Suicidal Behaviors and Associated Factors Among Adult Psychiatric Patients Attending Psychiatric Clinic at Public Hospitals in Ethiopia: A Cross-Sectional Study

Abstract

Suicidal behaviors in persons with mental illnesses are the most prevalent psychiatric crises, requiring scholars and mental health task teams to prioritize public health concerns. However, there is a scarcity of data in Ethiopia, particularly for patients with mental illness. As a result, the goal of this study was to assess the prevalence of suicidal behaviors and associated factors among individuals with mental illness visiting public hospital psychiatric clinic units in eastern Ethiopia. A facility-based cross-sectional study was conducted from October 15 to November 15, 2022, with 411 individuals with mental illness visiting psychiatric clinic units at public hospitals in eastern Ethiopia. To select participants in the study, a systematic random sampling method was used. A structured face-to-face interview was used to gather data. The Suicidal Behavior Questionnaire-Revised (SBQ-R) was used to measure suicidal behaviors. Epidata 3.1 version was used to enter the data, and SPSS version 24 was used to analyze it. Both bivariable and multivariable logistic regression analyses were employed. In the final model, variables with p-values less than 0.05 were considered statistically significant. To identify variables associated with suicidal behavior, the adjusted odds ratio (AOR) and 95% confidence interval (CI) were utilized. Out of a total of 411 eligible participants, 402 involved in this study, giving a response rate of 97.8%. The prevalence of suicidal behavior was 46.3%, (95% CI: 41-50.7). Depression (AOR = 2.21,95% CI: 1.04, 4.69), medication non-adherence (AOR = 1.95, 95% CI: 1.19, 3.18), bipolar disorders (AOR = 1.79, 95% CI: 1.55, 3.53), and current alcohol use (AOR = 1.81, 95% CI: 1.01, 3.28) were variables associated with suicidal behaviors. This study found a high rate of suicidal behaviors among adult individuals with mental illness in public hospitals in eastern Ethiopia. Suicidal behavior was highly associated with depression, bipolar disorders, current alcohol use, and medication non-adherence. Psychiatric professionals should assess patient suicidal risk assessment routinely and should put the diagnosis with suicidal if the client is suicidal so that every professional focuses on treatment besides the medication. Special attention is required for individuals who present associated features, such as history of medication non adherence, depression, and overall bipolar disorders.

Keywords

suicide suicidal behaviors associated factors adult mental illness Ethiopia

What do we already know about this topic?

Suicide is the intentional taking of one’s own life combined with a lethal act that expresses the person’s desire to die.

Suicide has emerged as the most frequent mental health emergency, trailed by homicide.

How does your research contribute to the field?

This study found that 46.3% of mental health patients—nearly half of all patients—exhibited suicidal behavior.

According to the World Health Organization (WHO), suicide is a serious global health concern in high-income countries and is becoming more of an issue in low- and middle-income countries where access to mental health services is limited.

What are your research’s implications toward theory, practice, or policy?

The results of this study can be used by national and international agencies or organizations that are concerned to plan and implement effective programs for the prevention and control of suicidal behavior as well as other mental illnesses that can help improve access to health care locally.

Introduction

Suicide is the deliberate termination of one’s own life, as well as a deadly act indicating the individual’s want to pass away.¹ Suicide becomes the most common mental health emergency, followed by homicide.² It is typically acted out of despair or as a result of underlying mental illnesses such as depression, bipolar disorder, psychosis, alcohol and substance abuse, and other adverse conditions. Suicidal behaviors are ideas or behaviors that raise a person’s chance of contemplating suicide. Suicidal behaviors can be split into 3 distinct types: suicidal thoughts, suicide plot or intent, and attempts at suicide.^3
-5

According to data from the World Health Organization (WHO), approximately 800 000 people worldwide take their own lives each year.² This translates to 1 suicide death every forty seconds.³ Suicidal ideation and attempt are far more prevalent. By a ratio of 20, the number of suicide attempts outnumbers the number of suicide deaths.³ According to WHO forecasts, around one and half million individuals will die by suicide by 2030, with 10 to 20 times that number attempting suicide globally. One person dies every 20 s, and one person tries suicide every 1 to 2 s, according to these figures.^3,6,7 Suicide, as reported by the World Health Organization (WHO), is a severe global health concern in countries with high incomes, and it is a growing problem in nations with low or middle incomes with limited access to mental health treatment.^3,8

The worldwide prevalence of suicide as an entirety is assessed to be 9 for every 100 000 occupants per year.⁹ Suicide contributes to 1.4% of the overall mortality rate and 15% of injury mortality.¹ Suicide rates have risen by 60% in the past 50 years, with the rise being more prominent in nations with limited resources.⁷ Suicidal behaviors are a multifaceted activity with multiple risk variables such as psychological, social, clinical, biological, and mental aspects.^10
-12 A significant number of the risk variables may be recognized, allowing for the prediction of suicide attempts as well as the implementation of appropriate interventions to prevent suicidal behavior.^13
-16

Talking about suicide can be very challenging.¹⁷ Prior suicide attempts are by far the strongest risk factor for suicide; therefore, silence can have more tragic outcomes while knowledge and communication can prevent suicide and save lives.^18,19 Suicide prevention is largely dependent on education and awareness, which can be achieved through prompt, evidence-based, and frequently low-cost interventions. To better understand, respond to, and lower the incidence of suicide, high-quality research in this area is therefore required. It also needs to be ethically sound.^20,21

Suicidal behaviors are frequently found to be strongly predicted by the presence of mental disorders in general and co-morbidity in particular.^22
-30 However, mental disorders alone cannot cause suicide sufficiently.³¹ The strongest indicator of suicide and suicidal thoughts among mental illnesses is major depressive disorder.^22,23,32
-34 Other mental disorders like schizophrenia,^23,35
-37 bipolar disorders,^37,38 and anxiety disorders^33,39 are risk factors for suicidal behaviors. Substance use disorders and substance co-morbidity are also the predictors of suicide and suicidal behaviors.^23,25,27,40 From substance use disorders; alcohol use disorders,^35,37,41,42 tobacco, and other illicit drug use²⁴ and cigarette smoking⁴³ are the predictors of suicide and suicidal behaviors. Suicide and suicidal behaviors are higher in those who are divorced/separated/widowed,⁴⁴ being female, younger, single, and less educated.^28,45
-47

Related major indicators of high suicide behavior includes: child neglect,⁴⁸ chronic medical issues, low socioeconomic status, interpersonal dysfunction, and an absence of social support,^49,50 or sexual abuse,^51
-53 or some personality characteristics for example perfectionist tendencies, unable to control impulse, high openness, nervousness, or poor self-esteem.^15,54
-56 Moreover, suicidal thought is frequently triggered by factors such as hopelessness and suffering.⁵⁷

Few studies reported about suicidal behavior in Ethiopia. A study from Addis Ababa revealed a rate of suicide is 7.76/100 000 individuals per year.⁵⁸ The lifetime prevalence of suicidal thoughts and attempted suicide was 64.8% and 19.2%, respectively, among psychiatric outpatients at Gondar Comprehensive Teaching Hospital,⁵⁹ and the lifetime prevalence of suicidal ideation and attempted suicide in the Addis Ababa urban community was 2.7% and 0.9% respectively.⁶⁰

Though suicide is a global issue, the degree of risk factors may differ based on conditions, traditions, or even inter-facilities within the same nation.^61
-63 When attempting to identify whether variables promote resilience or, conversely, vulnerability to suicide and suicidal behavior, the relationship between a variety of threats and protective factors at the individual and psychological levels must be taken into account.⁶⁴ In addition, while affluent countries have the highest age-standardized suicide rate, 79% of suicides globally occur in countries with middle and low incomes.⁹

Almost all of the prior research on suicidal behavior has been done in developed nations.^65,66 Even though suicide is one of the main causes of death and illness burden in developing countries, particularly Ethiopia, there is a dearth of knowledge about suicidal behavior in these regions. Numerous studies^67
-69 revealed that the population in Ethiopia’s east uses psychoactive substances far more frequently than the population in the country’s other regions, which may raise the likelihood of mental illnesses and suicide. Thus, the current finding provides pivotal information on the magnitude and associated factors of suicidal behaviors for clinicians and stakeholders in both governmental and non-governmental settings to earlier measure on reduction of suicidal harm. Additionally, accurate data on the prevalence and the risk factors for suicidal behavior in developing countries like Ethiopia are needed to develop more adequate screening, prevention, and intervention programs.

Studies on suicide and self-harm are categorized as “sensitive research topics” because they carry a risk of harming study participants or the researchers themselves.^70
-72 According to sensitive research, this harm could result from causing “a range of intense emotional responses” or other “emotional costs” for individuals involved.^73
-77 The Institutional Health Research Ethics Review Committee (IHRERC) at Haramaya University’s College of Health and Medical Sciences reviewed and approved the human subjects study with reference number C.O.H.M.S |10.0|15664|22 in order to address the ethical concerns with the study.

The main objective of the current study was to assess the prevalence of Suicidal Behaviors and Associated Factors among Adult Psychiatric Patients Attending treatment at the psychiatric clinic units of Hiwot Fana Specialized University Hospital (HFSUH) and Jegol General Hospital (JGH), Eastern Ethiopia. The primary reason we conducted suicidal behaviors at public hospitals is that they have an efficient patient flow, which allows us to obtain a representative sample. Additionally, while public hospitals charge less for medical care, the majority of participants prefer them because they come from lower socioeconomic backgrounds.

Methods and Materials

Study Areas, Design, and Period

A facility-based cross-sectional study was conducted from October 15 to November 15, 2022. The study was conducted in the Harari region in Eastern Ethiopia, around 525 km from Addis Ababa, the capital of Ethiopia. In the Harari region, there are 2 public hospitals: Hiwot Fana Specialized University Hospital (HFSUH) and Jegol General Hospital (JGH). Currently, they both offer psychiatric care and serve as teaching hospitals and offer community services like as obstetrics, gynecology, surgery, internal medicine, pediatrics, psychiatry, and laboratories. The main consideration in choosing the 2 hospitals was that they both offered psychiatric services, meaning that, only those 2 hospitals in the area provided psychiatric services.

Ethical Consideration

The Helsinki Declaration on Medical Research Ethics was followed during the study’s implementation. Haramaya University’s Institutional Health Research Ethics Review Committee provided ethical approval. The confidentiality of respondents was safeguarded by allowing them to complete the questionnaire anonymously. Password protection ensured the security of completed surveys and computer data. Each respondent consented in an informed, voluntary, written, and signed manner. The respondent was told that they might exit the interview at any time. Respondents were assured that their care or dignity would not be affected if they did not participate.

Population

Source population

All individuals with mental illness following treatment at psychiatric clinic units of public hospitals in eastern Ethiopia were considered the source population.

Study population

All adult individuals with mental illness following treatment at HFSUH and JGH mental clinics were considered as a study population.

Eligibility Criteria

Inclusion criteria

The study included all adult individuals with mental illness who were getting outpatient treatment at the HFSUH and JGH psychiatry clinics during the data collection period. The Structured Clinical Interview for DSM-5 (SCID-5) were used to include all patient with mental illness who have follow up at both Hiwot Fana Specialized University Hospital and Jegol General Hospital.

Exclusion criteria

Patients who were considered very sick, including those who are severely agitated, catatonic, or experiencing acute psychosis or had issues with their hearing, communication, or cognitive function were excluded. Hence, the severity of the physical or mental illness can render it impossible to collect adequate or comprehensive data.

Sample Size Determination and Sample Technique

The sample size was calculated using the single population proportion formula. A 95% confidence interval with a 5% margin of error was established, and the earlier study result from Gondar Comprehensive Teaching Hospital, Gondar (P = 42%) was used.²⁶ The outcome variable and the variables that exhibited a significant correlation with it were taken into consideration when determining the study’s sample size. Sample sizes for the primary and secondary objectives were calculated separately. Because of the larger sample size of the first objective than the second, the sample size for the first objective was taken. The sample size was calculated as follows:

n = \frac{z \frac{α^{2}}{2} p (1 - p)}{d 2}

While: n = the minimum needed sample size

Z = standard score corresponding to 95% confidence interval 1.96

P = the estimated proportion which is 42%

d = the margin of error (5%)

Considering this, $n = \frac{{(1 . 96)}^{2} \times 0.42 (1 - 0.42)}{{(0.05)}^{2}}$

=3.8416 × 0.2436/0.0025 = 374

Taking 10% into account for the non-response rate; (374 × 0.1 = 37.4) and 374 + 37.4 = 411; our total sample size was 411.

A total of 411 individuals with mental illness attending a psychiatric clinic at a public hospital in Harari Regional State were recruited using a systematic random sampling technique. Every month, an average of 777 patients attends psychiatric clinics in the health facilities chosen. The sample size was determined in proportion to the number of individuals with mental illness’ in each health facility. Since the systematic random sampling method was applied, the K-value can be found by dividing N = 777 by n = 411, which yields ~1.91, approximately an interval or K-value is 2 (K = 2). The first study participant was chosen through a lottery, and data collectors then randomly selected and interviewed the subsequent study participants every two2 participants.

Study Variables

Outcome variables

Suicidal behaviors (Yes/No).

Explanatory variables

Demographic factors include (age, marital status, sex, religion, ethnicity, income, educational status, employment status, and residence), mental disorders and psychosocial variables include (type of diagnosis, duration of mental illness, social support), and substance-related information including alcohol, khat, cigarette, and other substances (Cannabis/Shisha), co-morbid illness, and medication adherence status are an explanatory variable.

Data collection procedures and instruments

Instruments

The original English version of the survey was translated into Afaan Oromo and Amharic by 2 language experts so that the participants could easily understand it. After translating both ways, we tested the hypothesis with 21 participants in a pilot study. Cronbach’s alpha was used to verify internal consistency and provide preliminary validation. The SBQ-R, ASSIST, and PHQ-9 were among the tools used in this study pilot-test; their respective Cronbach alpha values were .82, .78, and .83.^78
-80 The questionnaire was divided into 5 parts. (1) Socio-demography, (2) mental health, (3) substance use, (4) questions on suicidal behavior, and (5) social support. Questions generated from the literature were used to measure socio-demographic factors. The shorter version of the alcohol, smoking, and substance involvement screening instrument (ASSIST) was used. ASSIST was developed by an international team of drug misuse researchers for WHO in order to identify psychoactive substance use and related difficulties in patients getting mental health service.⁸¹

The Oslo 3-item social support scale was used to assess the level of social support. The scores range from 3 to 14. A score of 3 to 8 indicates low social support, 9 to 11 shows moderate support, and 12 to 14 suggests strong support.⁸²

The Suicidal Behaviors Questionnaire-Revised (SBQ-R) is a self-report questionnaire for suicidal behavior. These shortened versions of the SBQ comprise 4 items and employ a Likert-type scale to assess suicidal behavior history, current suicide state, self-appraisal, and future suicidal behavior predictions. “Have you ever thought about or attempted to kill yourself?” is one example. (Rated from 1 to 4); “How often have you considered suicide in the last year?” (Rated on a scale of 1-5); “Have you ever told someone that you were going to commit suicide, or that you might do it?” (Rated from 1 to 3) “How likely is it that you will attempt suicide someday?” (Rated 0-6). A wide variety of information is acquired in a relatively short administration with a sensitivity of 80%% and specificity of 91%% for the adult clinical population with a score of 3 to 18 and a cutoff point of 8.⁸³

Data Collection Method

Four BSC psychiatry nurses conducted face-to-face interviews with all patients with mental illnesses at the HFSUH and JGH psychiatric clinic outpatient. One-day training was offered for those data collectors and the supervisor, with the main focus being on the process of data collection techniques, tools, and how to resolve ethical difficulties expressed by the participants.

Data Quality Control

Prior to the main investigation, 5% (n = 21) of the sample size was tested. In a pretest study, we tested the instruments’ applicability with 21 respondents after translating them both forward and backward. The final tool was refined with participant feedback, and internal consistency and initial validation were confirmed using Cronbach’s alpha. The supervisor and lead investigator offered regular monitoring, control, and support to the data collectors. The supervisor and lead investigator evaluated and established the acquired data on a daily basis for completeness and consistency.

Operational Definitions

Suicidal behavior: is a thought about unusual perception with suicide. The range varies from fleeting thoughts, intensive thoughts and unsuccessful attempts.⁸⁴ It is the umbrella term for a variety of suicide-related behaviors, such as suicidal thoughts, self-harming actions, and suicide attempts.⁸⁵

Suicidal ideation: refers to the desire to die suicide or the contemplation of suicide. Passive suicidal ideas happen when you wish you were dead or that you could die but have no intention of die by suicide. Active suicidal ideation, on the other hand, includes having an urge to die by suicide as well as preparing how to do so.⁸⁶ Suicidal ideation, which is defined as having thoughts of taking the lead in one’s own death, can range in severity based on the complexity of one’s plans and the level of suicidal purpose.⁸⁷

Suicide attempt: refers to an act in which a person attempts to take one’s own life suicide but lives. While it may be referred to as a “failed” or “unsuccessful” suicide attempt, mental health specialists advise against using these phrases since they suggest that a suicide that results in death is a successful or desired event.⁸⁸

The suicide behaviors questionnaire revised (SBQ-R) is a psychological self-report questionnaire designed to identify risk factors for suicidal behaviors. The overall scale scores range from 3 to 18. When a client scores 8 out of 18 on these measures, it indicates having suicidal behaviors.⁸³

Social support: Individuals with scores of 12 to 14, 9 to 11, and 3 to 8 on the 3-item Oslo social support scale reported strong, moderate, and poor social support, respectively.⁸²

Data Processing and Analysis

The data were coded, checked, and entered in EpiData version 3.1 prior to being exported to SPSS version 24 for analysis. Descriptive statistics were used to study the respondents’ socio-demographics and other factors. A bivariable logistic regression analysis was conducted to determine the association between each independent variable and the outcome variable. The multivariable logistic regression model includes all variables with a p-value of less than 0.25 in the bivariate logistic regression analysis. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was computed when the p-value was less than 0.05, which was considered statistically significant. The model’s fitness was assessed using the Hosmer-Lemshow test, and the result was 0.53.

Results

Socio-Demographic Characteristics of Respondents

Out of a total sample of 411, 402 participants agreed and participated in the study, giving a response rate of 97.8%. About 5 participants were unable to sign an informed consent form, and 4 were unable to converse because of a serious medical condition. Furthermore, there were no missing responses from any of the study participants. The actual non-response rate was 2.2% which means out of 411 participants, 402 participants were included in the study. Three participants were unable to communicate due to severity of the illness, and about 6 individuals were unable to sign the informed consent form. The average age of respondents was 34.65 (±10.56SD), with an age range of 18 to 64 years. More than half of the participants (56.2%) were male, 205 (51%) lived in urban areas, 239 (59.5%) followed the Muslim religion, and 236 (58.7%) were married. Among the respondents, 153 (38.1%) had studied up to primary school (1-8), 166 (41.3%) were farmers, and many of them, 340 (84.6%), living with family (Table 1).

Table 1.

Socio Demographic Characteristic of Adult Psychiatry Patients in Hiwot Fana Specialized University Hospital and Jegol Hospital, 2022 (n = 402).

Variables	Category	Frequency	Percentage (%)
Sex	Male	226	56.2
Sex	Female	176	43.8
Age	<20	37	9.2
	20-30	141	35.1
	30-40	121	30.1
	>40	103	25.6
Religion	Muslim	239	59.5
	Orthodox	105	26.1
	Protestant	45	11.2
	Catholic	5	1.2
	Others^a	8	2
Marital status	Single	124	30.8
	Married	236	58.7
	Divorced	31	7.7
	Widowed	11	2.7
Educational status	Able to read and write	63	15.4
	1-8 grade	153	38.1
	9-12 grade	65	16.2
	College	58	14.4
	Degree and above	63	15.7
Residence	Urban	205	51.0
Residence	Rural	197	49.0
Occupational status	Farmer	166	41.3
	Merchant	44	10.9
	Government employee	89	22.1
	Unemployed	30	7.5
	Daily labor	22	5.5
	Other^b	51	12.7
Monthly income (in ETB)	<1000	60	14.9
	1001-2000	37	9.2
	2001-3000	70	17.4
	3001-4000	73	18.2
	4001-5000	69	17.2
	>5000	93	23.1
With whom you living now	With family	340	84.6
	Alone	46	11.4
	Other^c	16	4.0

Wakefata and Jehovah.

Retired, house servant, preacher.

Those living with relatives.

Clinical, Medication Adherence Status, Substance Use, and Social Support, Characteristics

Of the total participants, 189 (47%) and 126 (31.1%) were diagnosed with schizophrenia and major depressive disorder, respectively, while 29.6% had comorbid medical illnesses. In terms of medication adherence, 136 (33.8%) of them forgot their medicine on occasion, and 129 (32.1%) were careless to take their prescription. Regarding social support, 197 (49%) of the respondents had a low level of social support, 148 (36.8%) had a moderate level of social support, and 57 (14.2%) had a high level of social support. In terms of substance usage, 243(60.4%) of participants had used substances at some point in their lives, and 157(39.1%) were presently using substances. In their lifetime, 211 (86.8%), 112 (46.1%), and 65 (26.7%) had used Khat, cigarettes, and alcohol, respectively. In the previous 3 months, 78.3%, 33.1%, and 28% of respondents used Khat, cigarettes, and alcohol respectively (Table 2).

Table 2.

Clinical, Medication Adherence Status, Substance Use, and Social Support Related Characteristics of Adult Psychiatry Patients in Hiwot Fana Specialized University Hospital and Jegol Hospital, 2022 (n = 402).

Variables	Category	Frequency	Percentage (%)
Types of diagnoses	Schizophrenia	189	47
	Depression	126	31.3
	Bipolar	43	10.7
	Anxiety	31	7.7
	Others^a	13	3.2
Duration of illness (years)	0-3	256	63.7
	3-6	95	23.6
	6-9	27	6.7
	>9	24	6
Treatment duration (years)	0-3	334	83.1
	3-6	51	12.7
	6-9	11	2.7
	>9	6	1.5
Gap between the treatment (years)	0-3	366	91
	3-6	27	6.7
	6-9	8	2
	>9	1	0.2
Family history of mental illness	Yes	78	19.4
Family history of mental illness	No	324	80.6
Comorbid physical illness	Yes	119	29.6
Comorbid physical illness	No	283	70.4
Medication adherence status	Forget their medication sometimes	136	33.8
	Stopped their medication when they feel better	109	27.1
	Stopped their medication were they feel worse	100	24.9
	Carless to take the medication.	129	32.1
Social support	Poor	197	49
	Moderate	148	36.8
	Strong	57	14.2
Have you ever? (substance use history)	Yes	243	60.4
Have you ever? (substance use history)	No	159	36.6
Which substance do/did you use?	Khat	211	86.8
	Cigarette	112	46.1
	Alcohol	65	26.7
	Others^b	11	4.5
Have you used a substance within the last 3 months?	Yes	157	39.1
Have you used a substance within the last 3 months?	No	245	60.5
Which substance have you used?	Chat	123	78.3
	Cigarette	52	33.1
	Alcohol	44	28.0
	Others^b	9	5.7

Others (somatoform, psychiatry disorders due to medical conditions, dissociative disorders, adjustment disorders, and personality disorders).

Others: marijuana, shish.

Magnitudes, Methods of Suicide Attempt, and Pattern of Suicidal Behaviors

The reliability of the Suicidal Behavior Questionnaire-Revised (SBQ-R) was calculated and resulted in Cronbach’s = 0.82. The overall prevalence of suicidal behavior (as determined by an SBQ-R total score of 8) was 46.3% (95% CI: 41, 50.7). The lifetime prevalence of suicidal ideation, intent, and attempts were 24.4%, 20.4%, and 16.9%, respectively. The total lifetime prevalence of suicidal ideation was 248 (61.7%). Suicidal ideation was present in 146(36.1%) of people in the previous year (12 months). Of those, 72 (17.9%) experienced suicide thoughts once and 46 (11.4%) had it twice at separate times in time. One hundred twenty (29.9%) patients threatened suicide or told others they were going to kill themselves. Out of them 103 (85.8%), 17 (14.2%) told others more than once. Only 8 (2.0%) of the patients identified a future risk of suicide behavior. Approximately 154 patients (38.3%) reported suicide thoughts, intent, or attempts.

Among the 68 suicide attempts, 53 (77.9%) occurred at home. In 31 (45.6%) suicide attempts, the most prevalent means/method was hanging, followed by poison in 15 (22.1%) and drug/medication overdose in 9 (13.2%). Family members intervened to prevent 44 (64.7%) of patients from attempting suicide. During the interview, 28 (41.2%) of individuals who had tried suicide felt angry (Table 3).

Table 3.

Magnitudes, Methods of Suicide Attempt, and Pattern of Suicidal Behaviors Among People With Mental Illness Attending Treatment at Hiwot Fana Specialized University Hospital and Jegol Hospital, 2022 (n = 402).

Variables	Category	Frequency	Percentage (%)
Life time suicidal ideation, intent and/or attempts	Never	154	38.3
	Suicidal ideation	98	24.4
	Intent	82	20.4
	Suicidal attempts	68	16.9
	Life time all suicidal ideation	248	61.7
Frequency of suicidal ideation in the past 1 year	Never	256	63.9
	Once	72	17.9
	Twice	46	11.4
	3-4 times	18	4.4
	Always (≥5)	10	2.4
	1 year all suicidal ideation	146	36.1
Suicidal threats	Once	103	85.8
Suicidal threats	Twice and more	17	14.2
Likely hood of suicide in the future	Never	240	59.7
	No chance at all	75	18.7
	Rather unlikely	58	14.4
	Unlikely	21	5.2
	Likely	8	2.0
Frequency of suicide attempts	Once	61	89.7
Frequency of suicide attempts	Twice and more	7	10.3
Places of suicide attempts	Home	53	77.9
Places of suicide attempts	Forest	7	10.3
	Field	4	5.9
	River	3	4.4
	School	1	1.5
Methods of suicide attempt	Hanging	31	45.6
	Poising	15	22.1
	Medication overdose	9	13.2
	Electricity	6	8.8
	Gin shot	4	5.9
	Vehicle injury	3	4.4
Abort of suicide attempt	Family	44	64.7
	Friend	13	19.1
	God	5	7.4
	Health Profession	4	5.9
	Others^a	2	2.9
Feeling after suicide attempt	Felt angry	28	41.2
	Felt Guilty	21	30.9
	Felt nothing	19	27.9

Others, neighbors, other people around there during the events.

Factors Associated With Suicidal Behaviors

In bivariate logistic regression analyses, age, marital status, religion, education status, occupation status, monthly income, social support, depressive disorders, schizophrenia, bipolar disorders, comorbid physical illness, duration of illness, residence, alcohol use disorders, nicotine dependence, Khat chewing, and other substance use were candidates for multiple logistic regression analysis at P-value .25. Finally, in the multivariate logistic regression analysis, major depressive symptoms, bipolar disorders, medication non-adherence, and current alcohol use were determined to be independent predictors of suicide behavior with a P-value of less than .05.

According to this study, individuals with major depressive disorders and bipolar disorders were 2.21 times and 1.79 times more likely to develop suicidal behavior, respectively, than patients with other mental disorders (AOR = 2.21, 95% CI: 1.04, 4.69) and (AOR = 1.79, 95% CI: 1.55, 3.53). Respondents with medication non-adherence and current alcohol use were 1.95 times and 1.81 times more likely to develop suicidal behaviors, respectively than those who took their medication properly and did not use alcohol currently (AOR = 1.95, 95% CI: 1.19, 3.18) and (AOR = 1.81, 95% CI: 1.01, 3.28) (Table 4).

Table 4.

Bivariable and Multi Variable Logistic Regression Analysis of Factors Associated With Suicidal Behavior Among Adult Psychiatry Patients in Hiwot Fana Specialized University Hospital and Jegol Hospital, 2022 (n = 402).

Variables	Category	Suicidal behaviors		COR (95% CI)	AOR (95% CI)
Variables	Category	Yes	No	COR (95% CI)	AOR (95% CI)
Diagnoses	Depression	71	55	3.2 (2.10-5.10)	2.21 (1.04, 4.69)**
	Bipolar	5	38	2.7 (1.37-5.39)	1.79 (1.55,3.53)*
	Schizophrenia	93	96	2.3 (1.21-4.41	1.52 (0.74,3.13)
	Anxiety	19	12	2.7 (1.37-5.39)	2.5 (0.90-7.45)
	Others	4	9	1.00	1.00
Medication non-adherence	Yes	54	162	3.2 (2.10-5.10)	1.95 (1.19,3.18)*
Medication non-adherence	No	75	111	1.00	1.00
Life time khat chewer	Yes	59	152	1.4 (1.00-2.20)	1.60 (0.51, 5.23)
Life time khat chewer	No	100	91	1.00	1.00
Current khat chewer	Yes	27	96	1.3(0.91-1.99)	1.9 (0.63-,6.15)
Current khat chewer	No	200	79	1.00	1.00
Social support	Poor	113	84	0.7 (0.29-2.09)	1.7 (0.44, 6.96)
	Moderate	61	87	4.1 (1.35-12.57)	4.3 (0.92, 20.45)
	Strong	8	49	1.00	1.00
Comorbid physical illness	Yes	78	41	1.8 (1.20-2.89)	1.0 (0.52,1.91)
Comorbid physical illness	No	84	199	1.00	1.00
Current alcohol use	Yes	25	161	2.9 (1.97-4.42)	1.81 (1.01,3.28) **
Current alcohol use	No	19	197	1.00	1.00

Note. 1.00 = Reference group.

COR = crude odd ratio; AOR = adjusted odd ratio; CI = confidence interval.

P < .05. **P < .001.

Discussion

One growing area of focus for healthcare prevention is suicidal prevention. Suicide prevention has not been viewed as a top priority in the healthcare system, despite the fact that many suicide deaths have been reported recently or are being treated in clinical settings.⁸⁹ In resource-constrained environments, such as Ethiopia, local evidence is crucial for integrating mental health services into mental health care levels and supporting suicidal prevention in clinical settings. The main objective of the present study was to assess the magnitude of suicidal behaviors and associated factors with suicidal behaviors among Adult Psychiatric Patients Attending Psychiatric Clinic Units of Public Hospitals in Eastern Ethiopia. To the best of our knowledge, this is the first study to screen suicidal behavior and/ or suicide attempts among patients with mental illness who visit Psychiatric Clinic Units of Public Hospitals in Eastern Ethiopia.

The prevalence of suicidal behavior in this study is similar to that found in a study of psychiatric outpatients at Gondar Hospital (42%), however suicidal ideation is lower (64.8%).²⁶ This might be because the SBQ-R utilized in this study was unable to determine how many individuals had suicidal ideation prior to attempting suicide. The SBQ-R tool examined minor suicidal thoughts and intent independently. The researcher at Gondar Hospital designed a standardized questionnaire to measure how many suicide attempters had suicidal thoughts before attempting suicide.²⁶

This study found a greater lifetime percentage of suicidal thoughts and suicide attempts than a community-based survey of adults in Addis Ababa, Ethiopia, which found a lifetime prevalence of 2.7% and 0.9%, respectively.⁹⁰ The lifetime suicide attempt in this study was also greater than the 3.2% lifetime suicide attempt in a study carried out in Butajira (Southern Ethiopia) among the general adult population.⁹¹ This is due to the fact that, in contrast to the previously described community-based research in Addis Ababa and Butajira, Ethiopia, our study was done in a hospital sample of patients living with mental illness. Several evidences suggest that persons with mental disorders are at a greater risk of suicide thoughts and attempts than the general population.^{22,32
-34,36,37,92,93}

In this study, the lifetime prevalence of suicidal ideation, intent, and attempt is lower than in a national survey conducted in South Africa among adults with previous evidence of a DSM-V psychiatric disorder diagnosed, in which 61%, 64%, and 70.3% of patients reported suicidal ideation, plan, and attempt, respectively.³³ This disparity may be related to the fact that this study was only done among follow-up patients who may have had controlled suicidal behavior as a result of the therapy. Nonetheless, the lifetime prevalence of suicidal thoughts, intent, and attempt in this study is higher than the lifetime prevalence rates of suicidal ideation, intent, and attempt in a stress and health survey conducted in South Africa, where the lifetime prevalence rates of suicidal ideation, intent, and attempt were 9.1%, 3.8%, and 2.9%, respectively.⁹² This might be because our research samples were persons living with psychiatric disorders, who are particularly vulnerable populations, as opposed to a community survey performed in South Africa.

However, the lifetime prevalence of suicidal behavior and suicide attempt in this study is lower than in a study of bipolar patients done in Finland. This might possibly be because patients with bipolar disease have a greater likelihood of suicide conduct during depressed periods. Depression was also found as an independent predictor of increased suicide behavior in this study. Suicidal behavior was prevalent at 80%, with 51% attempting suicide.³⁸ Furthermore, the lifetime incidence of suicidal thoughts and suicide attempts is lower than in research done in the United States of America among psychiatric outpatients who reported 55% and 25%, respectively, of suicidal ideation and suicide attempts.²² This disparity might be explained by the fact that suicide is becoming more widespread in Western nations.^3,4,25,94

The majority of suicide attempts in this study took place at home. The most prevalent method of recorded suicide attempts was hanging, followed by poisoning and drug/medication overdose. This is critical for preventing access by informing families and scheduling medicines for those at higher risk. Participation from families was the most readily available and often used kind of help to prevent attempted suicide. This is in accordance with research from other sections of the nation.^26,37,90,91 The medicine overdose is dissimilar to other research in Ethiopia. This might be because the study was done on follow-up outpatients who were taking drugs.

Even though many societies may not report suicide behavior,^95,96 mental illness is recognized as the most significant risk factor for suicide, making suicide a global public health concern.⁹⁷ In this study, suicidal behavior was more strongly associated with mood disorders, especially major depressive disorders and bipolar disorders, compared to those with schizophrenia. This finding was consistent with the findings of studies done in Taiwan,⁹⁸ South Korea,⁹⁹ and China,¹⁰⁰ which discovered that patients who felt hopeless or had comorbid depression were more likely to have suicidal behavior. One possible explanation for this could be that someone’s hopelessness warps their perception and prevents them from seizing any chances that could improve their situation.

A diagnosis of severe depressive disorders was substantially correlated with suicide behavior in this study, which is comparable to a study conducted in Butajira Ethiopia among persons suffering from severe psychiatric disorders,³⁷ in South African research.³³ Suicidal ideation was much more common among those with depressive disorders, and depression was found to be an indicator of risk for suicide attempts in multiple studies.^32,34,101 Suicidal behaviors have been correlated with bipolar disease, as well as major depressive disorders. It’s analogous to research carried out in high-income nations.^33,34,39 One of the most important determinants of suicidal behavior in bipolar disorders is the type/polarity of the current mood episode/state: pure major depressive episodes and mixed states carry the highest risk, while suicidal behavior is rarely present in (euphoric) mania, hypomania and during euthymic periods.¹⁰²

This study also showed that psychotropic medication non adherence associated with suicidal behavior. The finding of the current study was supported by study done in southern parts of Ethiopia³⁷ and Chinese study.¹⁰³ The possible explanation for this consistency might be due to treatment with psychotropic medication improves the quality of life and reduces symptoms in patients with severe mental illness.

In our research, we found that current alcohol usage was associated with suicidal behavior, which is similar to the research done on people with severe mental disorders in South Korea¹⁰² and Butajira, Ethiopia³⁷ as well as a research conducted on depressed inpatients in Malaysia.⁴¹ It was similarly comparable to research conducted among patients suffering from drug abuse problems in California, USA.⁵⁸ This is due to the fact that alcohol consumption impairs judgment and hope, which raises the risk of suicide.¹⁰⁴ Once a suicidal behavior is determined, alcohol drinking plays a critical role in behavior.¹⁰⁵ In other words, the hypothesis pertaining to the relationship between alcohol consumption and suicidal behavior holds that alcohol consumption and suicidal behavior are often impacted by an individual’s internalized or externalized psychopathology.^106,107

Strength and Limitations of the Study

When compared to previous research, this study has its own strengths: For starters, the researchers used standardized instruments rather than traditional methods for assessing suicidal behavior. Second, substance use/abuse and social support were thoroughly evaluated. Although supplying helpful baseline data, there are still certain drawbacks: First, because the information was gathered using a face-to-face interviewer-administered technique, social desirability bias exists. As a result, respondents may respond in favor of others who are either excesses reporting or inadequate reporting. Second, there was remembering bias, maybe forgetfulness, and no verification of the facts they provided us. Furthermore, social desirability has the potential to undermine the reliability of test results. Research may suffer from compromised measurement validity. Social desirability bias, for instance, may result in erroneously strong correlations, falsely suggesting that two variables are more strongly correlated than they actually are. To overcome this, the trained data collectors have been instructed to grant participants anonymity, which entails making the survey as faceless as possible and allowing respondents to respond freely and honestly without fear of being silently judged by another person.

Conclusion and Recommendation

The prevalence of suicidal behaviors among adult psychiatric patients visiting public hospitals in eastern Ethiopia was found to be quite high in the current research. The majority of suicide attempts take place at home. Suicide attempts (hanging oneself, poisoning, and drug/medication overdose) may have been avoided. The engagement of family members was the primary factor for the failed suicide attempt. Suicidal behavior was linked with major depressive illnesses, bipolar disorders, current alcohol use disorders, and medication non-adherence. Regular evaluation and management of suicide behaviors in patients with depressive disorders, bipolar disorders, co-morbid drug use disorders, and medication non-adherence will be a critical component of healthcare system practice. Given that family participation is a factor of failed suicide attempts, teaching and equipping family members to recognize and recommend suicidal behavior will benefit greater access to emergency psychiatric treatment.

Our findings suggest that preventing access to suicide methods, especially for those with severe mental disorders, should be a key component of Ethiopia’s new government initiative to increase access to mental health care. The significance of individualized, all-encompassing mental health treatment that addresses the root causes of suicidal behavior, such as mental illnesses and substance abuse, should be emphasized.

Psychiatric professionals ought to regularly evaluate the patient’s suicidal risk assessment and diagnose suicide if the client is suicidal. This will allow all other professionals to concentrate on psychological treatment rather than medication. Inform the family and caregivers of suicidal patients about their intention to have close follow-up, past attempts at suicide, and current suicidal ideation. It is also advised that researchers carry out additional research to help determine the magnitude and forecast variables that allow stakeholders to take the necessary precautions.

Supplemental Material

sj-docx-1-inq-10.1177_00469580241282653 – Supplemental material for Suicidal Behaviors and Associated Factors Among Adult Psychiatric Patients Attending Psychiatric Clinic at Public Hospitals in Ethiopia: A Cross-Sectional Study

Supplemental material, sj-docx-1-inq-10.1177_00469580241282653 for Suicidal Behaviors and Associated Factors Among Adult Psychiatric Patients Attending Psychiatric Clinic at Public Hospitals in Ethiopia: A Cross-Sectional Study by Jerman Dereje, Dawit Firdisa, Aklilu Tamire, Seid Tesi, Mesay Dechasa and Tilahun Abdeta in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-docx-2-inq-10.1177_00469580241282653 – Supplemental material for Suicidal Behaviors and Associated Factors Among Adult Psychiatric Patients Attending Psychiatric Clinic at Public Hospitals in Ethiopia: A Cross-Sectional Study

Supplemental material, sj-docx-2-inq-10.1177_00469580241282653 for Suicidal Behaviors and Associated Factors Among Adult Psychiatric Patients Attending Psychiatric Clinic at Public Hospitals in Ethiopia: A Cross-Sectional Study by Jerman Dereje, Dawit Firdisa, Aklilu Tamire, Seid Tesi, Mesay Dechasa and Tilahun Abdeta in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

We’d want to offer our deepest appreciation to our data collectors for their time and effort. We’d also want to thank the study participants who voluntarily supplied data for our study.

Author Contributions

Jerman Dereje and Tilahun Abdeta were engaged in conception, design, data acquisition, analysis, and interpretation, as well as drafting and revising the text. Dawit Firdisa, Seid Tesi, Aklilu Tamire, and Mesay Dechasa were the co-authors who contributed to the article review, tool assessment, interpretation, and critical review of the draft text. The final paper has been read and approved by all writers.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

The Institutional Health Research Ethics Review Committee (IHRERC) at Haramaya University’s College of Health and Medical Sciences evaluated and approved the human subject’s study with reference number C.O.H.M.S |10.0|15664|22. The patients/participants provided written informed consent in order to participate in this study.

Informed Consent

Each respondent provided informed, voluntary, written, and signed consent. Participants in the study were also informed that they had the option not to answer any questions. Completed questionnaires were handled with care, and all access to results was restricted to group members only. To protect responders’ confidentially, anonymity was maintained. Prior to participating in the study, all individuals received written consent in Amharic and Afan Oromo and signed it.

Trial Registration

Not applicable (N/A).

ORCID iDs

Jerman Dereje

Tilahun Abdeta

Supplemental Material

Supplemental material for this article is available online.

References

Värnik

Suicide in the world. Int J Environ Res Public Health. 2012;9(3):760-771.

World Health Organization . Preventing Suicide: A Global Imperative. World Health Organization; 2014.

Gvion

Apter

Suicide and suicidal behavior. Public Health Rev. 2012;34(2):1-20.

Nock

Borges

Bromet

Cha

Kessler

Lee

Suicide and suicidal behavior. Epidemiol Rev. 2008;30(1):133-154.

Nock

Kessler

RC.

Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the national comorbidity survey. J Abnorm Psychol. 2006;115(3):616-623.

Bertolote

Fleischmann

A global perspective in the epidemiology of suicide. Suicidologi. 2015;7(2).

Brown

Day

The role of loneliness in prison suicide prevention and management. J Offender Rehabil. 2008;47(4):433-449.

Week

Day

Mobile

May

Calendar

. Suicide prevention. 2013.

World Health Organization. Suicide in the World: Global Health Estimates. World Health Organization; 2019.

10.

Connor

Hsiao

Phillips

Johnson

KO.

Tactile roughness: neural codes that account for psychophysical magnitude estimates. J Neurosci. 1990;10(12):3823-3836.

11.

Fonseca-Pedrero

Al-Halabí

Pérez-Albéniz

Debbané

Risk and protective factors in adolescent suicidal behaviour: a network analysis. Int J Environ Res Public Health. 2022;19(3):1784.

12.

Turecki

Brent

DA.

Suicide and suicidal behaviour. Lancet. 2016;387(10024):1227-1239.

13.

Bliokas

Hains

Allan

Lago

Sng

Community-based aftercare following an emergency department presentation for attempted suicide or high risk for suicide: study protocol for a non-randomised controlled trial. BMC Public Health. 2019;19(1):1-11.

14.

Freeman

Mergl

Kohls

, et al. A cross-national study on gender differences in suicide intent. BMC Psychiatry. 2017;17(1):1-11.

15.

Hawton

Saunders

O'Connor

. Self-harm and suicide in adolescents. Lancet. 2012;379(9834):2373-2382.

16.

Hawton

Suicide prevention: a complex global challenge. Lancet Psychiatry. 2014;1(1):2-3.

17.

Mozaffor

Nurunnabi

Shahriah

Ethical issues in suicide research. J Psychiatr Assoc Nepal. 2020;9(1):5-9.

18.

Mortier

Auerbach

Alonso

, et al. Suicidal thoughts and behaviors among college students and same-aged peers: results from the World Health Organization World Mental Health Surveys. Soc Psychiatry Psychiatr Epidemiol. 2018;53(3):279-288.

19.

O'Connor

Pirkis

The International Handbook of Suicide Prevention. John Wiley & Sons; 2016.

20.

Fisher

Pearson

Kim

Reynolds

CF.

Ethical issues in including suicidal individuals in clinical research. IRB Ethics Hum Res. 2002;24(5):9-14.

21.

Lakeman

FitzGerald

The ethics of suicide research: the views of ethics committee members. Crisis. 2009;30(1):13-19.

22.

Asnis

Friedman

Sanderson

Kaplan

Van Praag

Harkavy-Friedman

Suicidal behaviors in adult psychiatric outpatients, I: description and prevalence. JTAjop. 1993;150(1):108-112.

23.

Fleischmann

De Leo

The World Health Organization’s report on suicide: a fundamental step in worldwide suicide prevention. 2014.

24.

Johnston

Pirkis

Burgess

Psychiatry

NZ.

Suicidal thoughts and behaviours among Australian adults: findings from the 2007 national survey of mental health and wellbeing. Aust N Z J Psychiatr. 2009;43(7):635-643.

25.

Karaman

Durukan

Suicide in children and adolescents. Curr Approach Psychiatry. 2013;5(1):30-47.

26.

Mekonnen

Kebede

The prevalence of suicidal ideation and attempts among individuals attending an adult psychiatry out-patient clinic in Gondar, Ethiopia. Afr Health Sci. 2011;11(1):103-107.

27.

Mofidi

Studies on mental health in Kurdistan-Iran. 2009.

28.

Nock

Borges

Bromet

, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192(2):98-105.

29.

Nock

Green

Hwang

, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the national comorbidity survey replication adolescent supplement. JAMA Psychiatr. 2013;70(3):300-310.

30.

Nock

Hwang

Sampson

Kessler

RC.

Mental disorders, comorbidity and suicidal behavior: results from the national comorbidity survey replication. Mol Psychiatry. 2010;15(8):868-876.

31.

Nath

Kalita

Baruah

Saraf

Mukherjee

Singh

Suicidal ideation in schizophrenia: a cross-sectional study in a tertiary mental hospital in north-East India. Indian J Psychiatry. 2021;63(2):179.

32.

Campos

Mesquita

Testing a model of suicidality in community adolescents: a brief report. 2014.

33.

Khasakhala

Sorsdahl

Harder

Williams

Stein

Ndetei

Lifetime mental disorders and suicidal behaviour in South Africa. Afr J Psychiatry. 2011;14(2):134–139. doi:10.4314/ajpsy.v14i2.5

34.

Oquendo

Brent

Birmaher

, et al. Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior. Am J Psychiatr. 2005;162(3):560-566.

35.

Hoceoglu

Suicidal ideation in patients with schizophrenia. JOP. 2009;46(3):195.

36.

Sadock

BJ.

Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Wolters Kluwer; 2015.

37.

Shibre

Hanlon

Medhin

, et al. Suicide and suicide attempts in people with severe mental disorders in butajira, Ethiopia: 10 year follow-up of a population-based cohort. BMC Psychiatry. 2014;14(1):1-12.

38.

Valtonen

Suominen

Mantere

Leppämäki

Arvilommi

Isometsä

ET.

Suicidal ideation and attempts in bipolar I and II disorders. J Clin Psychiatry. 2005;66(11):1456-1462.

39.

O'Neill

Ferry

Murphy

, et al. Patterns of suicidal ideation and behavior in Northern Ireland and associations with conflict related trauma. PLoS One. 2014;9(3):e91532. doi:10.1371/journal.pone.009153

40.

Di benedetto

. Comment on “the self-care of psychologists and mental health professionals” (Dattilio, 2015)—working with the mentally ill is a mental health hazard: what can we do about it? Aust Psychol. 2015;50(6):400-404.

41.

Fong

Shah

Maniam

Predictors of suicidal ideation among depressed inpatients in a Malaysian sample. 2012;3.

42.

Suokas

Perälä

Suominen

Saarni

Lönnqvist

Suvisaari

JM.

Epidemiology of suicide attempts among persons with psychotic disorder in the general population. Schizophr Res. 2010;124(1-3):22-28.

43.

Conwell

Duberstein

Suicide in Older Adults: Determinants of Risk and Opportunities for Prevention. Oxford University Press; 2005.

44.

Nock

Hwang

Sampson

, et al. Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO world mental health surveys. PLoS Med. 2009;6(8):e1000123. doi:10.1371/journal.pmed.1000123

45.

Apter

Suicide and suicidal behavior. Public Health Rev. 2012;34(2):1.

46.

Fleming

Merry

Robinson

Denny

Watson

PD.

Self-reported suicide attempts and associated risk and protective factors among secondary school students in New Zealand. Aust N Z J Psychiatr. 2007;41(3):213-221.

47.

Karch

Logan

McDaniel

Parks

Patel

Summaries

Surveillance for violent deaths—national violent death reporting system, 16 states, 2009. MMWR Surveill Summ. 2012;61(6):1-43.

48.

Demirkol

Uğur

Tamam

The mediating effects of psychache and dissociation in the relationship between childhood trauma and suicide attempts. Anadolu Psikiyatri Dergisi. 2020;21(0):1-60.

49.

Qin

Agerbo

Mortensen

PB.

Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register–based study of all suicides in Denmark, 1981–1997. Am J Psychiatr. 2003;160(4):765-772.

50.

Shain

Braverman

Adelman

Pediatrics saia. Comm Adolesc. 2016;138(1):e20161420.

51.

Brokke

Bertelsen

Landrø

Haaland

VØ.

The effect of sexual abuse and dissociation on suicide attempt. BMC Psychiatry. 2022;22(1):1-8.

52.

Kukoyi

Shuaib

Campbell-Forrester

Crossman

Jolly

PE.

Suicidal ideation and suicide attempt among adolescents in Western Jamaica. Crisis. 2010;31(6):317-327.

53.

Vajda

Steinbeck

Factors associated with repeat suicide attempts among adolescents. Aust N Z J Psychiatr. 2000;34(3):437-445.

54.

Bilsen

Suicide and youth: risk factors. Front Psychiatry. 2018;9:540.

55.

Mars

Heron

Klonsky

, et al. Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: a population-based birth cohort study. Lancet Psychiatry. 2019;6(4):327-337.

56.

O'Connor

Nock

MK.

The psychology of suicidal behaviour. Lancet Psychiatry. 2014;1(1):73-85.

57.

Klonsky

Saffer

Bryan

CJ.

Ideation-to-action theories of suicide: a conceptual and empirical update. Curr Opin Psychol. 2018;22:38-43.

58.

Tiet

Ilgen

Byrnes

Moos

RH.

Suicide attempts among substance use disorder patients: an initial step toward a decision tree for suicide management. Alcohol Clin Exp Res. 2006;30(6):998-1005.

59.

Hooman

Zahra

Safa

Hassan

Reza

MM.

Association between cigarette smoking and suicide in psychiatric inpatients. Tob Induc Dis. 2013;11(1):1-6.

60.

Bekry

Trends in suicide, parasuicide and accidental poisoning in Addis Ababa, Ethiopia. Ethiop J Health Dev. 1999;13(3):247-261.

61.

Talbott

Fleischmann

De Leo

Bolhari

Botega

De Silva

Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey. Yearb Psychiatr Appl Ment Health. 2007;2007(10):137-165.

62.

Jordans

Rathod

Fekadu

, et al. Suicidal ideation and behaviour among community and health care seeking populations in five low- and middle-income countries: a cross-sectional study. Epidemiol Psychiatr Sci. 2018;27(4):393-402.

63.

Platt

Bille-Brahe

Kerkhof

, et al. Parasiticide in Europe: the WHO/EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr Scand. 1992;85(2):97-104.

64.

Phillips

Cheng

HG.

The changing global face of suicide. Lancet. 2012;379(9834):2318-2319.

65.

Jacobs

DG.

The Harvard Medical School Guide to Suicide Assessment and Intervention. Jossey-Bass/Wiley; 1999.

66.

Kessler

Borges

Walters

EE.

Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey. Arch Gen Psychiatry. 1999;56(7):617-626.

67.

Bete

Lami

Negash

, et al. Current alcohol, tobacco, and khat use and associated factors among adults living in Harari regional state, eastern Ethiopia: a community-based cross-sectional study. Front Psychiatry. 2022;13:955371. doi:10.3389/fpsyt.2022.955371

68.

Birhanu

Bete

Eyeberu

, et al. Nearly one-fourth of eastern Ethiopian adolescents are current psychoactive substance users: a school-based cross-sectional study. Subst Abuse Rehabil. 2023;14:25-34.

69.

Abrahim Imar

. Prevalence and factors associated with regular khat chewing among college students in harar City, Eastern Ethiopia. Int J Psychol Sci. 2023;3(1):1-5.

70.

Dickson-Swift

James

Kippen

Liamputtong

Blurring boundaries in qualitative health research on sensitive topics. Qual Health Res. 2006;16(6):853-871.

71.

Dickson-Swift

James

Kippen

Liamputtong

Doing sensitive research: what challenges do qualitative researchers face?

Qual Res. 2007;7(3):327-353.

72.

Lee

RM.

Doing Research on Sensitive Topics. Sage; 1993.

73.

Dickson-Swift

Undertaking Sensitive Research in the Health and Social Sciences. Cambridge University Press; 2008.

74.

Dickson-Swift

James

Kippen

Liamputtong

Risk to researchers in qualitative research on sensitive topics: issues and strategies. Qual Health Res. 2008;18(1):133-144.

75.

Dickson-Swift

James

Kippen

Liamputtong

Researching sensitive topics: qualitative research as emotion work. Qual Res. 2009;9(1):61-79.

76.

Hubbard

Backett-Milburn

Kemmer

Working with emotion: issues for the researcher in fieldwork and teamwork. Int J Soc Res Methodol. 2001;4(2):119-137.

77.

Johnson

Clarke

JM.

Collecting sensitive data: the impact on researchers. Qual Health Res. 2003;13(3):421-434.

78.

Gelaye

Williams

Lemma

, et al. Validity of the patient health questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Res. 2013;210(2):653-661.

79.

Group

WAW

. The alcohol, smoking and substance involvement screening test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183-1194.

80.

Rueda-Jaimes

Castro-Rueda

Rangel-Martínez-Villalba

Corzo-Casasadiego

Moreno-Quijano

Camacho

PA.

Validity of the suicide behaviors questionnaire-revised in patients with short-term suicide risk. Eur J Psychiatry. 2017;31(4):145-150.

81.

Humeniuk

Henry-Edwards

Ali

Poznyak

Monteiro

The alcohol, smoking and substance involvement screening test (ASSIST): manual for use in primary care. 2010.

82.

Kocalevent

R-D

Berg

Beutel

, et al. Social support in the general population: standardization of the Oslo social support scale (OSSS-3). BMC Psychol. 2018;6(1):1-8.

83.

Osman

Bagge

Gutierrez

Konick

Kopper

Barrios

FX.

The suicidal behaviors questionnaire-revised (SBQ-R): validation with clinical and nonclinical samples. Assess. 2001;8(4):443-454.

84.

De Leo

Burgis

Bertolote

Kerkhof

Bille-Brahe

. Definitions of suicidal behavior: lessons learned from the WHO/EURO Multicentre study. Crisis. 2006;27(1):4-15.

85.

Doyle

Keogh

Morrissey

Caring for patients with suicidal behaviour: an exploratory study. Br J Nurs. 2007;16(19):1218-1222.

86.

Klonsky

May

Saffer

. Suicide, suicide attempts, and suicidal ideation. Annu Rev Clin Psychol. 2016;12(1):307-330.

87.

Tsegay

Damte

Kiros

. Determinants of suicidal ideation among patients with mental disorders visiting psychiatry outpatient unit in Mekelle town, psychiatric clinics, Tigray, northern Ethiopia: a case–control study. Ann Gen Psychiatry. 2020;19(1):1-12.

88.

Liu

Huang

Liu

Prevalence, distribution, and associated factors of suicide attempts in young adolescents: school-based data from 40 low-income and middle-income countries. PLoS One. 2018;13(12):e0207823. doi:10.1371/journal.pone.0207823

89.

Hogan

Grumet

JG.

Suicide prevention: an emerging priority for health care. Health Aff. 2016;35(6):1084-1090.

90.

Kebede

Alem

Suicide attempts and ideation among adults in Addis Ababa, Ethiopia. Acta Psychiatr Scand. 1999;100(S397):35-39.

91.

Alem

Kebede

Jacobsson

Kullgren

Suicide attempts among adults in butajira, Ethiopia. Acta Psychiatr Scand. 1999;100(S397):70-76.

92.

Atwoli

Nock

Williams

Stein

DJ.

Association between parental psychopathology and suicidal behavior among adult offspring: results from the cross-sectional South African stress and health survey. BMC Psychiatry. 2014;14(1):1-10.

93.

Schreiber

Culpepper

Fife

, MA, USA: UpToDate Inc. Suicidal ideation and behavior in adults. 2010.

94.

Karch

Logan

Patel

Summaries

Surveillance for violent deaths—national violent death reporting system, 16 states, 2008. MMWR Surveill Summ. 2011;60(10):1-49.

95.

Alem

Jacobsson

Kebede

Kullgren

Awareness and attitudes of a rural Ethiopian community toward suicidal behaviour: A key informant study in butajira, Ethiopia. Acta Psychiatr Scand Suppl. 1999;397:65-69.

96.

Pritchard

Amanullah

. An analysis of suicide and undetermined deaths in 17 predominantly Islamic countries contrasted with the UK. Psychol Med. 2007;37(3):421-430.

97.

Christiansen

Larsen

Agerbo

Bilenberg

Stenager

Incidence and risk factors for suicide attempts in a general population of young people: a Danish register-based study. Aust N Z J Psychiatr. 2013;47(3):259-270.

98.

Chiou

P-N

Chen

Y-S

Lee

Y-C.

Characteristics of adolescent suicide attempters admitted to an acute psychiatric ward in Taiwan. J Chin Med Assoc. 2006;69(9):428-435.

99.

Choi

Park

Hong

JP.

Suicide mortality of suicide attempt patients discharged from emergency room, nonsuicidal psychiatric patients discharged from emergency room, admitted suicide attempt patients, and admitted nonsuicidal psychiatric patients. Suicide Life Threat Behav. 2012;42(3):235-243.

100.

Xin

L-M

Chen

Y-A

, et al. Risk factors for recent suicide attempts in major depressive disorder patients in China: results from a national study. Front Psychiatry. 2018;9:300.

101.

September who JWSPD. International Association for Suicide Prevention. (2016). 2012.

102.

Gold

Frierson

RL.

The American Psychiatric Association Publishing Textbook of Suicide Risk Assessment and Management. American Psychiatric Publishing; 2020.

103.

Luo

, et al. Major depressive disorder and suicide risk among adult outpatients at several general hospitals in a Chinese Han population. PLoS One. 2017;12(10):e0186143. doi:10.1371/journal.pone.0186143

104.

Clark

Fawcett

An empirically based model of suicide risk assessment for patients with affective disorder. 1992.

105.

Goldman

Del Boca

Darkes

Alcohol expectancy theory: the application of cognitive neuroscience. 1999.

106.

Cooper

Wood

Orcutt

Albino

Personality and the predisposition to engage in risky or problem behaviors during adolescence. J Pers Soc Psychol. 2003;84(2):390-410.

107.

Derogatis

Fitzpatrick

. The SCL-90-R, the brief symptom inventory (BSI), and the BSI-18. 2004.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB

0.03 MB