Objectives: To follow-up individuals after the index attempt regarding repeated attempt, completed suicide, methods used and socio-demographic characteristics in rural area in Vietnam. Subjects and methods: All suicide attempt patients (104) during 2003 - 2007 were identified in a population.
Trang 1SUICIDE ATTEMPT IN RURAL AREA OF VIETNAM: FOLLOW-UP WITH REGARD TO REPEATED ATTEMPT
AND COMPLETED SUICIDE
Nguyen Van Tuan*; Peter Allebeck**
SUMMARY
Objectives: To follow-up individuals after the index attempt regarding repeated attempt, completed suicide, methods used and socio-demographic characteristics in rural area in
Vietnam Subjects and methods: All suicide attempt patients (104) during 2003 - 2007 were
identified in a population They were diagnosed and re-evaluated by trained physicians according to the research criteria of the WHO Multicentre Study of Attempted Suicide All people who had attempted suicide were followed for 1.5 - 6.5 years with regard to reattempted
or completed suicide Information was collected by interviews with those who had attempted suicide and family members of those who had committed suicide Interviews were performed by trained medical staff to investigate socio-demographic characteristics and methods used for
suicide attempt and completed suicide Results: Of the 104 attempt suicide people, 13 people
(12.5%) repeated suicide attempt and six people (5.8%) committed suicide during the follow-up period Drugs were used in mainly reattempt cases (8 cases) and pesticides (5 cases) for repeated suicide attempt, and pesticides, hanging and drowning for completed suicide All repeated attempt suicides were under 45 years old, whereas those who completed suicide had
a more diverse age distribution The proportion of unemployed and disabled people was higher than that at index attempt 10.6% of attempt suicide people received psychiatric care at the
index attempt Conclusion: The risk of reattempt and completed suicide is increased among
patients who have attempted suicide Drugs were used in many reattempt cases, whereas completed suicide mainly performed by pesticides or hanging Mental health services should be strengthened to take care of and follow-up patients who have attempted suicide Pesticides are still a public health problem in rural areas and should be better controlled
* Key words: Suicide; Attempt suicide; Completed suicide
INTRODUCTION
Attempted suicide is a strong predictor
for completed suicide, but it is also a
health problem in itself, since it may
cause severe harm and disability [1]
Individuals who have attempted suicide
often reattempted suicide [2, 3] Repetition
has been found to be a predictor for
completed suicide [4] Repetition of suicide
attempt is especially common during the
first year after the index attempt [5] In follow-up studies, the repetition rate within
a year has varied between 9% and 32% [6, 7, 8] Many attempts occur already within 6 months and this rate has been found to be between 10% and 37% [9]
We have found few studies on suicide attempts from Asian countries The crude rate of suicide attempt in India has been reported to be 49 - 81/100 000 annually [11]
* Hanoi Medical University
** Karolinska Institute, Stockholam, Sweden
Corresponding author: Nguyen Van Tuan (vntuannmh@hmu.edu.vn)
Trang 2In Singapore, Tsoi reported 55 - 92/100
000 in 1986 [11] Especially, South East
Asian countries with a rapid economic
development and social transition are
important to monitor with regard to the
epidemiology of suicide and suicide
attempt In an urban area of Vietnam, the
prevalence rate for lifetime suicide
attempts has been estimated to 0.4%
[12] A study on suicide attempt in Hanoi
[13] found that medical attention following
a suicide attempt was needed in 22.25%
of the attempts 22.2% of respondents
who reported one or more suicide attempts
required medical attention or hospital
admission We have not found any study
from Vietnam following person who have
attempted suicide, to assess predictor of
repeated attempt or completed suicide
In this study, we have followed up
these subjects with the aim to analyze the
occurrence of reattempted suicide and
completed suicide in this population In
particular, we want to 1) Assess prevalence
and methods used of reattempted suicide;
2) Assess prevalence and methods used
of completed suicides; and 3) Find out
to differences of socio-demographic
characteristics among this population at
the index attempt
PATIENTS AND METHODS
1 Setting
The study was conducted in a rural
area of Gialuong in Bacninh province,
located in the Red River Delta of the
northern part of Vietnam The majority of
residents are farmers Others are civil
servants, manual workers and small
traders The main economic activity in the
area is farming During the last years, a
growing number of people have left after
harvest time to work as temporary workers in the city or in other provinces The major ethnic group is Kinh, which is the biggest group in Vietnam
The health care system in this area is organized according to the national system
of rural health services of Vietnam The public health care services consist of two district hospitals, with approximately 120 beds in each, and 29 community health stations District hospitals are mainly responsible for curative care, while community health stations are responsible for primary health care including essential curative care and preventive care There
is a small pharmacy available in each community health station and only a few private pharmacies are located in this area
2 Data collection
As described previously [14], we identified people who had been admitted to the district hospitals, as well as all health care stations, during 2003 - 2007 in Gialuong area after having committed either a definite suicide attempt or an uncertain suicide attempt according to ICD-10 In addition, cases that were treated at home
by medical staff from the community health stations after suicide attempt were also included For those who had committed more than one suicide attempt during study period, the first attempt was defined
as the index attempt Each case of suicide attempt was diagnosed and re-evaluated
by trained physicians according to the research criteria of the WHO Multicentre Study of Attempted Suicide [1]
Data was initially collected retrospectively
in 2008 based on records kept at the health services and interviews with medical
Trang 3staff and covering the period from 1,
January 2003 to 31, December 2007 A
total of 104 people, 54 males and 50
females were identified in this procedure
In 2009, a follow-up study was performed
on these subjects up to 30, June 2009, in
order to identify repeated suicide attempt
and completed suicide with a follow-up
time of at least one and a half year
All individuals who had attempted
suicide and their family members who had
completed suicide after the index attempt
were interviewed face-to-face at their
home by trained medical staff working at
the community health stations We used
the instrument developed by the WHO
Multicentre Study of Attempted Suicide [1]
to record data on age, gender, marital status, types of living, occupation, date of the event, methods used, reattempted and completed suicide after the index attempt The study was approved by the Institutional Review Board of Hanoi Medical
University
* Statistical analyses:
Data were analyzed by using SPSS for Window Version 10.0 (SPSS, Chicago
IL, USA) Statistical significance for differences between groups was assessed by chi-2 test or whenever appropriate Fisher’s exact test
RESULTS
Of the 104 subjects, 13 people reattempt suicide and six people committed suicide during the follow-up period after the index attempt
Table 1: Methods used in reattempted and completed suicide in relation to methods
in the index attempt
Index attempt
(n = 104)
Reattempted suicide
(n = 13)
Completed suicide
(n = 6)
X61:
antiepileptics
X68:
pesticides
X68:
pesticides
X70:
hanging
X71:
drowning
analgesics, antipyretics
sedative-hypnotic,
anti-parkinsonism and
psychotropic drugs
X78: blunt object 1
Drugs were used in mainly reattempt cases (8 cases) and pesticides (5 cases) Thus, the proportion of attempt by drug poisoning was significantly higher (p = 0.032) than at the index attempt
Trang 4Although the study size is small, it is noteworthy that pesticides, hanging and drowning are main methods used in completed suicide
Table 2: Duration between index attempt and reattempted and completed suicide
Reattempted suicide (n = 13)
Completed suicide (n = 6)
The majority of cases of reattempted as well as completed suicide were committed
in the first year after the index attempt Only one case of repeated attempt occurred more than 3 years after the index attempt
Table 3: Socio-demographic characteristics of patients at the index attempt compared
to people who reattempted and completed suicide after the index attempt
Index attempt (n = 104)
Repeated attempt (n = 13)
Completed suicide (n = 6)
20 - 44
45 - 64
≥ 65
27
57
15
5
5
8
0
0
1
2
3
0
Female
54
50
6
7
3
3
Married Divorced/separated/widowed
31
68
5
2
9
2
2
4
0 Highest
completed
education
Primary education Secondary education Non-university higher education University education Others
5
29
47
21
2
0
6
5
2
0
2
1
1
2
0 Employment
status
Employment/studying/
housewife/homemaker/retired Unemployment Disabled, permanently sick
97
4
3
8
3
2
3
2
1 Psychiatric
care
No psychiatric care In-patient psychiatric care Out-patient psychiatric care
93
5
6
10
2
1
6
0
0
Trang 5Table 3 shows characteristics of those
who reattempted suicide and completed
suicide, in relation to characteristics at the
index attempt All reattempted suicides
were under 45 years old, whereas those
who completed suicide had a more diverse
age distribution The male-to-female ratio
of reattempted suicide and completed
suicide was basically the same the index
attempt Also the distribution regarding
to marital status and highest completed
education was basically similar to that at
the index attempt
The proportion of unemployed and
disabled people were significantly higher
(p = 0.004) compared to other groups
None of those who completed suicide had
been in contact with psychiatric care after
the index attempt, and only 3 of those who
reattempted suicide were found among
the 11 of attempt suicides who received
psychiatric care after the index attempt
DISCUSSION
The study is based on a limited number
of cases, but it is the only population
based follow-up patients who have
attempted suicide in Vietnam and a few in
Asian countries [13]
1 Reattempted suicide
In our study, 12.5% of the patients (or
31/100,000 person-years) reattempted
suicide during the follow-up period This
is three times higher than the rate of
attempted suicide in the general population
(10.2/100000 person-years) in the same
area [14] The rate of reattempted suicide
in our study is lower compared to the
results from other studies, 49-81/100 000
in India and 55-92/100 000 in Singapore
[7, 11]
Repetition of attempted suicide is common during the first year after the index attempt [3, 5] Our findings show that also in a Vietnamese rural population, the rate of repetition is high in general during the first year after the index attempt This should be known to general health services, since mental health services are not developed in the countryside in Vietnam,
as it is the case for many countries in the area The rate of reattempted suicide in our study within a year (during 2003 to 2009) was 8%, which is in the lower range
of what has been reported in the literature (9 - 32%) [7, 8]
The use of pesticides was less common among reattempted suicide compared to
at the index attempt This may reflect a tendency of more attempted suicide being committed by drugs compared to pesticides
as previously shown [14] This should be known by general health services as these often are the main points of contact
as mentioned above
2 Completed suicide
Six percent of our subjects were completed suicide during the follow-up and the majority of these during the first year after the index attempt This rate is higher than the figure given by Hawton and Fagg (1988) (1%) but lower than Isometsa and Lonnqvist’s report (10%)
We thus confirmed that also in this Vietnamese population, the risk of completed suicide after the index attempt
is considerable, as it has been noted in many Western studies
Methods used in completed suicide were high lethal methods, including pesticides, hanging and drowning It is interesting to note that we found no cases of completed
Trang 6suicide by pharmaceutical drugs,
although several of those who
reattempted suicide using pharmaceutical
drugs It is possible that people who do
have an intention to die from the act used
higher lethal methods and in that case it is
“better” that pharmaceutical drugs are
used in case of suicide attempt rather
than pesticides From our study as well as
many other previous findings, we thus
confirmed that pesticides are still common
and serious method of suicide in low and
middle income countries
In spite of small size of the study, it is
noteworthy that none of those who completed
suicide had been in contact with psychiatric
care after the index attempt This gives
further strength to the point raised in our
previous paper [14] that access to and
public acceptance of mental health care
should be strengthened in Vietnam
CONCLUSION
The rate of re-attempted and completed
suicide is increased among patients who
have attempted suicide, also in Vietnam
Drugs were the main method used in
re-attempt, whereas completed suicide
mainly was performed by pesticides or
hanging Mental health services should be
strengthened to take care of and follow-up
people who have attempted suicide
Pesticides are still a public health problem
in rural areas and should be better controlled
ACKNOWLEDGEMENTS
This study was funded by the Swedish
International Development Cooperation
Agency (SIDA) within the project of
collaboration between Hanoi Medical
University and Karolinska Institute
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