Lourens Schlebusch

Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey

BACKGROUND The objectives were to assess thoughts about suicide, plans to commit suicide and suicide attempts in the community, to investigate the use of health services following a suicide attempt, and to describe basic socio-cultural indices of the community. METHOD The community survey was one component of the larger WHO multisite intervention study on suicidal behaviours (SUPRE-MISS). In each site, it aimed at randomly selecting and interviewing at least 500 subjects of the general population living in the catchment area of the emergency department where the intervention component of the study was conducted. Communities of eight SUPRE-MISS sites (in Brazil, China, Estonia, India, Iran, South Africa, Sri Lanka, and Viet Nam) participated plus two additional sites from Australia and Sweden conducting similar surveys. RESULTS Suicide attempts (0.4-4.2%), plans (1.1-15.6%), and ideation (2.6-25.4%) varied by a factor of 10-14 across sites, but remained mostly within the ranges of previously published data. Depending on the site, the ratios between attempts, plans, and thoughts of suicide differed substantially. Medical attention following a suicide attempt varied between 22% and 88% of the attempts. CONCLUSIONS The idea of the suicidal process as a continuous and smooth evolution from thoughts to plans and attempts of suicide needs to be further investigated as it seems to be dependent on the cultural setting. There are indications, that the burden of undetected attempted suicide is high in different cultures; an improved response from the health sector on how to identify and support these individuals is needed.

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries

OBJECTIVE To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries. METHODS Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up. FINDINGS Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; chi2 = 13.83, P < 0.001). CONCLUSION This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.

Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries

BACKGROUND The objective was to describe patients presenting themselves at emergency-care settings following a suicide attempt in eight culturally different sites [Campinas (Brazil), Chennai (India), Colombo (Sri Lanka), Durban (South Africa), Hanoi (Viet Nam), Karaj (Iran), Tallinn (Estonia), and Yuncheng, (China)]. METHOD Subjects seen for suicide attempts, as identified by the medical staff in the emergency units of 18 collaborating hospitals were asked to participate in a 45-minute structured interview administered by trained health personnel after the patient was medically stable. RESULTS Self-poisoning was the main method of attempting suicide in all eight sites. Self-poisoning by pesticides played a particularly important role in Yuncheng (71.6% females, 61.5% males), in Colombo (43.2% males, 19.6% females), and in Chennai (33.8% males, 23.8% females). The suicide attempt resulted in danger to life in the majority of patients in Yuncheng and in Chennai (over 65%). In four of the eight sites less than one-third of subjects received any type of referral for follow-up evaluation or care. CONCLUSIONS Action for the prevention of suicide attempts can be started immediately in the sites investigated by addressing the one most important method of attempted suicide, namely self-poisoning. Regulations for the access to drugs, medicaments, pesticides, and other toxic substances need to be improved and revised regulations must be implemented by integrating the efforts of different sectors, such as health, agriculture, education, and justice. The care of patients who attempt suicide needs to include routine psychiatric and psychosocial assessment and systematic referral to professional services after discharge.

Controlling the environment to prevent suicide: international perspectives.

Background: Suicide and suicidal behaviour are multifaceted events requiring complex solutions. Controlling the environment is a neglected solution, despite strong support for this approach from the World Health Organization (WHO). Method To discuss this approach from a global view, this review is written by authors from various cultures: American, Australian, Canadian, Chinese, Cuban, Dutch, Indian, Irish, Japanese, Lithuanian, Native North American, Russian, and South African. Results We examine gun control to illustrate the environmental control approach; however, the worldwide diversity of suicide methods calls for diverse responses. Further, controlling the environment encompasses more than restricting the means of suicide, which we illustrate with examples of toned-down media reports and restricted medicine availability. Conclusions Controlling the environment may be a viable strategy for preventing suicide, although research shows that few clinicians implement such approaches.

Repetition of suicide attempts

BACKGROUND Attempted suicide is a strong risk factor for subsequent suicidal behaviors. Innovative strategies to deal with people who have attempted suicide are needed, particularly in resource-poor settings. AIMS To evaluate a brief educational intervention and periodic follow-up contacts (BIC) for suicide attempters in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, Peoples Republic of China) as part of the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS). METHODS Among the 1,867 suicide attempters enrolled in the emergency departments of the participating sites, 922 (49.4%) were randomly assigned to a brief intervention and contact (BIC) group and 945 (50.6%) to a treatment as usual (TAU) group. Repeated suicide attempts over the 18 months following the index attempt - the secondary outcome measure presented in this paper - were identified by follow-up calls or visits. Subsequent completed suicide - the primary outcome measure - has been reported in a previous paper. RESULTS Overall, the proportion of subjects with repeated suicide attempts was similar in the BIC and TAU groups (7.6% vs. 7.5%, chi(2) = 0.013; p = .909), but there were differences in rates across the five sites. CONCLUSIONS This study from five low- and middle-income countries does not confirm the effectiveness of brief educational intervention and follow-up contacts for suicide attempters in reducing subsequent repetition of suicide attempts up to 18 months after discharge from emergency departments.

Suicide prevention: a proposed national strategy for South Africa

Suicidal behaviour is an important public health problem globally and in Africa. A brief overview of the nature and severity of the problem is provided, but the primary aim of this paper is to identify priorities and prevention strategies for reducing suicidal behaviour in South Africa by discussing a framework for a proposed national prevention programme. South African suicide rates range from 11.5 per 100 000 to as high as 25 per 100 000 of the population, depending on sampling procedures and research methods. About 11% of all non-natural deaths are suicide related. On average 9.5% of non-natural deaths in young people are due to suicide. It is a complex phenomenon and risk factors are, therefore, multifactorial and multidimensional. Some of the most important ones are identified and several priorities and prevention possibilities for reducing suicidal behaviour are recommended. The outline and structure for such a national suicide prevention programme is underpinned by research undertaken locally and internationally. It requires a comprehensive multi-sectoral approach that involves both health care and non-health care sectors and action at various levels utilising a framework based on a set of guiding principles and a range of strategies with specific objectives as a national priority within an interdisciplinary context.

Depression and suicidal behaviour

Depression Depression afflicts people of all ages. It has a long historical past and has been described for centuries by poets, philosophers and physicians, and depicted in the works of some of the most creative artists. Depressive disorders are referred to as mood disorders because the predominant feature is a disturbance in mood. They are classified into major depressive disorder, dysthymic disorder, depressive disorder not otherwise specified, bipolar disorders I and II, cyclothymic disorder, bipolar disorder not otherwise specified, mood disorder due to a general medical condition, substance-induced mood disorder and mood disorder not o therw ise spec i f ied_ . Var ious psychopathological conditions have been identified as co-morbid or risk factors in the aetiology of suicidal behaviour, especially depression. This is also true for South Africa. A recent South African study reported that depression was the most common diagnosis, being present in nearly twothirds (63.9%) of non-fatal suicidal patients seen in a large academic hospital. Some 25 years ago depression was already considered such a major problem in South Africa that a group of experts conceived a national treatment programme. Depression which may co-occur with medical or psychiatric/psychological disorders may also be brought on by the use of certain medications. Other risk factors for depression include a personal or family history of depressive disorder, prior suicide attempts, substance use, lack of social support, and stressful life events. South African studies have also indicated a high incidence of depression in suicidal school children, findings which are of increasing concern. A sad mood is normally not considered to have passed into a clinical depression at a specific point. Usually it is diagnosed when the patient’s depressed mood persists for too long, has become pathological and interferes with the index patient’s psychosocial, biovegetative and other functioning. Therefore a combination of intensity, severity and duration of the depressive symptoms are significant markers in depression.

Age, Gender and Suicidal Ideation Following Voluntary HIV Counseling and Testing

The aim of this study was to determine the prevalence of suicidal ideation in patients who were tested for HIV-infection and whether along with their HIV status, age and gender influenced their risk for suicidal ideation. The sample consisted of 189 patients who attended a voluntary HIV counseling and testing clinic (VCT) at a general state hospital in Durban, South Africa. Their mean age at baseline was 34.2 years, with an age range of between 16–79 years. Seropositivity, age and gender were significantly associated with suicidal ideation. The majority of these patients were in the younger age group, and young males had a 1.8 times higher risk for suicidal ideation than females. Although risk factors for seropositive-related suicidal ideation can be complex and multi-factorial, this study identified a young age and male gender as important high risk factors in the sample studied. It is recommended that all, but especially young male HIV-infected patients seen at a VCT clinic be screened for suicidal ideation and that early intervention to prevent subsequent suicides or suicidal attempts be included in pre- and post-test HIV counseling.

Suicidal ideation in seropositive patients seen at a South African HIV voluntary counselling and testing clinic.

OBJECTIVE Suicidal behaviour and HIV/AIDS are significant public health concerns. The aim of this study was to investigate suicidal ideation in patients who were referred to a voluntary HIV counselling and testing (VCT) clinic and who were found to be seropositive. This in order to improve suicide prevention and intervention strategies amongst such patients. METHOD The sample studied consisted of volunteer adult patients referred over a three-month period to a HIVVCT clinic based at a university-affiliated general state hospital. Patients completed a questionnaire on sociodemographic data. Suicidal ideation was measured using the Beck Hopelessness Scale and the Beck Depression Inventory (BDI), at two time points (within 72 hours after notification and again at a 6 week follow-up). All patients received extensive pre-and post-test counselling. RESULTS HIV-test results were available for 189 (99.5%) of the original sample of 190 patients studied, with 157 (83.1%) testing positive. More females tested positive as did unemployed and single/divorced patients. The mean age for HIV-positive patients was 33.49 (SD = 9.449), and for HIV-negative patients it was 37.94 (SD = 15.238). Age was a significant factor in that for each year increase in age, the risk of testing HIV-positive decreased by 4.1%. Lower education and traditional beliefs were also significantly associated with testing HIV-positive. At 72 hours suicidal ideation was present in 17.1% (95% confidence interval 12.16% to 23.45%), and at 6 weeks in 24.1% (95% confidence interval 17.26% to 32.39%) of the seropositive patients. Their average BDI scores were 15.20 and 14.23 respectively at the two time points. CONCLUSION Suicidal ideation was present in a significant number of the seropositive cohort studied and increased over a six week period among these patients. The average BDI scores at both time points imply a clinical depression. The findings also suggest an association between positive HIV-test results and certain socio-demographic variables that can act as indicators for suicidal ideation in HIV-infected persons, although this requires further research. Although the relationship between suicidal ideation and HIV-infection is complex, it is an important consideration when assessing patient suicide vulnerability at HIV VCT clinics and when implementing suicide prevention and management strategies.

The development of a Stress Symptom Checklist

The development of a stress measure, and indications of its reliability and validity are reported in the present article. The human stress response and its deleterious consequences are discussed, including the fact that stress is a major problem in society at all levels of human interaction. South African stress levels are particularly high, and many lifestyle diseases, health-risk behaviours, suicidal behaviours, violence, trauma-producing behaviours, performance levels and difficulties in coping with change are stress-related, as are numerous medical, psychological and/or psychiatric disorders. Given this, a Stress Symptom Checklist (SSCL) was constructed as a user-friendly stress measurement. It was developed as part of a major stress research initiative. The aim was to produce an authoritative, reliable and valid stress checklist that can stand up to critical inspection, yet be an easy-to-use measure. It focuses on the respondents stress level rather than on the stimuli leading to that stress. It is not intended to be a diagnostic tool that measures specific stress-related psychopathological conditions or disorders, but rather the intensity (or severity) of stress as reflected by an individuals physical, psychological and behavioural reactions. To date, the data show that the SSCL is a useful measure of non-pathological stress in the general population. Further refinements and validation studies are in progress.