Ten-year Epidemiological Study on Suicide Attempts in Skopje, Republic of Macedonia

Abstract

The aim of our study was to provide basic epidemiological data on suicide attempts that resulted in admission to the University Clinic of Toxicology and Emergency Medicine in Skopje during a 10-yearperiod (1999-2008). There is a lack of published information regarding suicide attempts in the Republic of Macedonia. Methods: Participants were 1683 patients from the territory of Skopje, who attempted suicides and who were hospitalized in the University Clinic of Toxicology and Emergency Medicine in School of Medicine, Skopje during the period of ten years (1999-2008). The following variables were included in the analysis: age, gender, religion, method of suicide attempt and admission date. The results were analyzed with the Statistic for Windows program, release 7.0. Results: A significantly higher number of suicide attempts were registered in females than in males from the territory of Skopje during the period of 1999-2008. Men who attempted suicide were older than women. Women of Christian religion affiliation attempted suicide more frequently than women of Muslim religion. The greatest number of attempts was during the summer season. The most common method of suicide attempt was intoxication with medications. Conclusions: Our study has shown that attempted suicide rate has had a stable trend over the last decade. It has also shown female predominance of suicide attempts with a greater number of attempts during the summer months. There is a need for intervening strategies to be targeted at younger females.

Ten-year Epidemiological Study on Suicide Attempts in Skopje, Republic of Macedonia

ORIGINAL PAPER

Ten-year Epidemiological Study on Suicide Attempts in Skopje, Republic of Macedonia

Mirjana Polazarevska1, Sanja Manchevska2, Angelina Filipovska1, Vesna Gerazova1

University Clinic of Psychiatry, University Ss. Cyril & Methodius, Skopje, R. Macedonia1

Department of Physiology, Faculty of Medicine, University Ss. Cyril & Methodius, Skopje, R. Macedonia2

The aim of our study was to provide basic epidemiological data on suicide attempts that resulted in admission to the University Clinic of Toxicology and Emergency Medicine in Skopje during a 10-year-

period (1999-2008). There is a lack of published information regarding suicide attempts in the Republic of Macedonia. Methods: Participants were 1683 patients from the territory of Skopje, who attempted suicides and who were hospitalized in the University Clinic of Toxicology and Emergency Medicine in School of Medicine, Skopje during the period of ten years (1999-2008). The following variables were included in the analysis: age, gender, religion, method of suicide attempt and admission date. The results were analyzed with the Statistic for Windows program, release 7.0. Results: A signicantly higher number of suicide attempts were registered in females than in males from the territory of Skopje during the period of 1999-2008. Men who attempted suicide were older than women. Women of Christian religion afliation attempted suicide more frequently than women of Muslim religion. The greatest number of attempts was during the summer season. The most common method of suicide attempt was intoxication with medications. Conclusions: Our study has shown that attempted suicide rate has had a stable trend over the last decade. It has also shown female predominance of suicide attempts with a greater number of attempts during the summer months. There is a need for intervening strategies to be targeted at younger females. Key words: suicide attempt, epidemiology, prevention.

Corresponding author: Sanja Manchevska MD, PhD. Department of Physiology. Faculty of Medicine University Ss.Cyril and Methodius 50 Divizija br. 6 1000 Skopje Republic of Macedonia. Phone: [phone]. Fax: [phone]. [email protected]

1. INTRODUCTION

Suicide is a complex phenomenon with psychological, social, biological, cultural and environmental factors involved (1, 2, 3, 4, 5, 6, 7, 8, 9, 10).

Every year almost one million people die from suicide; a global mortality rate of 16 per 100,000, or one death every 40 seconds (11, 12, 13, 14, 15).

In the last 45 years suicide rates have

increased by 60% worldwide. Suicide is among the three leading causes of death among people aged 1544 years in some countries, and the second leading cause of death in the 10-24 years age group (1).

These gures do not include suicide attempts which are up to 20 times more frequent than completed suicide (16,17,18,19, 20). Although traditionally suicide rates have been highest among

the male elderly, rates among young people have been increasing to such an extent that they are now the group at highest risk in one third of all countries, both developed and developing.

Mental disorders (particularly depression and substance and alcohol abuse disorders) are a major risk factor for suicide in Europe and North America (21, 22). Attempted suicide is both one of the strongest risk factors for completed suicide and an important indicator of extreme emotional distress ( 7).

In the Republic of Macedonia, available data show that the rate of committed suicides and the number of attempted suicides was 2.7 per 100 000 for suicide in 1957; 3.12 per 100 000 for suicide in 1970, and 29 attempted suicides in 1970; 4.55 per 100.000 for suicide in 1980 and 148 suicide attempts in 1980; 154 committed suicides and around 1100 attempted suicides in 2005. In 2008 there were 167 completed suicides and around 900 attempted suicides (Statistical review, 2008).

Unfortunately, currently there is no official registry (statistical and registration) database of all attempted suicides that ask for medical help in the Republic of Macedonia. There is also a lack of published information regarding this issue. One of the aims of this study was to suggest the need of continuous surveillance of suicide and attempted suicide by a national sentinel network of general practitioners as it is

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Ten-year Epidemiological Study on Suicide Attempts in Skopje, Republic of Macedonia

done in most western countries (5, 21).

This paper presents findings obtained from an epidemiological study of suicide attempts from the territory of Skopje, R. Macedonia, that resulted in admission to the University Clinic of Toxicology and Urgent Medicine during a 10-year period (from 1999 to 2008).

More generally, the aim of this study was to provide an overview of time trends in suicide attempts from the territory of Skopje, that resulted in admission to the University Clinic of Toxicology and Emergency Medicine during the last decade (1999-2008) and to suggest measures of suicide prevention.

Specic aims of this study were to describe time trends in overall rates of admission for attempted suicide cases from the territory of Skopje during the last decade (1999-2008); to examine age, gender, season, and religious dierences in time trends in suicide attempt admission and to explore methods used for attempted suicide.

2. METHODS

Participants of the study are included as consecutive series of 1683 individuals admitted to the University Clinic of Toxicology and Emergency Medicine for attempted suicide from the territory of Skopje during a 10-year period. Skopje has a population of approximately 668.000 (2006), which is one third of the overall population in the Republic of Macedonia. The University Clinic of Toxicology and Emergency Medicine is almost the sole entry point for individuals who have attempted suicide in the region of Sko-

pje. Additionally, individuals from the University ORL Clinic who attempted suicide with hanging, poisoning or gas were referred to the University Clinic of Toxicology and Emergency Medicine.

Parameters for creating the database of the study - the following parameters were obtained at each admission of individuals presented with suicide attempts: date of admission, date of birth and place of residence, gender, religion, and method used for suicide attempt. The method of suicide attempt was classied according to ICD -10.

Statistical methods Data were analyzed with the Statistic, release 7.0 software package. The chi-square method was used for the analysis of category variables and the Students t-test and one-way ANOVA for the continuous ones. A p value of 0.05 for two-tailed test was considered signicant. Dynamics of the changes in attempted

suicides was determined by creating seasonal index, rate of increase and decrease, and trend.

3. RESULTS

In the period of 1999-2008 in the city of Skopje, a total of 1683 cases of attempted suicide were registered, of which 463 (27.51%) were males and 1220 (72.49%) females (Table 1).

Table 1 shows data that refer to dis

tribution of patients according to the examined variables: gender, age, religion and method used for attempted suicide. The age of male patients varied in the range of 40.25 14.87 years, 95.0% condence interval 38.8941.61, the youngest patient being 14 years old and the oldest 94 years. In women, the age ranged 38.04 15.62 years, 95.0% condence interval 37.1638.91; the youngest patient being 14 years old and the oldest 95 years. For t=2.64 and

Parameters Men Women Total

N % N % N %

Patients 463 27.5 1220 72.5 1683 100 Age 40.25 38.04

Religion Christian Muslim

250 14.8 739 43.9 989 58.8 213 12.7 481 28.6 694 41.2 Method of attempted suicideIntoxication withmedications 343 20.4 1009 60 1352 80.3

Intoxication withcorrosive agents 94 5.6 175 10.4 269 16

Intoxication withpesticides 22 1.3 35 2.1 57 3.4

Poisoning with gases 1 0.06 1 0.06 2 0.12 Hanging 2 0.12 0 0 2 0.12 Drowning 1 0.06 0 0 0 0.06

Table 1. Distribution of patients with attempted suicide according to examined parameters

Month Years Seasonal index

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 % I 16 10 21 13 20 7 12 10 7 14 13 0.93 93

II 20 13 13 14 21 13 16 8 10 18 14.6 1.04 104 III 18 13 13 6 18 14 13 7 14 32 14.8 1.06 106 IV 11 14 19 13 13 13 12 8 13 18 13.4 0.96 96 V 14 12 23 7 23 11 12 9 15 17 14.3 1.02 102 VI 19 25 16 10 24 13 8 8 31 10 16.4 1.17 117 VII 17 9 20 12 23 16 20 2 32 27 17.8 1.27 127 VIII 24 11 9 17 8 8 18 4 13 21 13.3 0.95 95 IX 26 27 13 9 9 9 14 7 15 17 14.6 1.04 104 X 13 13 10 6 16 13 10 14 15 19 12.9 0.92 92 XI 9 19 8 9 10 15 13 14 5 10 11.2 0.80 80 XII 11 18 9 15 11 17 5 15 9 10 12 0.86 86 Total 198 184 174 131 196 149 153 106 179 213

Table 2. Seasonal index of attempted suicides in Skopje, during ten year period 1999-2008 Monthly average rate for the period of 1999-2008: x=14.03

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Ten-year Epidemiological Study on Suicide Attempts in Skopje, Republic of Macedonia

Gender I II III IV V VI VII VIII IX X XI XII Men 30 49 44 37 42 46 49 39 36 32 36 23 % 1.78 2.91 2.61 2.20 2.50 2.73 2.91 2.32 2.14 1.90 2.14 1.37 Women 100 97 104 97 101 118 129 94 110 97 76 97 % 5.94 5.76 6.18 5.76 6.00 7.01 7.66 5.59 6.54 5.76 4.52 5.76 Total 130 146 148 134 143 164 178 133 146 129 112 120 % 7.72 8.67 8.79 7.96 8.50 9.74 10.58 7.90 8.67 7.66 6.65 7.13

Table 3. Distribution of attempted suicides by gender and months

p<0.01 (p=0.008), men were significantly older than women.

Concerning the distribution of patients by gender and religious afliation, there was no difference among men: Christians 250 (14.85%), Muslims 213 (12.66%). However, more women with Christian denomination (43.91%) than those with Muslim denomination 481 (28.58%) attempted suicide, yielding a signicant difference, for c2 = 5.99 and p = 0.01. The number of men with different religious affiliation who attempted suicide was almost equal contrary to the number of women. Of the total of 463 men with suicide attempts, 54.3% were Christians and 45.7% Muslims. Of the total of 1220 women with suicide attempts, 60.6% were Christians and 39.4% Muslims.

Distribution according to gender and method used for attempted suicide is given in Table 1. It is evident that in both men and women, the most common method of attempted suicide was intoxication with medications (80.33%), followed by intoxication with caustic agents (15.98%), pesticides (3.39%), gases (0.12%), hanging (0.12%) and drowning (0.06%). The presented distribution has shown a signicant difference, for c2 =

22.49 and p < 0.001 (p = 0.0004). Values for the seasonal index in

the attempted suicides on the territory of the city of Skopje for the period of 1999-2009 are given Table 2. The mean monthly index in the attempted suicides was x = 14.03. Seasonal index had the biggest values in July (127%) and June (117%), whereas the lowest values were registered in November (80%) and December (86%).

Monitoring the dynamics in the changes for attempted suicides, the biggest increase in the number of attempts was registered in 2007 (compared to 2006) and the increase rate was 68.87% (Graph 1). The biggest decrease in

the number of attempts was registered in 2004 (compared to 2003) and in 2006 (compared to 2005), and the decrease rate was 23.98%.

In the period between 1999 and 2008, attempted suicides have shown a stable trend (Graph 2). There was no statistical difference in the distribution of attempted suicides by gender and months, for c2 = 11.28 and p > 0.05 (p = 0.42) (Table 3).

4. DISCUSSION

The results obtained are the rst epidemio-logical data about attempted suicides in the Republic of Macedonia, although earlier there were studies regarding suicides in Macedonia.

4.1. Gender

The ndings of gender prevalence in attempted suicide pointout to a significantly higher prevalence in women (72.49%) than in men (27.51%) and these ndings are in agreement with the majority of studies performed in other countries (7, 11) .The mode of manifestation of self-harm was in close correlation with gender. In women, the attempt was more often in the function of appeal phenomenon and consequently the methods of attempts were more benign: less aggressive and destructive. However, each attempt must be seriously taken and adequately treated.

4.2. Age

In our study the age of the patients who attempted suicides ranged from 14 years for both sexes up to 95 years for

men and 96 years for women. The largest number of patients who attempted suicide (45%) was found in the age group of adolescents (below 24 years of age) particularly in females. These ndings are consistent with the general observation reported in the literature that the groups at highest risk for attempted suicides are adolescents, predominantly of

Seasonal index / Attempted suicides -Skopje, 1999 - 2008

130

120

110

%

100

90

80

70 I II III IV V VI VII VIII IX X XI XII months

Graph 1. Seasonal index of attempted suicides in Skopje, during ten year period from 1999 to 2008

Graph1. Seasonal index of attempted suicides in Skopje, during ten year period from 1999 to 2008

Attempted suicides - Skopje Trend:1999-2008

N

220

200

180

160

140

120

100 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 years

Graph 2. Time trend of attempted suicides on the territory of Skopje during ten year period, from 1999 to 2008

Graph 2. Time trend of attempted suicides on the territory of Skopje during ten year period, from 1999 to 2008

female gender and males older than 60 years (3, 10, 9).

4.3. Religion

There was no statistically signi-cant dierence in percentage frequency of men of Christian and men of Muslim affiliation in the total number of attempted suicides in the city of Skopje during the period of 1999-2008, who were hospitalized at the University Clinic of Toxicology and Urgent Medicine. On the other hand, a substantially higher percentage of Christian women attempted suicides than did Muslim women. In literature, there has been a long-term prevailing attitude that religion has a protective role and a reducing eect on the rate of suicides in dier-

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ent countries, in spite of many controversial data presented in various studies on this topic.

Data related to religious beliefs in our study are of a demographic character and they do not emphasize the impact of the religion on attempted suicides. According to our results, distribution by gender and religion may indicate weaker religious views in Muslim men than in Muslim women. Attempted suicides in men more frequently result in completed suicides, which goes in favor of their stronger and more determined self-harm as well as in their choice of methods used for suicide that are more fatal ones. In our view, the statistically signicant dierence in the number of attempted suicides in Christian women as compared to Muslim women is socially and culturally conditioned by the transitional changes in the society and family, with increasing of the stress-related risk factors. Our results urge the need for further additional investigations about the inuence of religion and mode of its practicing by the individuals of both major religious traditions in our country (Christians and Muslims). Also the inuence of several other socio-cultural factors, unemployment, abuse of alcohol and other psychoactive substances, disintegration of the traditional family in the countries of transition, should be taken into account when inferring on the prevalence of the attempted suicides and the rate of suicides in the Republic of Macedonia.

4.4. Seasonal index

The increased number of attempted suicides in the summer months, especially in July, coincided with the results of the study of Asif and coworkers, (2005) (8), but it was dierent from that found in many other countries. These data advocate the need of increased monitoring of the risk groups in the critical months and greater availability of the institutions for help in crisis situations in our country.

4.5. Method used for attempted suicides

The most frequent method of attempted suicide was intoxication with medications, in 59.95% of women and 20.38% of men (3 vs. 1), followed by intoxication with corrosive agents, 10.40% of women against 5.59% of men (2 vs. 1).

In our opinion, the easy access of medications and caustic agents, particularly the free market medications, requires commitment to prevention with strict control of drug prescription.

The stable trend, more generally with a mild overall reduction of cases of attempted suicides over the last decade of transition in the Republic of Macedonia that we detected could speak in favor of increased antidepressant prescription in the treatment of depression and anxious disorders, which is in agreement with studies performed in several western countries (12). However, the data from 2008 show an increase in the number of admissions of attempted suicides in the Clinic of Toxicology. This fact might be a result of a higher registration discipline of the involved Institutions, as well as of the inuence of other uninvestigated factors.

One of the limitations of the study is the small number of investigated parameters which restrict us from more general conclusions regarding the epidemiology of attempted suicide. Never the less, in a situation in which published information on this matter in our country is lacking, our data could give basic information for further investigation and cross-cultural comparison of the socioeconomic and cultural factors that inuence the prevalence of attempted suicides in the Republic of Macedonia as well as in other countries in the region.

5. CONCLUSIONS

Our study has shown that attempted suicide rate has had a stable trend over the last decade. It has also shown a female predominance of suicide attempts with a greater number of attempts during summer months. There is a need for intervening strategies to be targeted at younger females. In support of the prevention of attempted suicides and committed suicides, it is necessary to focus on preventive programs for recognizing and treatment of crisis situations and depressive disorders, and comprehensive preventive measures for preservation and enhancement of mental health.

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