicide hotlines are widely used, with potential for identification of callers at especially high risk.

METHODS

This prospective study was conducted at the largest psychological support hotline in China. From 2015 to 2017, all distressed callers were consecutively included and assessed, using a standardized scale consisting of 12 elements, yielding scores of high risk (8-16), moderate risk (4-7), and low risk (0-3) for suicidal act. All high-risk and half of moderate- and low-risk callers were scheduled for a 12-month follow-up. Main outcomes were suicidal acts (nonlethal attempt, death) over follow-up.

RESULTS

Of 21,346 fully assessed callers, 5822, 11,791, and 3733 were classified as high-, moderate-, or low-risk for suicidal acts, with 8869 callers (4076 high-, 3258 moderate-, and 1535 low-risk) followed up over 12 months. Over follow-up, 802 (9.0 %) callers attempted suicide or died by suicide. The high-risk callers (15.1 %) had 3-fold higher risk for subsequent suicidal acts than moderate- (5.1 %) and 12-fold higher risk than low-risk callers (1.3 %). The weighted sensitivity, specificity, and positive predictive value of high risk scores were 56.4 %, 74.9 %, and 14.4 %.

LIMITATIONS

Assessed callers with different risk levels were followed disproportionally.

CONCLUSIONS

Suicidal risk assessment during a hotline call is both feasible and predictive of risk, guiding resource allocation to higher risk callers.

Acute organophosphate and carbamate pesticide poisonings - a five-year survey from the National Poison Control Center Of Serbia

Pesticide poisonings, intentional as well as accidental, are common, especially in undeveloped and developing countries. The goal of this study was to analyze the clinical presentation of patients hospitalized due to acute organophosphate (OPP) or carbamate pesticide (CP) poisoning as well as to analyze the factors that potentially influenced the severity and outcome of the poisonings. A retrospective cross-sectional study was performed. The age and gender of each patient were recorded, the type of ingested pesticide, whether the poisoning was intentional or accidental, number of days of hospitalization, the severity of the poisoning, and the outcome of the treatment (i.e., whether the patient survived or not). Clinical aspects of poisonings were analyzed, as well as the therapeutic measures performed. 60 patients were hospitalized due to acute OPP or CP poisoning, out of 51 (85.00%) were cases of intentional self-poisoning. The majority of patients were poisoned by OPPs (76.67%), in one-third the causative agent was malathion, followed in frequency by chlorpyrifos and diazinon. Dimethoate poisonings were manifested with the most severe clinical picture. A 70% or lower activity of reference values of acetylcholinesterase and butyrylcholinesterase was found in 50% and 58% of patients, respectively. The most common symptom was miosis (58.33%), followed by nausea and vomiting. Pralidoxime reactivated acetylcholinesterase inhibited by chlorpyrifos or diazinon, but not with malathion or dimethoate. Impairment of consciousness and respiratory failure, as well as the degree of acetylcholinesterase and butyrylcholinesterase inhibition, were prognostic signs of the severity of poisoning. The lethal outcome was more often found in older patients (t = 2.41, p = 0.019). The type of ingested pesticide significantly affects the severity and outcome of poisoning as well as the effectiveness of antidotes.

Clinical characteristics of patients with cardiac arrest induced by pesticide poisoning: Analysis of 15 cases

INTRODUCTION AND OBJECTIVE

Pesticide poisoning induced cardiac arrest (PPICA) has rarely been reported before, and can easily be overlooked by physicians. The aim of the study was to investigate the clinical characteristics of PPICA patients.

METHODS

This was a single-center, retrospective analysis in the emergency intensive care unit (EICU) at tertiary medical facility, from January 2015 to December 2018.

RESULTS

A total of 15 patients with PPICA in EICU were included, of which nine were females, where suicide was the only cause of poisoning. Thirteen were in-hospital cases and only three cases showed an initial shockable rhythm. On admission, patients' median acute physiology and chronic health evaluation II score was 20 (12, 21) and median sequential organ failure assessment score was 7 (4, 10). All cases required invasive mechanical ventilation and vasopressors therapy. Seven patients received blood purification therapy. The primary toxic agent was organophosphorus pesticide (OP) and all OP cases (8/15) received pralidoxime and atropine therapy. Thirteen patients received gastric decontamination. The primary complications were cardiogenic shock (10/15) and acute kidney injury (3/15). Seven patients survived at discharge. Of these, three made a full recovery without neurological sequelae.

CONCLUSIONS

Cardiac arrest has rarely been reported in pesticide poisoning before, and can easily be overlooked. Physicians therefore should pay attention to specific therapy and best supportive treatment, which could be critical to improve the disease outcomes.

Aberrant integrity of the cortico-limbic-striatal circuit in major depressive disorder with suicidal ideation

BACKGROUND

Suicidal ideation is a common symptom of major depressive disorder (MDD) that reflects a cognitive alteration in the background of intense emotional dysregulation. Amygdala is a critical emotion processing center that facilitates moving from emotional appraisal to action. However, whether MDD patients with suicidal ideation show dysconnectivity of the amygdala within a large-scale neurocognitive circuitry remains unknown.

METHODS

Participants were 22 MDD patients without suicidal ideation (MDD-NSI), 59 MDD patients with suicidal ideation (MDD-SI), and 60 healthy controls (HCs). We compared the amygdala-based resting-state functional connectivity of four amygdala subregions across the three groups. We selected brain regions with significant between-group differences in amygdalar conectivity as the regions of interest (ROI) and performed ROI-to-ROI and graph-theoretical analyses to explore dysconnectivity patterns at various granularity levels.

RESULTS

Brain regions showing omnibus differences across the three groups were distributed across a cortico-limbic-striatal circuitry. MDD-SI had unique dysconnectivity of the lateral amygdala with caudate, middle temporal gyrus, and postcentral gyrus compared with the other two groups. MDD-SI and MDD-NSI had shared dysconnectivity of the medial amygdala with medial superior frontal gyrus and middle temporal gyrus. Within the derived cortico-limbic-striatal circuitry, MDD-SI exhibited lower global connectivity, reduced sigma (small-worldness), but increased lambda (path-length) than HCs. Reduced sigma correlated with increased severity of suicidal ideation. We achieved high classification accuracy (84.09%, with AUC 0.82) in distinguishing MDD-SI from MDD-NSI.

CONCLUSIONS

Aberrant integrity of the cortico-limbic-striatal circuit centered on the amygdala provides a promising neural substrate for suicidal ideation that requires further investigation in MDD.

The lethality of suicide methods: A systematic review and meta-analysis

BACKGROUND

The use of suicide methods largely determines the outcome of suicide acts. However, no existing meta-analysis has assessed the case fatality rates (CFRs) by different suicide methods. The current study aimed to fill this gap.

METHODS

We searched Scopus, Web of Science, PubMed, ProQuest and Embase for studies reporting method-specific CFRs in suicide, published from inception to 31 December 2020. A random-effect model meta-analysis was applied to compute pooled estimates.

RESULTS

Of 10,708 studies screened, 34 studies were included in the meta-analysis. Based on the suicide acts that resulted in death or hospitalization, firearms were found to be the most lethal method (CFR:89.7%), followed by hanging/suffocation (84.5%), drowning (80.4%), gas poisoning (56.6%), jumping (46.7%), drug/liquid poisoning (8.0%) and cutting (4.0%). The rank of the lethality for different methods remained relatively stable across study setting, sex and age group. Method-specific CFRs for males and females were similar for most suicide methods, while method-CFRs were specifically higher in older adults.

CONCLUSIONS

This study is the first meta-analysis that provides significant evidence for the wide variation of the lethality of suicide methods. Restricting highly lethal methods based on local context is vital in suicide prevention.

Listening to the Shenzhen Primary Healthcare Context to Adapt the mhGAP-IG.v2 for the Assessment of Depression: Qualitative Workshops with Primary Healthcare Leaders

In Shenzhen, despite recent primary and mental healthcare reform, Primary healthcare doctors (PHC) have limited access to diagnostic tools and a significant mental health treatment gap presides. The World Health Organization's (WHO) mental health gap intervention guide (mhGAP-IG.v2) offers a non-specialist and evidence-based guide for the assessment of depression however requires adaptation to the context of use. Bilingual (Mandarin and English) qualitative research was undertaken with 30 PHC leaders from Shenzhen to compare their assessment approach for depression against the mhGAP-IG.v2 in order to identify context-specific modifications for a local guide. Local assessment differentiators included: a need for culturally sensitive translation of depression symptoms; a preference for a broad, non-hierarchical symptom presentation (including somatic, behavioural and anxiety items); national prioritisation of suicide patients; the integration of family into the cycle of care; limited primary care awareness of a depressive episode in Bipolar Disorder; and China's specialist-led diagnostic approach. Contextual modification of mhGAP-IG.v2 is recommended to take account of China's unique cultural and primary health system response to depression. Ongoing mental health training is required to develop professional confidence in the recognition of mental disorders.

Adapting the depression component of WHO Mental Health Gap Intervention Guide (mhGAP-IG.v2) for primary care in Shenzhen, China: a DELPHI study

Background

Primary care doctors in Shenzhen, China are increasingly expected to identify and prevent depressive disorder; however, they have received limited mental health training and community healthcare centres (CHC) do not provide standardised protocols for the diagnosis and care of depressive disorder. The World Health Organization’s mental health gap intervention guide, version 2 (mhGAP-IG.v2) is a decision support tool for non-specialists for the assessment, management and follow-up of mental, neurological and substance use disorders (including depressive disorder). Given that mhGAP-IG.v2 is a generic tool, it requires adaptation to take account of cultural differences in depression presentation and unique characteristics of China’s emergent mental health system.

Methods

A two-round, web-based, Delphi survey was conducted. A panel of primary care doctors from Shenzhen, were invited to score their level of agreement with 199 statements (arranged across 10 domains) proposing changes to the content and structure of mhGAP-IG.v2 for use in Shenzhen. Consensus was predefined as 80% panelists providing a rating of either “somewhat agree/definitely agree”, or “definitely disagree/somewhat disagree” on a five-point scale for agreement.

Results

79% of statements received consensus with a mean score of 4.26 (i.e. “somewhat agree”). Agreed adaptations for mhGAP-IG.v2 included:- an assessment approach which considers a broader spectrum of depression symptoms and reflects the life course of disease; incorporating guidance for screening tool usage; clarifying physicians’ roles and including referral pathways for intersectorial care with strong family involvement; aligning drug treatment with national formularies; stronger emphasis of suicide prevention throughout all sections of the guide; contextualizing health education; reflecting a person-centred approach to care. Panelists chose to maintain diagnostic and treatment advice for bipolar patients experiencing a depressive episode as in the current guide.

Conclusions

An adapted mhGAP-IG.v2 for depression recognises China’s cultural and contextual needs for assessment guidance; unique primary healthcare system organization, priorities and treatment availability; and diverse psychosocial educational needs. An adapted mhGAP-IG.v2 could both inform the future training programs for primary care in Shenzhen and also offer an additional mental health resource for non-specialists in other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00523-0.

A descriptive mapping review of suicide in vulnerable populations in low and middle countries

INTRODUCTION

In 2016, low-and-middle income countries (LMICs) accounted for 79% of the global suicide deaths. In LMICs, vulnerable groups-women, sexual minorities and refugees, and internally displaced persons (IDPs)-are at high risk of suicidal ideation, attempts and deaths by suicide, but information for designing targeted interventions for them is fragmented and missing, making it difficult to address gaps in the existing system. This review highlights these gaps by mapping: (a) risk factors associated with suicides and suicidal behavior including challenges in implementing targeted programmes for vulnerable groups; and (b) recommendations for effective suicide prevention interventions and strategies in LMICs as documented in the literature.

METHODS

A descriptive mapping review of literature was conducted. Three electronic databases-PubMed, Google Scholar, and Refworld-were searched for specific keywords. The researchers mapped and reviewed 34 studies on suicide and suicide prevention across three main vulnerable groups.

RESULTS

This review highlighted the need for gender-specific interventions for women and sexual minorities, addressing gender-based discrimination, access to healthcare, abuse and violence, while for refugees and IDPs, critical concerns are monitoring and understanding suicidal behaviors and to address psychological and emotional responses to resettlement.

CONCLUSION

In LMICs, specific and unique socio-cultural and environmental factors may increase the risk of vulnerable groups to suicidal behaviors. In order to develop effective and comprehensive suicide prevention strategies, it is crucial to evaluate these differential risk factors and develop culturally appropriate and sensitive interventions and strategies.

Trends in suicide rates and the case-fatality of pesticide self-poisoning in an agricultural county in china, 2009 to 2014

BACKGROUND

Suicide rates in China have declined substantially in the last two decades, however, the correlates of the decreases are still unclear.

METHODS

Using hospital-based suicidal acts registry system in Meixian county, we reviewed all episodes of suicidal behaviors presented at hospitals from 2009 to 2014. The data was combined with the suicides reported in the same period by the county's Center for Disease Prevention and Control. Stratified by gender and method, age-standardized incidences of suicide death, suicide attempts, suicidal acts, as well as the case-fatalities of suicidal acts, were calculated. Joinpoint regression analysis was applied to test the time trends changes of the annual incidences and case-fatalities. Correlation coefficients between suicide rates and case-fatality were estimated.

RESULTS

Age-standardized suicide rates among females declined by 20.4% per year, meanwhile, overall suicide rates were characterized by downward trend without statistical significance. The annual proportions of suicide deaths by pesticide self-poisoning ranged from 57.1% to 82.6%. There were positive or marginally positive correlations between suicide rates and case-fatalities of suicidal acts in gender- and method-specific groups (r values range from 0.77 to 0.89).

LIMITATIONS

Underreporting in the hospital-based registry system and misclassification in the death reporting system. Changes in other related factors are not yet accessible.

CONCLUSION

Suicide rates in females declined prominently in Meixian from 2009 to 2014, even though overall suicide rates remained steady. Pesticide ingestion were most common suicide method. Restriction of pesticide and reduction in the case-fatality are critical targets of suicide prevention in rural China.

Comparison of Characteristics of Suicide Attempts Registered in Urban and Rural Areas in China

Objective: The objective of this study is to compare the characteristics of suicide attempts registered in general hospitals in urban and rural areas in China. Methods: From January 2007 to December 2011, suicide attempts registered in hospitals in five rural counties and in the Beijing Municipality were included. Univariate and multivariate analysis were used to compare the characteristics of rural and urban suicide attempts in China. Results: A total of 5,515 episodes of suicide attempts were included, 1,966 (35.6%) of them were from rural counties and 3,549 (64.4%) were from Beijing. Compared with urban counterparts, the rural suicide attempters had lower proportion of females (61.9% vs. 72.3%), more likely reporting previous suicide attempt history (56.9% vs. 16.4%), and staying in hospital for more than 1 day (81.5% vs. 44.6%). The most common methods of suicide attempts were pesticide ingestion in rural areas (52.1%) and taking medications in urban area (39.2%). Results of multivariate analysis indicated that suicide attempt registered in rural areas, pesticide ingestion, and previous suicide attempts history were associated with longer treatment in hospitals. Conclusions: Suicide attempts registered in rural areas were different from those in urban areas in China. It is essential to improve the equipment and ability of medical resuscitation for pesticide ingestion in rural hospitals in China.

Prospective study of association of characteristics of hotline psychological intervention in 778 high-risk callers with subsequent suicidal act

OBJECTIVES

This study aimed to assess the association of the quality scores of hotline psychological intervention and the reduction of subsequent suicidal acts among high suicidal risk callers.

METHODS

High-risk callers at a national crisis hotline service in China were recruited and prospectively followed for up to 3 months after receiving a hotline psychological intervention. The quality of the intervention was evaluated by supervisors who listened to the tape-recorded calls using the Counseling Skills Rating Scale for Psychological Support Hotlines, which assessed three counseling domains: process, attitude and communication skill. The primary outcome was the occurrence of suicidal acts during the follow-up period. Secondary outcomes were before versus after changes during the intake intervention call in hopefulness, psychological stress and suicide intention reported by the callers.

RESULTS

Over the 3-month follow-up, 45 of 778 high-risk callers reported 61 suicide attempts, and 3 other callers died by suicide. Subsequent suicidal act was significantly more common in callers classified as being at higher risk during the intake call. Higher scores on the quality of suicidality assessing of the Counseling Skills Rating Scale for Psychological Support Hotlines were associated with reduced risk of suicidal acts during follow-up (hazard ratio = 0.38, 95% confidence interval = [0.18, 0.85]). Higher scores on the communication skill domain were associated with increases in hopefulness (β = 0.09) after the intervention, and higher scores on the counseling process domain (β = -0.12) and higher suicidal risk scores (β = -0.12) were associated with decreased suicide intention after intervention.

CONCLUSION

Several characteristics of a hotline intervention for suicide prevention were associated with decreased risk of suicidal acts during follow-up. Intervention skill training for hotline operators should emphasize these specific counseling skills.