Repetition of suicide attempts: data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS Study.

BACKGROUND: Attempted suicide is a strong risk factor for subsequent suicidal behaviors. Innovative strategies to deal with people who have attempted suicide are needed, particularly in resource-poor settings. AIMS: To evaluate a brief educational intervention and periodic follow-up contacts (BIC) for suicide attempters in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, People's Republic of China) as part of the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS). METHODS: Among the 1,867 suicide attempters enrolled in the emergency departments of the participating sites, 922 (49.4%) were randomly assigned to a brief intervention and contact (BIC) group and 945 (50.6%) to a treatment as usual (TAU) group. Repeated suicide attempts over the 18 months following the index attempt - the secondary outcome measure presented in this paper - were identified by follow-up calls or visits. Subsequent completed suicide - the primary outcome measure - has been reported in a previous paper. RESULTS: Overall, the proportion of subjects with repeated suicide attempts was similar in the BIC and TAU groups (7.6% vs. 7.5%, chi(2) = 0.013; p = .909), but there were differences in rates across the five sites. CONCLUSIONS: This study from five low- and middle-income countries does not confirm the effectiveness of brief educational intervention and follow-up contacts for suicide attempters in reducing subsequent repetition of suicide attempts up to 18 months after discharge from emergency departments.

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries.

OBJECTIVE: To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries. METHODS: Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up. FINDINGS: Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; chi2 = 13.83, P < 0.001). CONCLUSION: This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.

Psychological reactions and coping strategies of Sri Lankan women carrying fetuses with lethal congenital malformations.

INTRODUCTION: Termination of pregnancy is a popular option for pregnancies complicated by lethal congenital malformations (LCMs). In Sri Lanka, where abortion laws are restrictive, this is not available. We studied the psychological responses and coping strategies of women who had to continue their pregnancies knowing the baby had a LCM. SETTING: A teaching hospital in Sri Lanka. STUDY DESIGN: Qualitative inquiry. METHOD: We conducted a semi-structured interview of 10 women whose fetuses were diagnosed to have a LCM. RESULTS: All women showed a grief reaction on hearing the news and were distressed about having to carry a futile pregnancy. Eight women were grateful they knew of the abnormality because it prepared them for the birth better, while the other two wished they had not known. They all found having to share facilities with 'normal' women to be painful. Seven women who received 'routine' antenatal care felt that the doctors were ill-equipped to deal with their situation. All felt that abortion should be legalised for LCMs. All engaged in religious rites believed to have miraculous powers, hoping that these will result in a normal baby. Two required specialised counselling. CONCLUSIONS: The diagnosis of a LCM causes severe distress and psychological reactions, which the staff dealing with these women should be aware of. Ideally, they should be provided care with minimum contact with other women, taking into account the futility of the pregnancy. Engagement in religious rites, even though with unreal expectations, may possibly help them in the long term bereavement process.

A randomized, double-blind, placebo-controlled, clinical trial of the impact of malaria prevention on the educational attainment of school children.

A double-blind, placebo-controlled trial of nine months duration was carried out to investigate the impact of malaria and its prevention on the educational attainment of school children in a malaria-endemic area in southern Sri Lanka where both Plasmodium falciparum and P. vivax infections are prevalent. A total of 587 children attending grades 1-5 in four schools and resident in the area were randomly allocated to chloroquine (n = 295) and placebo (n = 292) arms. Language and mathematics scores of end-of-term school examinations for 1998 and 1999 and number of days absent and reasons for absenteeism during seven months pre-intervention and nine months of the intervention were recorded. The results indicate that there were no differences in language (95% confidence interval [CI] = 48.44-53.78 in chloroquine group and 50.43-55.81 in placebo group) and mathematics (95% CI = 49.24-54.38 in chloroquine group and 51.12-56.38 in placebo group) scores between the two groups prior to the intervention. During the intervention, the malaria incidence rate decreased by 55% (95% CI = 49-61%) and school absenteeism due to malaria was reduced by 62.5% (95% CI = 57-68%) in children who received chloroquine compared with the placebo group. Post-intervention, children who received chloroquine scored approximately 26% higher in both language (95% CI = 21-31%) and mathematics (95% CI = 23-33%) than children who received placebo. In a multivariate model, educational attainment was significantly associated with taking chloroquine prophylaxis and absenteeism due to malaria (P < 0.001 for both) but not due to health causes other than malaria or non-health causes. Language scores were associated with number of malaria attacks (P < 0.022). Educational attainment was significantly better among children whose compliance to chloroquine prophylaxis was higher (P < 0.001). The data suggest that malarial attacks have an adverse impact on the educational attainment of the school child and prevention of these attacks significantly improves educational attainment of children living in malaria-endemic areas.

Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey.

BACKGROUND: The objectives were to assess thoughts about suicide, plans to commit suicide and suicide attempts in the community, to investigate the use of health services following a suicide attempt, and to describe basic socio-cultural indices of the community. METHOD: The community survey was one component of the larger WHO multisite intervention study on suicidal behaviours (SUPRE-MISS). In each site, it aimed at randomly selecting and interviewing at least 500 subjects of the general population living in the catchment area of the emergency department where the intervention component of the study was conducted. Communities of eight SUPRE-MISS sites (in Brazil, China, Estonia, India, Iran, South Africa, Sri Lanka, and Viet Nam) participated plus two additional sites from Australia and Sweden conducting similar surveys. RESULTS: Suicide attempts (0.4-4.2%), plans (1.1-15.6%), and ideation (2.6-25.4%) varied by a factor of 10-14 across sites, but remained mostly within the ranges of previously published data. Depending on the site, the ratios between attempts, plans, and thoughts of suicide differed substantially. Medical attention following a suicide attempt varied between 22% and 88% of the attempts. CONCLUSIONS: The idea of the suicidal process as a continuous and smooth evolution from thoughts to plans and attempts of suicide needs to be further investigated as it seems to be dependent on the cultural setting. There are indications, that the burden of undetected attempted suicide is high in different cultures; an improved response from the health sector on how to identify and support these individuals is needed.

Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries.

BACKGROUND: The objective was to describe patients presenting themselves at emergency-care settings following a suicide attempt in eight culturally different sites [Campinas (Brazil), Chennai (India), Colombo (Sri Lanka), Durban (South Africa), Hanoi (Viet Nam), Karaj (Iran), Tallinn (Estonia), and Yuncheng, (China)]. METHOD: Subjects seen for suicide attempts, as identified by the medical staff in the emergency units of 18 collaborating hospitals were asked to participate in a 45-minute structured interview administered by trained health personnel after the patient was medically stable. RESULTS: Self-poisoning was the main method of attempting suicide in all eight sites. Self-poisoning by pesticides played a particularly important role in Yuncheng (71.6% females, 61.5% males), in Colombo (43.2% males, 19.6% females), and in Chennai (33.8% males, 23.8% females). The suicide attempt resulted in danger to life in the majority of patients in Yuncheng and in Chennai (over 65%). In four of the eight sites less than one-third of subjects received any type of referral for follow-up evaluation or care. CONCLUSIONS: Action for the prevention of suicide attempts can be started immediately in the sites investigated by addressing the one most important method of attempted suicide, namely self-poisoning. Regulations for the access to drugs, medicaments, pesticides, and other toxic substances need to be improved and revised regulations must be implemented by integrating the efforts of different sectors, such as health, agriculture, education, and justice. The care of patients who attempt suicide needs to include routine psychiatric and psychosocial assessment and systematic referral to professional services after discharge.

Short-term impact of an acute attack of malaria on the cognitive performance of schoolchildren living in a malaria-endemic area of Sri Lanka.

A prospective study was conducted from January 1998 to November 1999 in a malaria-endemic area of Sri Lanka to determine the short-term impact of an acute attack of malaria on the cognitive performance of 648 schoolchildren attending grades 1 to 5 (mostly aged 6-11 years) in 4 schools. Three groups were studied comprising children with malaria, children with non-malarial fever, and healthy controls. Cognitive performance in language and mathematics at the time of presentation and 2 weeks later was assessed. At the time of presentation, children with malaria scored significantly less in both mathematics and language than children with non-malarial fever and healthy controls. Two weeks later, the mathematics and language scores of children with malaria improved but the scores were significantly lower than the scores of children with non-malarial fever (P < 0.001) and controls (P < 0.001). Having malaria was a significant predictor of cognitive performance after controlling for other confounding factors. These findings suggest that an acute attack of uncomplicated malaria causes significant short-term impairment of cognitive performance. The impairment persists for more than 2 weeks and appears to be cumulative with repeated attacks of malaria.