Suicidal behaviors and associated factors among patients attending an emergency department: a facility-based cross-sectional study

The main objective of the present study was to assess the magnitude of suicidal behaviors and the possible factors associated with suicidal behaviors among patients attending ED of AABET. To the best of our knowledge, this is the first study to screen suicidal behavior and/or suicide attempts in Ethiopian patients who visit the ED. The results showed that the prevalence of suicidal attempt was 6.3% and the rate of suicidal behavior was 8%. There were even sex distribution for suicidal attempts in the overall participants. Suicide was attempted most frequently in the age group 18–24. The common underlying reason for the attempt was social reasons, while the most frequently reported attempt method was hanging. The majority (60%) reported that they feel happy for surviving. No factor was found to be significantly associated with suicidal attempt.

We have screened that 43% the participants had CMDs, which is comparable with a recent large scale study report that based on several national registers [44]. A meta-analysis study found that a psychiatric-related illnesses were around 85% among patients with suicidal behaviors in EDs [43]. Likewise, another meta-analysis study on the prevalence of a psychiatric-related illnesses at EDs reported that 4% of the attendants were because of mental-illnesses, but around 58% of attendants were identified with a mental illness history [78]. In contrast, our finding is higher than other studies that reported 30–36% depression or mood disorders but these studies assessed only affective disorders [79‐81]. Regardless of the magnitude variations across different nations, results show that mental-illnesses are a common problem among patients attending EDs. However, most patients with suicidal behaviors at the EDs are discharged without receiving assessments for common mental-illnesses [30, 82].

The present study detected that suicidal behavior among patients attending ED is 8%, which is comparable with previous finding (10%) among patients attending a primary care facilities in five low-and middle income countries, including Ethiopia [7]. However their report [7] indicates that the overall prevalence of suicide attempt (2.2%) was lower than our finding. Moreover, the present suicidal behavior magnitude is in the range of prevalence that Jordans, Rathod [7] found in five countries: suicidal ideation in facility-based samples was 5.0-14.8%, while it was 3.5–11.1% in community-based samples. Our finding is also consistent with previous suicidal behavior reports in the USA [83, 84] but slightly higher than most multicenter-based findings (3–6%) in the USA [35, 85, 86] and China [87]. However, our finding is lower than the report (12%) of the same team [81] and other reports (12.8%) among patients in the EDs in the USA [80], indicating that suicidal behaviors vary across nations.

Furthermore, the magnitude of suicidal attempt in Ethiopia is not consistent [31‐34, 56‐63]. The present results showed that the prevalence of suicidal attempt in the ED is 6.3% which is higher than the global lifetime prevalence rates of 2.7% [88] and some previous reports in the Ethiopia general population that ranges between 0.9 and 4.4% [58‐60, 63]. Other studies in Ethiopia reported that a suicidal attempt among psychiatric patients [31‐34, 59] and epileptic patients [61] ranges between 4.1 and 51.3%, which is higher than the findings in the general population and the present finding. However, the prevalence obsereved in our study is generally in agreement with previous reports about overall suicidal attempt in the Ethiopian general population that ranges between 1.4 and 19% [for review, see 56]. Altogether, the present result shows that the magnitude of a suicidal attempt among patients in the ED lies between previous reports about suicidal attempt in the general population and patients with psychiatric disorders. This could be explained by the fact that our study was done in emergency patients who are at high risk as compared to the general population found in the community, but at a lesser risk than patients with severe mental illness.

Interestingly, the sex distribution of the suicidal attempt in the present study varies based on the age category, which is comparable with sex and gender based suicidal behavior in South Africa [89]. In the present study, females predominate in attempt distribution for the 18–27 age category, but males predominate for the 28–37 age category, and both sexes are similar in the 38–47 age category. However, regardless of age category, the overall sex distribution of suicidal attempt is nearly equal for both sexes, which is comparable with previous studies in Ethiopia [55] and at the ED in the UK [26]. Likewise, Kebede and Alem [64] found that magnitude of suicidal attempt and ideation among adults in Addis Ababa are similar for female and male, although female sex and younger age group is associated with suicidal ideation. A previous study in our facility that focused on suicidal behaviour among outpatient adults found that there was no significant difference in suicidal attempt by sex, although females had significant predominance in suicidal behaviours than males [59]. There was no association between suicidal behaviour and gender among high-school adolescents [64]. Alem, Kebede (61) also found that the sex distribution for suicidal attempt among adults in Butajira/Ethiopia is nearly equal. On the contrary, a study conducted in Gambella/Ethiopia reported that more female youths in the age group of 20–28 attempted and completed suicide [58]. The findings for sex-based distribution in suicidal attempt in Africa is mixed, some reporting equal ratio or higher prevalence in either male or females [see 55 for review], which is comparable with reports from the European multi-center study some decades ago [6]. On the other hand, the evidence from Italy showed that females have predominance in attempting suicide [13]. Jordans, Rathod [7] and colleagues also found that the overall suicidal behavior is associated with being female in five low and middle income countries. Another study in South Africa found that being female was associated with suicidal behavior, although the suicidal attempt was nearly equal among both sexes [89]. Moreover, among adults with psychiatric disorders in Gonder/Ethiopia, Mekonnen and Kebede [31] found that more females attempted suicide than males, although suicide ideation is similar for both sexes. There were no sex differences in suicidal behavior among adults with psychiatric disorders in Jimma/Ethiopia [32]. Likewise, Shibre, Hanlon [33] reported that there were no sex differences in suicidal attempt among people with psychiatric disorders in Butajira, although completed suicide was more common in males. The equal prevalence between females and males in most studies in Ethiopia could be because of the belief in society that “suicide is a cursed act” that makes females more conservative in disclosing about their suicidal behavior. These results overall suggest that although males and females are equal suicide ideators and attempters in the general population, females in the younger age group need special attention to prevent suicidal behavior.

In our study, the most common age of suicidal attempt was 18–24 years, which is in agreement with previous community-based [60, 63] and facility-based studies in Ethiopia [32]. Importantly, Kebede and Ketsela [57] reported that suicidal attempts in adolescents in Addis Ababa high schools is 14.3% that is higher than studies in the general population, which may indicate that the adolescent age group is at higher risk. Likewise, a community-based study among high school students found that suicide attempt is around 16% [64]. Studies in different countries, including South Korea, USA, Jamaica and Spain, reported that the suicidal attempt rate in late school-aged children and adolescents is around 4–25% [16, 36, 42, 90‐92]. For example, a study in the USA reported that the rate of suicidal attempt in adolescent is 7.4% [28], but the risk of suicide is higher (18.5%). Scocco, de Girolamo [13] also reported that although the overall rate of suicidal behavior (i.e., 4%) or attempt (i.e., 0.5%) was lower in Italy relative to other European countries, there was increased risk of suicide ideation among students (OR, 4.0). Whittier, Gelaye [60] also found that suicidal behaviour is most common in middle-aged adult outpatients in Ethiopia. A cohort study conducted in Butajira by Shibre, Hanlon [33] found that being ≥ 40 years was inversely correlated with suicidal attempt in people with mental illness, similarly indicating that younger age is a risk factor for suicidal behaviour. Alem also showed that there seems to be a decline in the frequency of suicidal attempt with increasing age [60], which is consistent with the finding in Italy [13]. A facility-based study in South Africa reported that suicidal behavior is inversely associated with age [89]. Likewise, a study in the USA reported that suicidal behavior declined with age among older patients attending an ED [93], although there are contrasting reports regarding the association of age and suicide [53]. There are several factors that might trigger adolescents or youths around 20 years old to have suicidal behavior. Some of the important factors include drug or alcohol abuse, psychotic disorders, smoking, a history of sexual abuse, severe medical conditions, and parental issue [52, 90]. Previous suicide attempt history is also associated with current suicide attempt among adolescents, compared to adults,in the emergency departments [74]. Overall, the present result supports previous findings that the younger adults are more vulnerable to suicidal behavior.

Regarding method of suicidal attempt, the present result showed that the predominant methods were hanging and poisoning which is in agreement with previous facility or community-based studies in Ethiopia [31‐34, 58, 60, 61, 63, 94]. Likewise, the most common methods of suicidal attempt in African countries are hanging and poisoning [95]. In our study, intentional pesticides use rather than medication-overdose was the most common method of poisoning next to hanging, which is also comparable with other studies in Ethiopia [32, 33] and Africa [96]. Our finding is also consistent with the global suicide rate (14–20%) because of pesticide self-poisoning [97]. A previous study at a specialized hospital in Ethiopia also showed that pesticide poisoning most frequently applied as a suicidal attempt method, suggesting that pesticide-use control method is nationally required [98]. The other important finding in the current study is that electricity was as common as pesticide-based poisoning method, although it was rarely reported in previous studies [31, 94]. Overall, although it is easy to identify the common suicide attempt methods, the intervention program may not be as easy as a policy implications for pesticide control mechanisms. A “one-size-fits-all” approach to reduce or to prevent suicidal behaviour will not be effective [99]. Therefore, holistic approaches starting from mental-health assessments in the EDs and exploring the psychopathology of suicide to multiple clinical treatment options warrant.

The majority (44%) of participants in our study stated that their underlying reason to attempt suicide was social problems (such as divorce or conflict with other people) which is comparable with other community-based [60] and institution-based studies in Ethiopia [61]. Our finding also showed that mental illness and other medical conditions are the second and third most common reasons to attempt suicide, respectively. We also found that all (100%) of patients who attempted suicide were with CMD, and 97.7% of suicidal behaviours were among patients with CMD. Mekonnen and Kebede [31] reported that social reason (21%) was a second predominant factor next to medical illness (65.1%) to attempt suicide. The main reason for the discrepancy between Mekonnen and Kebede [31] and our result might be due to that they conducted their studies among adults with psychiatric disorders, while we conducted among adults in the ED. Although poor social support, occupation status, and alcohol use level showed crude association with suicide attempt, multivariate analysis failed to show significant association between one of those factors or other factors (such as sex, age, substance use history and mental illness) and suicidal attempt. Likewise, other community or facility-based studies in Ethiopia did not find associations between sex, ethnicity, or religion and suicidal attempt [63] or between suicidal attempt and sex, marital status, educational level, religion, family history of suicide or type of mental illness [31]. In contrast, facility-based studies conducted in Jimma [32] and Mekelle [34] found that factors such as major depressive disorder, other mental illnesses or family history of mental illness are associated with suicidal behaviour among people with psychiatric disorders, which are consistent with reports from other countries [38, 39]. In addition, alcohol use disorder and nicotine dependence are associated with suicidal behaviour among people with mental illness in Ethiopia [32]. Another community-based study in Ethiopia found a strong association between major depressive disorder with suicidal attempts among people with severe psychiatric disorders [33]. Haile, Awoke [62] also found that poor social support, mental illness or co-morbid depression and family suicide history were associated with suicidal behaviour among patients with epilepsy. Overall, results support that mental illnesses, poor social support, and alcohol use level are important risk factors for a suicidal behavior.

We found that around one third of participants (36%) attempted suicide more than once. A study in Ethiopia reported that a previous attempts history and family history of suicide [34] are associated with suicidal behaviour among people with mental illness. Studies in several countries also showed that a prior suicidal attempt or thought [100‐106] and family history of suicidal attempt [38‐40, 107] were associated with an increased risk of a new suicide attempt. Importantly, some studies emphasized that a prior suicide attempt is the greatest predictor of a completed suicide [37] or a subsequent attempt [36]. A study conducted in four English speaking countries showed that the factors that have strong association with suicidal behaviour were depression, hopelessness, poor self-esteem, poor resilience, and less access to mental health services [103, 108]. However, earlier identified risk factors such as depression, hopelessness, impulsivity or most psychiatric disorders do not strongly predict suicidal attempts but suicide ideation [9]. It has been found that in addition to non-fatal self-harm [50], factors that decrease fear of death, pain or injury make the transition easier from suicidal ideation to action [for review, see 8]. In general, worldwide evidence suggests that important risk factors for suicide among adolescents or late school-aged children include mental illnesses, suicide attempt history [36], self-esteem and bullying, personality traits, family issues, and means of committing suicide [for review, see 19, 53].

Finally, the present study tried to screen the magnitude of suicidal behaviors and associated factors using standard instruments tools. It has the strength to provide valuable baseline data to initiates further studies and also to devise interventions since suicidal behavior studies among ED patients are lacking in Ethiopia. Screening for suicidal behaviors in ED patients will be an important opportunity for suicide intervention program. However, the present study has important limitations to be considered in the future studies. First, it was not free from social desirability bias as the data was collected by a face to face interview approach that might result in over-or under reporting. Second, there might be recall bias because of forgetfulness and the information they provided was not cross-checked. Third, the present study included only adult patients in the ED. Future studies need to include school- children and adolescents. Fourth, the present study focused on CMD but not subgroups of patients. Further screening of mental illness in the EDs and its association with suicidal behavior is required. Lastly, future multi-centre studies need to assess the main medical conditions of ED visiting patients to identify whether visit triggering medical conditions and suicidal behaviours are associated.