Suicidality and depression among adult patients admitted in general medical facilities in Kenya

Perspectives on reasons for suicidal behaviour and recommendations for suicide prevention in Kenya: qualitative study

BACKGROUND

Little is known about the reasons for suicidal behaviour in Africa, and communities' perception of suicide prevention. A contextualised understanding of these reasons is important in guiding the implementation of potential suicide prevention interventions in specific settings.

AIMS

To understand ideas, experiences and opinions on reasons contributing to suicidal behaviour in the Coast region of Kenya, and provide recommendations for suicide prevention.

METHOD

We conducted a qualitative study with various groups of key informants residing in the Coast region of Kenya, using in-depth interviews. Audio-recorded interviews were transcribed and translated from the local language before thematic inductive content analysis.

RESULTS

From the 25 in-depth interviews, we identified four key themes as reasons given for suicidal behaviour: interpersonal and relationship problems, financial and economic difficulties, mental health conditions and religious and cultural influences. These reasons were observed to be interrelated with each other and well-aligned to the suggested recommendations for suicide prevention. We found six key recommendations from our thematic content analysis: (a) increasing access to counselling and social support, (b) improving mental health awareness and skills training, (c) restriction of suicide means, (d) decriminalisation of suicide, (e) economic and education empowerment and (f) encouraging religion and spirituality.

CONCLUSIONS

The reasons for suicidal behaviour are comparable with high-income countries, but suggested prevention strategies are more contextualised to our setting. A multifaceted approach in preventing suicide in (coastal) Kenya is warranted based on the varied reasons suggested. Community-based interventions will likely improve and increase access to suicide prevention in this study area.

Community suicide rates and related factors within a surveillance platform in Western Kenya

BACKGROUND

Suicide is an important contributor to the burden of mental health disorders, but community-based suicide data are scarce in many low- and middle-income countries (LMIC) including Kenya. Available data on suicide underestimates the true burden due to underreporting related to stigma and legal restrictions, and under-representation of those not utilizing health facilities.

METHODS

We estimated the cumulative incidence of suicide via verbal autopsies from the Health and Demographic Surveillance System (HDSS) in Kisumu County, Kenya. We then used content analysis of open history forms among deaths coded as accidents to identify those who likely died by suicide but were not coded as suicide deaths. We finally conducted a case-control study of suicides (both verbal autopsy confirmed and likely suicides) compared to accident-caused deaths to assess factors associated with suicide in this HDSS.

RESULTS

A total of 33 out of 4306 verbal autopsies confirmed suicide as the cause of death. Content analysis of a further 228 deaths originally attributed to accidents identified 39 additional likely suicides. The best estimate of suicide-specific mortality rate was 14.7 per 100,000 population per year (credibility window = 11.3 - 18.0). The most common reported method of death was self-poisoning (54%). From the case-control study interpersonal difficulties and stressful life events were associated with increased odds of suicide in both confirmed suicides and confirmed combined with suspected suicides. Other pertinent factors such as age and being male differed depending upon which outcome was used.

CONCLUSION

Suicide is common in this area, and interventions are needed to address drivers. The twofold increase in the suicide-specific mortality rate following incorporation of misattributed suicide deaths exemplify underreporting and misclassification of suicide cases at community level. Further, verbal autopsies may underreport suicide specifically among older and female populations.

Intimate Partnerships, Suicidal Ideation and Suicide-Related Hospitalization Among Young Kenyan Men

The first study focused on a three-month chart review containing information on suicide attempts (n = 34) admitted to a local mission hospital in Meru County, Kenya. The second study utilized a cross-sectional survey administered to men 18-34 years old (n = 532) residing in rural Kenya. Data posit intimate partnership discord as salient to suicide ideation and behavior. Men who reported their partner status was "divorced" had four-times the odds of reporting suicide ideation than other partnership states, an association significantly mediated by loneliness. Violent conflict tactics predicted suicidal ideation, mediated by loneliness and decreased marital satisfaction.

What drives distress? Rethinking the roles of emotion and diagnosis among people with diabetes in Nairobi, Kenya

Type 2 diabetes mellitus is a condition that both results from and produces social and psychological suffering. As 'diabetes' increases among low income patients in poorer nations, new challenges arise that drive, co-occur, and result from the condition. In this article, we describe how social suffering produces diabetes by way of addressing the varied social, psychological, and biological factors that drive diabetes and are reflected in diabetes experiences among patients seeking care at a public hospital in Nairobi, Kenya. We recruited a non-probability sample to participate in a cross-sectional study of 100 patients (aged 35-65 years), where half of the participants sought care from a diabetes clinic and half sought care from the primary healthcare clinic. We obtained informed consent in writing, and collected life history narratives, surveys, anthropometrics, and biomarkers. This paper evaluates survey data using frequencies and regression tables. We found that social factors as opposed to disease factors were major drivers of psychological distress among those with and without diabetes. Psychological distress was associated with female gender and feelings of financial and personal insecurity. We also found insulin resistance was common among those undiagnosed with diabetes, suggesting that many seeking primary care for other health conditions did not receive a routine diabetes test (most likely because it is an out-of-pocket cost, or other competing social factors) and therefore delayed their diagnosis and care. Thus, social and economic factors may drive not only emotional distress among people with diabetes but also delayed care seeking, testing, and self-care as a result of cost and other social challenges.

Lifetime Prevalence and Determinants of Suicidal Ideation and Attempt Among All Patients Living with HIV/AIDS in Hiwot Fana Specialized Hospital, Harar, Ethiopia, 2020

Background

Suicide is a psychiatric emergency and the second leading cause of death among youths. Suicide risk is 7 to 36 times greater among PLWHA as compared to the general population. This study was aimed at determining the prevalence of suicide and its associated factors among PLWHA and attendings at Hiwot Fana Specialized University Hospital, Ethiopia, 2020.

Patients and Methods

We conducted a cross-sectional study on 412 randomly selected respondent PLWHA and attendingz at Hiwot Fana Specialized University Hospital from February 1–March 1, 2020. The interviewers administered a structured questionnaire consisting of the World Health Organization Composite International Diagnostic Interview (CIDI) tool to measure suicidality. We used the clinical records to collect clinical variables of the respondents. We used simple logistic regression ≤ 0.25 at p-value ≤ 0.25 and multiple logistic regression at p-value ≤ 0.05 to identify the predictor variables of the outcome.

Results

A total of 412 participants have completed the questionnaire, with a response rate of 97.4%. The majority, 252 (61.2) of the participants were female, while 112 (27.2%) of the respondents were in the age group of 28–37. The prevalence of suicidal ideation and attempt among PLWHA was 24.3% (CI; 20.4, 28.4) and 12.6% (9.5–15.8), respectively. Predictors for suicidal ideation were being in extreme poverty, living alone, widowed, CD4 level less than 250, and current alcohol use, and for suicidal attempt were an urban residence, stage IV HIV, family history of suicide, and depression.

Conclusion

Nearly one-fourth of the respondents reported suicidal ideation. So, early screening and working on those identified predictors of suicidality is vital to prevent the mortality of it in PLWHA.

Suicidality and associated risk factors in outpatients attending a general medical facility in rural Kenya

BACKGROUND

Low-and-Middle-Income-Countries (LMICs) account for 75% of global suicides. While primary care populations in high-income countries (HIC) typically have higher prevalence of suicidal behavior relative to general populations, few studies have explored suicidal behavior among general medical outpatients in LMICs. This study addresses the research gap by characterizing potential risk factors for suicidal ideation in a large general medical outpatient setting in rural Kenya.

METHODS

A cross-sectional study of adult general medical outpatients attending a rural sub-county hospital in Kaloleni, Kenya. Primary outcomes included major depressive disorder (MDD), posttraumatic stress disorder (PTSD) and suicidal behavior measured by the Mini International Neuropsychiatric Interview (MINI 5.0). We use binary logistic regression to model suicidality, mental disorders, intimate partner violence, and lifetime abuse.

RESULTS

394 outpatients completed the assessment. The prevalence of SI over the past month was 20%. 18% of those with suicidal ideation over the past month also attempted suicide in the past month. Participants who met criteria for MDD (suicidality item removed) were 19 times [CI: 4.56, 79.05] more likely to report suicidal ideation compared to those without MDD (adjusted odds ratio 12.15 [CI: 2.66, 55.49]).

LIMITATIONS

This was a cross sectional study design with convenience sampling and hence vulnerable to selection and recall bias.

CONCLUSION

The prevalence of SI and its strong association with actual suicide attempt in this population, make an urgent public health case for intervention. These data identify MDD as a highly significant correlate of SI.

Effect of fish oil omega-3 fatty acids on reduction of depressive symptoms among HIV-seropositive pregnant women: a randomized, double-blind controlled trial

BACKGROUND

Globally, it is known that HIV-infected pregnant women are prone to depressive symptoms. Research evidences also suggest that nutrient deficiencies may enhance the depressive illness, and that fish oil omega-3 fatty acids may alleviate the depressive symptoms. The aim of this study was to assess the effect of fish oil omega-3 eicosapentaenoic acid-rich supplements on depressive symptoms among HIV-seropositive pregnant women.

TRIAL DESIGN

A randomized double-blinded controlled trial with two parallel groups was conducted. The intervention group received fish oil omega-3 of 3.17 g (eicosapentaenoic acid = 2.15 g; docosahexaenoic acid = 1.02 g) per day for 8 weeks, while the control group received soybean oil for a similar period.

METHOD

Participants were HIV-seropositive pregnant women who were enrolled in prevention of mother-to-child transmission programs and attending antenatal clinics at selected Nairobi city county's health facilities. Recruitment was done from health records of HIV-infected pregnant women. Data analysis followed per-protocol analysis. Participants who completed the 8-week trial were included in the analysis of covariance statistical model with omega-3 as main effect. The covariates in the change in BDI-II depressive symptom score outcome were baseline characteristics and nutrient adequacy.

RESULTS

282 participants were recruited 109 randomized to fish oil, and 107 to soybean oil. Completion rate was 86/109 (78.9%) and 96/107 (89.7%) respectively. At the end of week-8 of follow up most participants in both arms had mild depressive symptoms 82/86 (95.3%) in the Fish oil group and 94/96 (97.9%) in the Soybean oil group. The difference in effect between the intervention and control group was not statistically significant (1.01 (95% CI - 0.58 to 2.60), p = 0.21).

CONCLUSION

Fish oil omega-3 with a daily dosage of 3.17 g (eicosapentaenoic acid = 2.15 g; docosahexaenoic acid = 1.02 g) appears to provide no added benefit in reduction of the symptoms of depression in HIV-infected pregnant women.Trial Registration Clinical Trial Registry: NCT01614249. Registered on June 5, 2012. https://clinicaltrials.gov/ct2/show/NCT01614249.

Mental Health Outcomes of Psychosocial Intervention Among Traditional Health Practitioner Depressed Patients in Kenya

Task-shifting in mental health such as engaging Traditional Health Practitioners (THPs) in appropriate management of mental disorders is crucial in reducing global mental health challenges. This study aims to determine the outcomes of using evidence-based mental health Global Action Programme Intervention guide (mhGAP-IG) to provide psychosocial interventions among depressed patients seeking care from THPs. THPs were trained to deliver psychosocial interventions to their patients screening positive for mild to severe depression on Beck's Depression Inventory (BDI). Assessments were conducted at 0, 6 and 12 weeks and Analysis of Variance (ANOVA) performed to determine the change in depression scores over the three time period. BDI mean score was 26.52 before intervention and reduced significantly at 6 (13%) and 12 (35%) weeks after intervention. 58 and 78% of patients showed reduction in symptoms of depression at 6 and 12 weeks. It is therefore crucial to engage THPs in the care of patients with depression and the need for inclusion of training packages; and other mental disorders in order to establish and maintain collaboration between THPs and conventional health workers and promote evidence-based care among marginalized populations. Moreover, further research on randomized control trials of mhGAP-IG intervention versus usual care is required.

Clinical correlates of suicidality among individuals with HIV infection and AIDS disease in Mbarara, Uganda

The association between suicidality and HIV/AIDS has been demonstrated for three decades, but little is know about risk factors that can help understand this association and help identify who is most at risk. Few research studies have been conducted in sub-Saharan Africa, a region that accounts for more than 70% of the HIV global burden. This paper describes clinical risk factors for suicidality among individuals with HIV infection and AIDS disease in Mbarara, Uganda. In this study, suicidality includes both suicidal ideation and suicidal attempts. A cross-sectional survey was conducted with 543 HIV-positive individuals aged 15 years and above, recruited from 2 HIV specialised clinics in Mbarara. Using logistic regression analysis, factors significantly associated with suicidality at 95% confidence interval were identified. The rate of suicidality was 10% (n = 54; 95% CI: 5.00-15.00). Risk factors for suicidality were: perception of poor physical health (OR 2.22, 95% CI 1.23-3.99, p = 0.007), physical pain (OR 1.83, 95% CI 1.01-3.30, p = 0.049), reducing work due to illness (OR = 2.22, 95% CI 1.23-3.99, p = 0.004) and recent HIV diagnosis (OR 1.02, 95% CI 1.01-1.03, p = 0.001). These findings suggest that HIV/AIDS in south-western Uganda is associated with a considerable burden of suicidality. HIV is associated with several clinical factors that increase vulnerability to suicidality. There is need for more appropriate interventions targeting these clinical risk factors, systematic suicide risk assessment and management of suicidal ideation and behaviours in HIV care.

Stress, diabetes, and infection: Syndemic suffering at an urban Kenyan hospital

The complexity of sickness among Kenya's urban poor cannot be dissociated from how social and health problems become syndemic. Increasingly diabetes and other non-communicable diseases (NCDs) are emerging among low-income populations that also are most afflicted by social stress and infection. This article examines how social stress, psychological distress, and physical illness among patients in a public hospital in Nairobi, Kenya, produce syndemic suffering, defined by lived experiences of syndemic clustering such as diabetes with depression and infection. We recruited 100 urban public hospital patients, of which half were women, and half had type 2 diabetes from June to August 2014. We administered written informed consent and collected anthropometrics and blood samples before we conducted lengthy mixed qualitative and survey interviews. We analyzed social stress in narrative interviews using content analysis and evaluated social and physical contributors to mental distress with frequency tables and logistic regression. We found that people experienced diabetes through a complex social and medical framework, where social problems were cause and consequence to psychological and physical suffering. Women's narratives revealed more social suffering as well as more mental distress and somatic symptoms, including multi-morbidities, than men's. People with diabetes reported not only concurrent anxiety and depression but also common infections, including malaria, tuberculosis, and HIV/AIDS. Narratives reveal how NCDs concurrent with infections, and HIV in particular, produce financial challenges for patients, especially when HIV treatment is free and patients must pay out-of-pocket for diabetes care. Future studies should investigate syndemic clustering of infections and NCDs among low-income populations at the population-level.

Tedium vitae, death wishes, suicidal ideation and attempts in Kenya-prevalence and risk factors

BACKGROUND

There has been no previous household population study of suicidal ideation and attempts in Kenya. Therefore this study aimed to establish the prevalence of suicidal ideation and attempts in a rural population in Kenya, and to assess risk factors.

METHODS

An epidemiological survey of a household population, using standardised structured interviews. We examined the prevalence of suicidal ideation and suicide attempts and the predictors of suicidal thoughts and attempts, using STATA to calculate unadjusted and adjusted odds ratios.

RESULTS

A quarter of the sample (24.1 %) had thought that life was not worth living (tedium vitae) at some point in their lives, while a fifth had experienced death wishes at some stage. About 7.9 % reported suicidal thoughts and 1.9 % had made actual suicide attempts at some point in their lives. It can be seen that the prevalence of suicidal thoughts was 0.7 %, 4.2 %, 3.7 % and 7.9 % for last week, last year, at some other time, and lifetime respectively, while the prevalence of suicidal attempts was 0.5 %, 1.2 %, 0.7 and 1.9 % respectively. In the adjusted analysis of factors associated with suicidal thoughts, being female (OR 1.8, p = 0.017), having CMD (OR 2.7, p = 0.001), having a number of recent life events (OR 2.3, p = 0.001 for 2-3 life events and OR 2.6, p = 0.004 for 4 or more life events), and having a large social group size (OR 7.7, p = 0.006 for social group size of 4-8 and OR 9.1, p = 0.003 for social group size of 9 or more) were all associated with increased rates of life time suicidal thoughts, but psychotic symptoms were no longer significant after adjustment for the other variables. In the adjusted analysis of suicide attempts, having any psychotic symptoms (OR 5.1, p = 0.001) was the only factor associated with suicide attempts after adjustment for other factors significant at the bivariate level.

CONCLUSION

Suicidal ideation and attempts pose a significant public health burden in this poor rural area of Kenya. The findings are relevant for mental health promotion and prevention programmes, public education and professional training programmes in relevant sectors, especially in front line health workers and social workers.

Prevalence, types and comorbidity of mental disorders in a Kenyan primary health centre

PURPOSE

To estimate the prevalence, types and comorbidity of the most common mental disorders and the spread of suicide risk in a primary care practice in Kenya.

METHODS

This was a cross-sectional descriptive study. A total of 300 adult outpatients were randomly selected while they were consulting their general practitioner. The M.I.N.I. Plus interview five was used to diagnose psychiatric disorders and suicide risk.

RESULTS

Thus, 56.3 % of the sample (n = 169) presented one or more psychiatric disorders. The most prevalent disorders were Affective (39.0 %), Anxiety (31.3 %), and Somatoform (13.0 %). Regarding specific disorders, the most common were Major Depressive Disorder (26.3 %), Agoraphobia (16.7 %), Pain Disorder (12.5 %), Generalized Anxiety Disorder (9.3 %) and Bipolar Disorder (9 %). We found three cases of Bulimia Nervosa (1 %); 29.7 % had more than one current mental disorder. Suicide risk was present in 12.7 % of participants. No associations were identified between socio-demographic factors and the presence of mental disorder. Suicide risk was higher in women and in patients who came from slum areas. Gastric pain was positively associated with presence of mental disorder.

CONCLUSION

High prevalence of mental disorders and suicide risk calls for integrating mental health services in primary health care; in particular, this study highlights the importance of differentiating between specific types of mental disorders (which require different therapeutic approaches), and of diagnosing comorbidities.

Psychiatric morbidity among physically ill patients in a Ugandan Regional Referral Hospital

BACKGROUND

Mental illness is a global health burden that remains poorly understood even by health care providers. It is important to get insight of the prevalence, clinical features and management of psychiatric morbidity in general practice in Uganda as it affects treatment outcome.

OBJECTIVE

To determine the prevalence, types and associations of psychiatric morbidity as seen among adult in-patients on medical and surgical wards of Mbarara Regional Referral hospital as a prototype Ugandan regional referral hospital.

METHODS

This was a cross sectional descriptive study. Psychiatric diagnosis was arrived at by administering the Mini International Neuropsychiatric Interview (MINI) as the diagnostic instrument.

RESULTS

Of the 258 participants in this study, 109 (42%) met criteria for at least one DSM IV psychiatric diagnosis. Only 6% of all the psychiatrically diagnosed patients were recognized by their treating doctors as having mental illness.

CONCLUSION

The psychiatric disorders on the general medical and surgical wards are highly prevalent and not recognized by staff on these wards despite their common occurrence. There is need for sensitisation of staff on recognition and management of psychiatric disorders in physical illness.

Psychological distress among adults admitted to medical and surgical wards of a Regional Referral Hospital, Uganda

BACKGROUND

Physical illness is commonly associated with psychological distress that may be a direct effect of the illness or an adjustment in coping with the physical illness or its treatment. Little is known about psychological distress of patients on general wards in developing countries.

OBJECTIVES

This study aimed to determine the extent and associations of psychological distress among adult in-patients on medical and surgical wards of Mbarara hospital in Uganda.

METHODS

It was a cross sectional descriptive study among 258 adult in-patients. The WHO endorsed self report questionnaire (SRQ-25) was used to assess psychological distress with a cut off of 5/6. The MINI International Neuropsychiatric Interview (MINI) was used to identify specific psychiatric disorders. Cross-tabulations and multivariate analysis was used to analyze the relationship between psychological distress and different factors.

RESULTS

One hundred and fifty eight individuals (61%) had psychological distress. One hundred and nine (42%) met criteria for at least one major psychiatric diagnosis. Only 6% of these were recognized by the attending health workers. Psychological distress was significantly associated with previous hospitalizations, ward of admission and marital status.

CONCLUSIONS

There is a high level of psychological distress among the physically ill and it is often unrecognized and untreated.