The main objective of the present study was to assess the magnitude of suicidal behaviors and the possible factors associated with suicidal behaviors among patients attending ED of AABET. To the best of our knowledge, this is the first study to screen suicidal behavior and/or suicide attempts in Ethiopian patients who visit the ED. The results showed that the prevalence of suicidal attempt was 6.3% and the rate of suicidal behavior was 8%. There were even sex distribution for suicidal attempts in the overall participants. Suicide was attempted most frequently in the age group 18–24. The common underlying reason for the attempt was social reasons, while the most frequently reported attempt method was hanging. The majority (60%) reported that they feel happy for surviving. No factor was found to be significantly associated with suicidal attempt.
We have screened that 53% the participants had common mental disorders, which is consistent with a recent large scale study report that based on several national registers (Bøe et al., 2022). Another study reported around 90% mental illness triage among adult ED patients in the USA (Ting et al., 2012), which is much higher than our finding. A meta-analysis study found that a psychiatric-related illnesses were around 85% among patients with suicidal behaviors in EDs (Hawton et al., 2013). Likewise, another meta-analysis study on the prevalence of a psychiatric-related illnesses at EDs reported that 4% of the attendants were because of mental-illnesses, but around 58% of attendants were identified with a mental illness history (Barratt et al., 2016). In contrast, our finding is higher than other studies that reported 30–36% depression or mood disorders but these studies assessed only affective disorders (Allen et al., 2013; Boudreaux et al., 2006; Boudreaux et al., 2008). Regardless of the magnitude variations across different nations, results show that mental-illnesses are a common problem among patients attending EDs. However, most patients with suicidal behaviors at the EDs are discharged without receiving assessments for common mental-illnesses (Hickey et al., 2001; Tu et al., 2022).
The present study detected that the risk of suicide among patients attending ED is 8%, which is comparable with previous finding (10%) among patients attending a primary care facilities in five low-and middle income countries, including Ethiopia (Jordans et al., 2018). However their report (Jordans et al., 2018) indicates that the overall prevalence of suicide attempt (2.2%) was lower than our finding. Moreover, the present suicidal behavior magnitude is in the range of prevalence that Jordans et al. (2018) found in five countries: suicidal ideation in facility-based samples was 5.0-14.8%, while it was 3.5–11.1% in community-based samples. Our finding is also consistent with previous suicidal behavior reports in the USA (Claassen & Larkin, 2005; Ilgen et al., 2009) but slightly higher than most multicenter-based findings (3–6%) in the USA (Boudreaux et al., 2016; Boudreaux et al., 2005; Ting et al., 2012) and China (Lee et al., 2007). However, our finding is lower than the report (12%) of the same team (Boudreaux et al., 2006) and other reports (12.8%) among patients in the EDs in the USA (Allen et al., 2013), indicating that suicidal behaviors vary across nations.
Furthermore, the magnitude of suicidal attempt in Ethiopia is not consistent (Alem et al., 1999; Fekadu et al., 2016; Gesese & Ochan, 2022; Haile et al., 2018; Hussien et al., 2015; Kebede & Alem, 1999; Kebede & Ketsela, 1993; Mekonnen & Kebede, 2011; Salelew et al., 2016; Shibre et al., 2014; Tsegay et al., 2020; Whittier et al., 2016). The present results showed that the prevalence of suicidal attempt in the ED is 6.3% which is higher than the global lifetime prevalence rates of 2.7% (Nock et al., 2008) and some previous reports in the Ethiopia general population that ranges between 0.9 and 4.4% (Alem et al., 1999; Gesese & Ochan, 2022; Kebede & Alem, 1999; Whittier et al., 2016). Other studies in Ethiopia reported that a suicidal attempt among psychiatric patients (Mekonnen & Kebede, 2011; Salelew et al., 2016; Shibre et al., 2014; Tsegay et al., 2020; Whittier et al., 2016) and epileptic patients (Haile et al., 2018) ranges between 4.1 and 51.3%, which is higher than the findings in the general population and our finding. However, the prevalence is generally in agreement with previous reports about overall suicidal attempt in the Ethiopian general population that ranges between 1.4 and 19% (for review, see Bifftu et al., 2021). Altogether, the present result shows that the magnitude of a suicidal attempt among patients in the ED lies between previous reports about suicidal attempt in the general population and patients with psychiatric disorders. This could be explained by the fact that our study was done in emergency patients who are at high risk as compared to the general population found in the community, but at a lesser risk than patients with mental illness.
Interestingly, the sex distribution of the suicidal attempt in the present study varies based on the age category, which is comparable with sex and gender based suicidal behavior in South Africa (Sadanand et al., 2021). In the present study, females predominate in attempt distribution for the 18–27 age category, but males predominate for the 28–37 age category, and both sexes are similar in the 38–47 age category. However, regardless of age category, the overall sex distribution of suicidal attempt is nearly equal for both sexes, which is comparable with previous studies in Ethiopia (Bifftu et al., 2021) and at the ED in the UK (Dennis et al., 1997). Likewise, Kebede and Alem (1999) found that magnitude of suicidal attempt and ideation among adults in Addis Ababa are similar for female and male, although female sex and younger age group is associated with suicidal ideation. A previous study in our facility that focused on suicidal behaviour among outpatient adults found that there was no significant difference in suicidal attempt by sex, although females had significant predominance in suicidal behaviours than males (Whittier et al., 2016). There was no association between suicidal behaviour and gender among high-school adolescents (Amare et al., 2018). Alem et al. (1999) also found that the sex distribution for suicidal attempt among adults in Butajira/Ethiopia is nearly equal. On the contrary, a study conducted in Gambella/Ethiopia reported that more female youths in the age group of 20–28 attempted and completed suicide (Gesese & Ochan, 2022). The findings for sex-based distribution in suicidal attempt in Africa is mixed, some reporting equal ratio or higher prevalence in either male or females (see Mars et al., 2014 for review), which is comparable with reports from the European multi-center study some decades ago (Platt et al., 1992). On the other hand, the evidence from Italy showed that females have predominance in attempting suicide (Scocco et al., 2008). Jordans et al. (2018) and colleagues also found that the overall suicidal behavior is associated with being female in five low and middle income countries. Another study in South Africa found that being female was associated with suicidal behavior, although the suicidal attempt was nearly equal among both sexes (Sadanand et al., 2021). Moreover, among adults with psychiatric disorders in Gonder/Ethiopia, Mekonnen and Kebede (2011) found that more females attempted suicide than males, although suicide ideation is similar for both sexes. There were no sex differences in suicidal behavior among adults with psychiatric disorders in Jimma/Ethiopia (Salelew et al., 2016). Likewise, Shibre et al. (2014) reported that there were no sex differences in suicidal attempt among people with psychiatric disorders in Butajira, although completed suicide was more common in males. The equal prevalence between females and males in most studies in Ethiopia could be because of the belief in society that “suicide is a cursed act” that makes females more conservative in disclosing about their suicidal behavior. These results overall suggest that although males and females are equal suicide ideators and attempters in the general population, females in the younger age group need special attention to prevent suicidal behavior.
In our study, the most common age of suicidal attempt was 18–24 years, which is in agreement with previous community-based (Alem et al., 1999; Kebede & Alem, 1999) and facility-based studies in Ethiopia (Salelew et al., 2016). Importantly, Kebede and Ketsela (1993) reported that suicidal attempts in adolescents in Addis Ababa high schools is 14.3% that is higher than studies in the general population, which may indicate that the adolescent age group is at higher risk. Likewise, A community-based study among high school students found that suicide attempt is around 16% (Amare et al., 2018). Studies in different countries, including South Korea, USA, Jamaica and Spain, reported that the suicidal attempt rate in late school-aged children and adolescents is around 4–25% (Ivey-Stephenson et al., 2020; Kukoyi et al., 2010; Nock et al., 2013; Park, 2008; Sanchez-Gistau et al., 2013; Ung, 2003). For example, a study in the USA reported that the rate of suicidal attempt in adolescent is 7.4% (King et al., 2015), but the risk of suicide is higher (18.5%). Scocco et al. (2008) also reported that although the overall rate of suicidal behavior (i.e., 4%) or attempt (i.e., 0.5%) was lower in Italy relative to other European countries, there was increased risk of suicide ideation among students (OR, 4.0). Whittier et al. (2016) also found that suicidal behaviour is most common in middle-aged adult outpatients in Ethiopia. A cohort study conducted in Butajira by Shibre et al. (2014) found that being ≥ 40 years was inversely correlated with suicidal attempt in people with mental illness, similarly indicating that younger age is a risk factor for suicidal behaviour. Alem also showed that there seems to be a decline in the frequency of suicidal attempt with increasing age (Alem et al., 1999), which is consistent with the finding in Italy (Scocco et al., 2008). A facility-based study in South Africa reported that suicidal behavior is inversely associated with age (Sadanand et al., 2021). Likewise, a study in the USA reported that suicidal behavior declined with age among older patients attending an ED (Betz et al., 2016a), although there are contrasting reports regarding the association of age and suicide (Bilsen, 2018). There are several factors that might trigger adolescents or youths around 20 years old to have suicidal behavior. Some of the important factors include drug or alcohol abuse, psychotic disorders, smoking, a history of sexual abuse, severe medical conditions, parental issue (Park, 2008; Vajda & Steinbeck, 2000). Importantly, previous suicide attempt history is associated with adolescents than adults in the emergency departments (Lee et al., 2019). Overall, the present result support previous findings that the younger adults are more vulnerable to suicidal behavior.
Regarding method of suicidal attempt, the present result showed that predominant methods were hanging and poisoning which is in agreement with previous facility or community-based studies in Ethiopia (Alem et al., 1999; Gesese & Ochan, 2022; Haile et al., 2018; Kebede & Alem, 1999; Mekonnen & Kebede, 2011; Salelew et al., 2016; Shibre et al., 2014; Tadesse et al., 2021; Tsegay et al., 2020). Likewise, the most common methods of suicidal attempt in African countries are hanging and poisoning (Martin et al., 2014). In our study, intentional pesticides use rather than medication-overdose was the most common method of poisoning next to hanging, which is also comparable with other studies in Ethiopia (Salelew et al., 2016; Shibre et al., 2014) and Africa (Mars et al., 2014). Our finding is also consistent with the global suicide rate (14–20%) because of pesticide self-poisoning (Mew et al., 2017). A previous study at a specialized hospital in Ethiopia also showed that pesticide poisoning most frequently applied as a suicidal attempt method, suggesting that pesticide-use control method is nationally required (Abebe, 1991). The other important finding in the current study is that electricity was as common as pesticide-based poisoning method, although it was rarely reported in previous studies (Mekonnen & Kebede, 2011; Tadesse et al., 2021). Overall, although it is easy to identify the common suicide attempt methods, the intervention program may not be as easy as a policy implications for pesticide control mechanisms. A “one-size-fits-all” approach to reduce or to prevent suicidal behaviour will not be effective (Jobes & Chalker, 2019). Therefore, holistic approaches starting from mental-health assessments in the EDs and exploring the psychopathology of suicide to multiple clinical treatment options warrant.
The majority (44%) of participants in our study stated that their underlying reason to attempt suicide was social problems (such as divorce or conflict with other people) which is comparable with other community-based (Alem et al., 1999) and institution-based studies in Ethiopia (Haile et al., 2018). Our finding also showed that mental illness and other medical conditions are the second and third most common reasons to attempt suicide, respectively. We also found that all (100%) of patients who attempted suicide were with CMD, and 97.7% of suicidal behaviours were among patients with CMD. Mekonnen and Kebede (2011) reported that social reason (21%) was a second predominant factor next to medical illness (65.1%) to attempt suicide. The main reason for the discrepancy between Mekonnen and Kebede (2011) and our result might be due to that they conducted their studies among adults with psychiatric disorders, while we conducted among adults in the ED. Although poor social support, occupation status, and alcohol use level showed crude association with suicide attempt, multivariate analysis failed to show significant association between one of those factors or other factors (such as sex, age, substance use history and mental illness) and suicidal attempt. Likewise, other community or facility-based studies in Ethiopia did not find associations between sex, ethnicity, or religion and suicidal attempt (Kebede & Alem, 1999) or between suicidal attempt and sex, marital status, educational level, religion, family history of suicide or type of mental illness (Mekonnen & Kebede, 2011). In contrast, facility-based studies conducted in Jimma (Salelew et al., 2016) and Mekelle (Tsegay et al., 2020) found that factors such as major depressive disorder, other mental illnesses or family history of mental illness are associated with suicidal behaviour among people with psychiatric disorders, which are consistent with reports from other countries (Qin et al., 2002, 2003). In addition, alcohol use disorder and nicotine dependence are associated with suicidal behaviour among people with mental illness in Ethiopia (Salelew et al., 2016). Another community-based study in Ethiopia found a strong association between major depressive disorder with suicidal attempts among people with severe psychiatric disorders (Shibre et al., 2014). Haile et al. (2018) also found that poor social support, mental illness or co-morbid depression and family suicide history were associated with suicidal behaviour among patients with epilepsy. Overall, results support that mental illnesses, poor social support, and alcohol use level are important risk factors for a suicidal behavior.
We found that around one third of participants (36%) attempted suicide more than once. A study in Ethiopia reported that a previous attempts history and family history of suicide (Tsegay et al., 2020) are associated with suicidal behaviour among people with mental illness. Studies in several countries also showed that a prior suicidal attempt or thought (Borges et al., 2008; Links et al., 2012; Miranda et al., 2012; O'Connor et al., 2013; Ribeiro et al., 2016; Rosenbaum Asarnow et al., 2017; Wenzel et al., 2011) and family history of suicidal attempt (Murphy & Wetzel, 1982; Qin et al., 2002, 2003; Runeson & Åsberg, 2003) were associated with an increased risk of a new suicide attempt. Importantly, some studies emphasized that a prior suicide attempt is the greatest predictor of a completed suicide (Harris & Barraclough, 1997) or a subsequent attempt (Sanchez-Gistau et al., 2013). A study conducted in four English speaking countries showed that the factors that have strong association with suicidal behaviour were depression, hopelessness, poor self-esteem, poor resilience, and less access to mental health services (Holman & Williams, 2022; Links et al., 2012). However, earlier identified risk factors such as depression, hopelessness, impulsivity or most psychiatric disorders do not strongly predict suicidal attempts but suicide ideation (Klonsky et al., 2017). It has been found that in addition to non-fatal self-harm (Mars et al., 2019), factors that decrease fear of death, pain or injury make the transition easier from suicidal ideation to action (for review, see Klonsky et al., 2018). In general, worldwide evidence suggests that important risk factors for suicide among adolescents or late school-aged children include mental illnesses, suicide attempt history (Sanchez-Gistau et al., 2013), self-esteem and bullying, personality traits, family issues, and means of committing suicide (for review, see Bilsen, 2018; Fonseca-Pedrero et al., 2022).
Finally, the present study tried to screen the magnitude of suicidal behaviors and associated factors using standard instruments tools. It has the strength to provide valuable baseline data to initiates further studies and also to devise interventions since suicidal behavior studies among ED patients are lacking in Ethiopia. Screening for suicidal behaviors in ED patients will be an important opportunity for suicide intervention program. However, the present study has important limitations to be considered in the future studies. First, it was not free from social desirability bias as the data was collected by a face to face interview approach that might result in over-or under reporting. Second, there might be recall bias because of forgetfulness and the information they provided was not cross-checked. Third, the present study included only adult patients in the ED. Future studies need to include school- children and adolescents. Lastly, the present study focused on CMD but not subgroups of patients. Further screening of mental illness in the EDs and its association with suicidal behavior is required.
Conclusion
Although suicidal behaviors are more common in the ED than the previously reported prevalence in the general population, it has been ignored in the EDs. The present findings support the need for more-detailed assessment of suicidal behaviours in patients attending EDs. Efforts are required to make ED an important site to assess patients with suicidal behaviors.