Rural and Remote Health Journal

Original = Research

Suicide and attempted = suicide: the=20 Rehoboth experience

Submitted: = 24 December=20 2005
Revised: 20 July 2006 =
Published:=20 30 October 2006=20
Author(s) : Ikeal= umba=20 NV, Couper= =20 ID.

<= /TD> <= /TD>

Ndidi=20 Ikealumba Ian=20 = Couper

Citation: Ikealumba NV, Couper=20 ID. Suicide and attempted suicide: the = Rehoboth=20 experience. Rural and Remote Health 6 (online), = 2006:=20 535. Available from: http://www.rrh.org.au=20

[Vi= ew=20 Author Details]
ABSTRACT

Introduction:=20 St Mary=92s Hospital in Rehoboth, Namibia, attends to = all=20 individuals who have health problems that are = considered=20 serious by the community. The aim of this study was to = describe the existing suicide management approach in = Rehoboth.=20
Method:=20 Clinical charts of all patients who attended St = Mary=92s=20 Hospital Rehoboth were manually collected and = reviewed. In the=20 process, analysis of the past records of patients of = Rehoboth=20 who exhibited the risk factors and/or were diagnosed = and=20 treated for suicide and/or attempted suicide for a=20 predetermined period of 1 January to=20 31 December 2001 was undertaken.
Results:=20 A total of 45 individuals were found to have = attempted=20 and/or committed suicide out of a total of 12 910 = patient=20 visits for the period. Of these, 51% were admitted, 7% = were=20 referred out and 42% were treated as out patients. = Sixty-three=20 per cent of the people used prescribed and over the = counter=20 drugs for attempting suicide. The words suicide = or=20 attempted suicide were not commonly used by = healthcare=20 providers in Rehoboth. Incidentally, HIV/AIDS did not = seem to=20 be associated with the patients who attempted suicide = in this=20 community.
Conclusions:=20 While there was no particular strategy in place in = Rehoboth to=20 deal with suicide and parasuicide, the emergency care = for=20 patients who attempted suicide in Rehoboth was = apparently=20 adequate, with no deaths in the hospital. However, the = lack of=20 a clear, coordinated multidisciplinary management = approach to=20 the survivors of a suicide attempt appeared to be a = serious=20 gap in management. It is also recommended that an = appropriate=20 name, code, recording and reporting system for suicide = and=20 attempted suicide should be adopted for use by health = care=20 personnel in Namibia in order to more accurately = document the=20 level of suicidal activity in the country. =

Key=20 words: Africa, Namibia, suicide, suicide = attempt.=20

ARTICLE

Introduction

The word = suicide=20 derives from a synthesis of Latin words su=EE = (of=20 himself) and caed=EAre (to kill)¹. Attempted suicide is = self-harm with=20 intent to kill.

Worldwide, suicide is the = third most=20 common cause of death in adolescents and young = adults². Suicide attempts outnumber = successful=20 suicides by as much as 200:1. Generally women make = more=20 attempts than men but successful suicide is four times = more=20 common in men^3,4. Professional women, including = physicians, have higher suicide rates than = professional=20 men^4,5. Native Americans have much = higher=20 suicide rates than blacks and Hispanics in the = USA⁵. Divorced, widowed, and = separated=20 individuals have higher suicide rates than married=20 people^4,6.

Suicide is more = common,=20 particularly in men of all ages, in rural areas = compared with=20 urban areas of Australia⁷ and the USA⁸. A number of studies from = different=20 countries have suggested that farmers have a = particularly high=20 suicide rate⁹.

Many factors are = associated with=20 suicide but the common denominator seems to be = depression and=20 emotional instability^3,4,5,=20 where the affected individual sees death as the only = way out=20 of what ever s/he considers to be the problem. =

Mental=20 illness and socioeconomic status are also factors to = consider=20 when assessing suicide risks. People with history of = mental=20 illness and a high income are at greater risk of = committing=20 suicide than their lower income counterparts, probably = because=20 the rich feel more ashamed, vulnerable, and = stigmatized by=20 their perceived failure¹⁰.

One study found that = the=20 relative risk of suicide in men with AIDS aged=20 20-59 years was 36 times that of men of the = same age=20 without this diagnosis and 66 times that of the = general=20 population¹¹. AIDS is thus a recognized = significant=20 risk factor for suicide^11,12.

There are no research = reports=20 on suicides and attempted suicides in Namibia. = However, some=20 records do show that the populace recognizes it as a = problem.=20 A lack of sufficient counselling for people infected = with=20 HIV/AIDS was one of many factors contributing to the = high=20 suicide rate in the North of Namibia, according to = students in=20 the Oshana region¹³. Guchu, in his outcry for the = impact of=20 HIV/AIDS on death rates in Namibia, calls on the = communities=20 to become actively involved as the situation was seen = to be=20 very serious¹⁴. This gained more credence = when Secure=20 the Future¹⁵ noted that the availability = of lay=20 counsellors will provide some data on the increasing = incidence=20 of suicide among young people, which is suspected to = be linked=20 to HIV infections.

Study=20 setting

The setting for this study was = St=20 Mary=92s Hospital in Rehoboth which is approximately = 87 km=20 south of Windhoek (capital of Namibia) along the = highway to=20 the Republic of South Africa. With its three feeder = clinics,=20 St Mary=92s Hospital is the only hospital catering for = a=20 district with a population of approximately = 44 000=20 people. Approximately 36 000 people live in the = municipal=20 area (where St Mary=92s Hospital is located) while the = remainder=20 are in the Rehoboth Gebiet (the surroundings of = Rehoboth which=20 are mainly in the form of farm settlements and rural=20 villages). Like most of Namibia, the area is a rural = one, with=20 a population density of 4 persons per square=20 kilometre¹⁶. Agriculture is the dominant = industry.=20 Although Rehoboth is a rural town, it is a vibrant = community=20 with most inhabitants in the low and middle = income-earning=20 brackets.

There is great understanding between = public=20 and private sector doctors in Rehoboth. Both = professional=20 groups admit patients into St Mary=92s Hospital. All = emergency=20 patients go first to the outpatients department (OPD), = which=20 serves as the emergency department of the hospital, = from where=20 the appropriate doctor is called in to see the = patient. All=20 the doctors are generalists; the nearest specialists = are in=20 Windhoek.

The aim of this study was to describe = existing management modalities for suicide and = attempted=20 suicide in Rehoboth and to reflect on the findings in = order to=20 highlight areas for improvement. Prior to this, there = has been=20 no specific study on suicide in Rehoboth.

Methods

This was a=20 retrospective descriptive study using chart reviews. A = review=20 was performed on the past records of patients who = attended St=20 Mary=92s Hospital, Rehoboth and were diagnosed and = treated for=20 suicide and/or attempted suicide during the period=20 1 January to 31 December 2001. This was = performed by extracting all the outpatient and = in-patient=20 records for the period and reading through them in = search of=20 the listed reasons for consultation. In the case of=20 in-patients, their final discharge summaries were also = studied. Both private and public patients=92 records = were=20 included.

The records of the following = patients were=20 included in the study:

Patients 10 years of age and older with a = record of=20 suicide or attempted suicide.
Patients who admitted that they had attempted=20 suicide.
Patients where relatives and/or friends implied = or=20 stated that an act of suicide had been intended.
Patients who refused to communicate, after an = apparent=20 failed suicide attempt.
Patients with a history of obvious emotional or = mental=20 health problems around the time of an indeterminate = act of=20 possible attempted suicide.
Patients with a questionable history of suicide = but with=20 a previous history of attempted = suicide.

Records=20 of the following class of patients were excluded:

Age less than 10 years.
Geriatric patients of older than 70 years who = were on=20 the same drugs as the ones used for the questionable = event=20 and where there was a confounding element of = dementia or=20 cognitive impairment.
Where patients and their relatives clearly = stated that=20 there was a mistake in the counting and taking of=20 medication.

Written permission was obtained = from the=20 Principal Medical Officer, St Mary=92s Hospital and = the Head of=20 the District Health Coordinating Committee, Rehoboth, = before=20 the study was carried out.

Results

The total = number of OPD=20 and admitted patient records for the period under = review was=20 12 910.

Records of 45 patients with = suicide=20 and/or attempted suicide were found, of which 53% were = female=20 and 47% were male (Table 1).

Table 1: Age = and sex=20 distribution for suicide/attempted suicide = (n =3D=20 45)

= A=20 majority (51%) of patients were admitted to hospital, = while 19=20 (42%) were seen as out patients and sent home, and 3 = (7%) were=20 referred out. In only 3 of the 45 patient records = was=20 there evidence of referral to social welfare services = prior to=20 discharge.

There were no deaths among those who = were=20 admitted to Rehoboth. Out of the three patients who = were=20 referred to Windhoek, one of these died at the = referral unit.=20

In terms of associated conditions, 3 patients = were=20 noted to be pregnant, one each was found to have = diabetes=20 mellitus and pulmonary TB respectively, and none were = noted to=20 be HIV positive.

Only five patients, out of = the 45=20 studied, had reasons clearly stated in their records = for their=20 attempted suicide, all related to domestic problems, = viz.=20 =91problems at home=92 (3), =91upset at home=92 (1), = and =91disagreement=20 with daughter at home=92 (1).

A range of = descriptions=20 for suicide was used in the records studied=20 (Fig 1).

Figure=20 1:  Descriptions used for = suicide/parasuicide in=20 patients=92 files. Note that the same patient record = could have=20 more than one expression concurrently.

The = most=20 common methods of committing or attempting suicide = were by=20 using prescription drugs (63%), self-inflicted knife = wounds=20 (26%) and chemical poisons (11%).

Knives were = used to=20 cut the wrists (6), the throat (1), the head (1), and = the=20 vagina (1). All the knife users were males except a=20 40-year-old woman who attempted suicide by cutting her = vagina.

Of the four patients who used = chemicals, one=20 drank crushed batteries while the others swallowed ant = poison.=20

The drugs used in the suicide attempts are = listed in=20 Table 2.

Table 2:  List of drugs = used in=20 suicide attempts

The=20 distribution of suicide acts across the months in the = year as=20 well as the range of time in the month were also = studied=20 (Table 3, Fig 2).

Table=20 3:  Distribution of suicide attempts over = the=20 year

Figure=20 2:  Timing of suicide attempts within each=20 month.

Discussion

The total = number of=20 suicide cases for the period studied was 45. = Considering the=20 fact that all patients attended St Mary=92s Hospital, = this=20 represents an incidence of 102.3 suicide and attempted = suicide=20 cases per 100 000 population. This was considered = to be=20 high. However, out of this, there was one death, = giving a rate=20 of 2.3/100 000 which is lower than international and = regional=20 figures^17,18. This may be because it is a = rural=20 area; national figures are not separated into urban = versus=20 rural, whereas it could be postulated that = urbanisation may be=20 associated with greater risk of suicide. However, the = evidence=20 internationally suggests that people in rural areas,=20 particularly men, are at greater risk of = suicide^7-9=20 than their urban counterparts.

The WHO listed = New=20 Zealand in 1996 as having the highest suicide rate in = the=20 world with 40.9/100 000 for males and = 10.8/100 000=20 for females¹⁸. Southern Africa was reputed = to have=20 the highest rate in Africa with an average of about = 5-7 per=20 100 000¹⁸.=20 There is a suggestion that this relates to the greater = degree=20 of development and urbanisation in South Africa. The=20 possibility is that the rural-urban gap may be much = smaller in=20 Namibia. This is in contrast, for example, with the = UK, where=20 a recent study found that the suicide rate in a poor = rural=20 area (Cornwall) has increased disproportionately over = the last=20 90 years¹⁹. It is difficult to postulate = the=20 causes for rural-urban differentials in suicide rates; = while a=20 range of possibilities have been suggested, an = Australian=20 study suggests rural people have significantly more = reasons=20 for living than their urban counterparts²⁰.

It is recognised that = the=20 Rehoboth figures do not include the small but possibly = significant number of suicide cases which might not be = reported to the authorities (Department of Health or=20 police).

The involved persons were mainly = healthy=20 adolescents and young adults, which fits into the = global=20 pattern^5,15,18,21. The traumatic versions = involved mainly=20 healthy men. Similar observations were made by El = Obeid et=20 al²² while looking at Namibia as a = whole.=20 The reasons for suicide in Rehoboth point to domestic=20 problems.

It is also interesting to note that = HIV/AIDS=20 was associated with an increased rate of suicide in = global=20 literature^12,23, but it did not seem to be so = in the=20 Rehoboth study. This would need to be verified as = there was no=20 specific process of recording HIV status for suicide = or=20 attempted suicide cases and this study did not search = for the=20 sero-status of attempted suicide patients beyond the = patient=20 records.

The absence of firearms as a method = of=20 suicide is interesting. In Australia, in the period = 1979-1998,=20 the most frequent method used by men was firearms = (27%),=20 followed by hanging (26%), carbon monoxide (20%), and=20 poisoning (12%)⁴.=20 The most common methods used by Scottish farmers were=20 similar⁹.=20 This may be a culturally-related = difference.

That only=20 three of the patients (7%) were referred suggests that = local=20 health professionals felt competent to handle the = majority of=20 patients, except where there were obvious = life-threatening=20 complications. It is of concern, though, that only = three of=20 the 45 patients were apparently reported to the = Intake=20 Officer of the Developmental Social Welfare Services=20 Department. This unit is supposed to follow up each = case to=20 deal with causative factors. In addition, 42% of the = patients=20 were treated and discharged as outpatients without = reassuring=20 evidence that they would not try it again, possibly = more=20 successfully. This is an area that calls for more = research,=20 and which should focus on following the attempted = suicide=20 patients to record the recurrence rate and outcome of = such=20 recurrences. It was noted that two patients out of the = total=20 of 45 attempted suicide cases actually repeated = the=20 attempts but neither was successful.

The fact = that the=20 death rate from attempted suicide in Rehoboth is = rather low=20 may suggest that the intervention by the hospital, = which is=20 fortunately centrally located, is sufficient in most=20 situations. Actual death rates as percentage of = attempted=20 suicide rates are difficult to obtain, just as it is = quite=20 difficult to confirm whether a suicidal person = (especially=20 after intense resuscitation efforts) really wanted to = die or=20 just call attention to him or herself.

Rehoboth = is a=20 rural community where trauma of all sorts tends to = increase=20 with money in circulation, especially if it goes along = with=20 weekends and/or public holidays²⁴. A closer look at the timing = of=20 suicides (Figure 2) reveals a major peak in attempted = suicide,=20 which corresponds with the days on which teachers and = the=20 majority of low income earners are paid. That peak=20 statistically lingers on into the end of the month = when the=20 rest of higher income earners are paid. The habit of = most=20 Rehobotherns is that once some people are paid, = virtually=20 everyone (employed or not) gets involved in the = celebration as=20 part of their communal lifestyle. One might have = expected this=20 to be the time when suicide is lowest, but Agerbo et = al¹⁰=20 and Jones⁶=20 suggest that the majority of suicides are signs of=20 expectations not met. The peaks in March and December = months=20 (Table 3) may relate to the Easter and Christmas = holiday=20 periods. The rest of Namibia seems to experience a = similar=20 association of increased suicide rates to increased=20 festivity/holidays and more money in = circulation^16,24.

A=20 significant difficulty in this study was the fact that = there=20 was no uniformity of nomenclature in the records. Only = eight=20 out of 45 patients had their diagnoses described as = suicide or=20 attempted suicide. This not only made the statistics = difficult=20 to access, it also served to hide the problem. This = problem=20 was further compounded by the finding that the = in-patient=20 discharge diagnosis and cause of death codes = (numerical=20 order), which is the reference document for coding of=20 diagnosis in health institutions in Namibia, did not = have the=20 word suicide represented in it at the time of=20 conducting this research.

The importance of = uniformity=20 of nomenclature in science cannot be overemphasized. = At=20 statistical level, the researchers could not find any = record=20 of suicide and/or attempted suicide in official = documents, not=20 because there were no cases, but because there were = other=20 expressions for the same condition. Some of those = expressions=20 trivialize the condition and reduce the seriousness of = interest and reporting sequences that should have = taken place.=20 At the national level, the health information system = should=20 reconsider this issue with the view to eliminating = euphemisms=20 from this serious medical condition. =91Suicide=92 or = =91attempted=20 suicide=92 should have their deserved places in the = diagnostic=20 codes for health care providers and statisticians to = use.=20 Utilization of The International Classification of = Diseases,=20 10th Revision (ICD-10) is recommended for this = purpose²⁵.

Conclusion

A = retrospective study=20 of suicide and attempted suicide, carried out in rural = Namibia, identified a high incidence of attempted = suicide, but=20 a lower than expected death rate from = suicide.

The=20 utilization of uniform nomenclature for recording = suicide=20 events was also identified as a priority for health = managers.=20 It is hoped that implementation of such an approach = may assist=20 Namibia, and other rural regions with similar = recording=20 ambiguities, to be alert to the actual incidence of = suicide=20 and para-suicide, and to develop appropriately = coordinated=20 strategies to reduce their impact on rural = communities.=20

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=A9 Ndidi Ikealumba, Ian = Couper 2006 A=20 licence to publish this material has been given to = Deakin=20 University, http://www.rrh.org.au=20

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