Suicidality and Non-Fatal Self-Injury Behaviors Among Epileptic Patients in Neurology Clinic at Zewditu Memorial Hospital and Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, a Cross-Sectional Study

doi:10.21203/rs.3.rs-2231435/v1

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Suicidality and Non-Fatal Self-Injury Behaviors Among Epileptic Patients in Neurology Clinic at Zewditu Memorial Hospital and Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, a Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-2231435/v1

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Background: - Suicidality /suicidal ideation and plan/ and non-fatal self-harm behaviors are more frequent among People living with Epilepsy (PWE) than the general population. The increased risk of suicidality and non-fatal self-harm behaviors and associated factors among people with Epilepsy varies across sociodemographic and disease-related factors as well as comorbid psychiatric conditions. The study aimed to determine the magnitude of suicidality and non-suicidal self-injury behaviors and identify its associated factors among People with Epilepsy seeking medical care at Amanuel Mental Specialized Hospital and Zewditu Memorial Hospital, Addis Ababa, Ethiopia 2021.

Methods: - Facility-based cross-sectional study was conducted on randomly selected 345 epileptic patients that attended the outpatient neurology treatment service at Amanuel Mental Specialized Hospital and Zewditu Memorial Hospital. The study was conducted from 15 December 2020 to 15 February 2021. The WHO composite international diagnostic interview (CIDI) was used to assess suicidality, depression, and epilepsy-related factors. Association between outcome variables and selected independent variables was tested using a logistic regression model.

Result: - The magnitude of suicidal ideation, plan, and non-fatal self-injury behavior among people living with epilepsy were 21.2, 18.3, and 11.9% respectively. Living alone, Poor social support, and comorbid depression were significantly associated with suicidal ideation, plan, and nonfatal self-injurious behavior. Those who were taking 2 or more Anti-Epileptic Drugs also showed statistical association with suicidal ideation (AOR 0.45, 95% CI= .21, .97; p=0.041) and suicidal plan (AOR 0.36, 95% CI= .162, .815; p=0.014) respectively.

Conclusion - The prevalence of suicidal ideation, and non-fatal self-injurious behavior among people with epilepsy was high among Ethiopian epileptic patients in a hospital setting. Routine screening and proper intervention for comorbid depression as well as avoiding polytherapy might prevent suicidality and non-fatal self-injurious behavior, A strong social support also helped in preventing suicide as well as improving quality of life.

Suicidal ideation

Suicidal plan/intent

Suicide attempt

non-fatal self-injury behaviors

Epilepsy

Ethiopia

Suicide remains one of the major public health burdens and primary psychiatric emergencies in the world, with the 15th leading cause of death globally, attributing one death every 40 minutes. An estimated 804 000 deaths by suicide were reported globally. It is the second cause of mortality in 15–29 years old. About 75% of all suicides are estimated to occur in LMIC(1). A recent review on suicidal and non-suicidal self-harm behavior among young people in sub-Saharan Africa shows a lifetime prevalence of 10.3% (2). In Ethiopia, the 12-month prevalence of non-fatal suicidal self-injurious behavior was 7.9%, with a higher magnitude in health facilities at 10.3%(3).

The risk of suicide is increased by 2–3 fold or more among People Living With Epilepsy (PLWE) than among the general population (4).In addition to suicide, psychiatric disorders in particular depression (23%) and anxiety (20%) are also common comorbidities with epilepsy (5). The presence of psychiatric disorders can be either a direct or an intermediate risk factor for suicidality among people with epilepsy (6). The relation between epilepsy, depression, and suicidality has raised a complex phenomenon known as the “bidirectional hypothesis”, which means that epilepsy can be a risk for depression/suicide and on the reverse suicide/depression can be a risk factor for the onset of epilepsy (6–8).

There is a question of whether people with epilepsy taking Anti-Epileptic Drugs (AED) are at increased risk of suicidal behavior than those not taking AED(9). In particular, this patient taking 2 or more AED may have increased suicidality with a likely explanation given to be because a seizure that is not controlled by a single AED usually indicates severe and frequent epilepsy (6, 10). Another explanation could be the possible influence of AED on Depression, cognition, and suicidality(11).

Although the magnitude, character, and methods of suicidal behaviors vary across the world, the true prevalence of suicidality is under-recognized due to various factors (1). Psychiatric disorders and Suicidality are often comorbidities among patients with epilepsy (4, 7, 12, 13). Apart from the perceived stigma of epilepsy and suicide, sociodemographic variation and psychiatric comorbidities pose an important factor to hinder help-seeking behaviors in people living with epilepsy, which in turn leads to an increased risk of suicidality and self-harm behaviors(10, 14).

Since there is a limited number of studies done in Africa and Ethiopia that examined the risk of suicide and epilepsy from a cultural point of view and a socially sensitive perspective. This study attempted to elaborate and clarify the possible association between suicide and non-fatal suicidal behaviors. This could further be explained by whether there is a direct association between epilepsy and suicidality, or other factors such as the presence of comorbid psychiatric disorders in particular depression, the use of 2 or more Anti-Epileptic Drugs (AED), type of epileptic seizure, and social disadvantages could contribute indirectly to increased suicidality or non-suicidal self-harm behaviors.

Study design and setting

A hospital-based cross-sectional study design was employed. The study was conducted at Zewditu Memorial Hospital (ZMH) and Amanuel Mental Specialized Hospital (AMSH), located in the Ethiopian capital Addis Ababa. Both hospitals are tertiary-level government referral hospitals, which serve patients referred from every corner of the country. AMSH gives services in two major specialties namely Psychiatry and Neurology. The Neurology service gives only outpatient service which has 4 clinic rooms serving more than 150 epileptic patients daily. ZMH is a general hospital with a dedicated outpatient epilepsy clinic and a comprehensive inpatient neurology unit. There are 2 clinic rooms in its outpatient service that serves 6–10 patients per clinic a day. The clinic gives service to epileptic patients 3 times per week. Neurologists are leading the care of patients on both sites, each accommodating an average of 7 trained professionals respectively.

Study Population And Sampling

Data were collected from people with epilepsy (PLWE) who attended outpatient epilepsy clinics at these two hospitals over a period of 2 months. Adult patients above the age of 18, with a clinically confirmed diagnosis of epilepsy and are able and were able to give consent. The required sample size was calculated based on a single population proportion formula using the assumption of a 95% confidence interval, a 5% margin of error, and 80% power. The expected prevalence of suicidality of 29.8% was based to calculate the sample size (15). Using a finite population correction formula and a 10% non-response rate, the final sample size was 354.

The total monthly number of epileptic patients attending outpatient service in the study sites was taken from the respective outpatient directorates. Samples that are eligible based on the inclusion criteria were randomly selected until the proposed sample size is reached. Patients were invited for an interview once their routine clinical care. A proportionate stratified random sampling technique ( ni = (Ni / N) * n ) was used for respective hospitals, taking an average number of patients seen at AMSH to be 150 per day, whereas ZMH was 60 per day, the total sample for AMSH would be 253 and ZMH was 101 respectively.

Data Collection And Quality Assurance

Relevant information about the participants was collected using interviewer-administered questionnaires. The questionnaires used were classified into three sections. The first section was a semi-structured questionnaire used for the collection of socioeconomic and demographic data. The second section was used to collect data on patient clinical characteristics. Data on the types of epilepsy, duration of treatment, and the number of current AED used for the management of epilepsy were collected from the patient’s medical chart review. The types of epilepsy were based on the 2017 International League Against Epilepsy (ILAE) classification (1). Depression was screened using the Amharic version of Patient Health Questioners-9 (PHQ-9). It is a validated tool used to screen the presence of depression and measure its severity. A cut-off value of PHQ-9 ≥ 5 was used to identify depression. severity scores consist of none (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27). The third section was a tool to identify and assess Suicidality. The WHO composite international diagnostic interview (CIDI) was used to assess participant experience of suicidality and non-fatal self-injury behaviors as “ever”, and “the past, 12-months” among people with epilepsy. It was a validated tool to use in Ethiopia in various institutes as well as population-based studies.

Data was collected by 2 trained psychiatry nurses who were familiar with the survey tools and ethical conduct of research. The first and third sections of the data collection were done through a face-to-face interview. The second version of data collection was done using data abstraction format from the medical chart review after the face-to-face interview of the participants.

Data Management And Analysis

The collected data was cleaned, checked for completeness, compiled, and entered into SPSS/PC version 25 statistical software for data analysis. Descriptive statistics using central tendency such as (mean, percentage, and standard deviation) were used to report the results of continuous and categorical variables. describe participants' demographics, concerning study variables (patient clinical characteristics and suicidality). Using inferential statistics, factors associated with suicidal ideation and attempt were identified using binary logistics, and those that showed statistical significance results were re-entered for multivariate logistic regression test to identify independent factors. Results were presented using the crude and adjusted odds ratio and 95% CI with a statistical significance of P-value ≤ 0.05.

A total of 352 participants were enrolled in the study. Of these participants, 345 were interviewed, yielding a 98% response rate. The participant's ages ranged from 18 to 67 years with a median age of 28 years (Table1). The majority of the participants were male (66.1%) and single (71.6%). More than one-third attended secondary school (40.3%) and most were students (22.6%) during the period. Regarding the monthly income, more than half of the participants earn less than 500 ETB per month. Most of the participants live with families having good social support.

Table 1

Socio-demographic characteristics
No	Variable		Number (n = 345)	Percentage (%)
1	sex	Male	228	66.1
1	sex	Female	117	33.9
2	Age	18–24	130	37.7
		25–34	123	35.7
		35–44	67	19.4
		>=45	25	7.2
3	Marital Status	Single	247	71.6
		Married	84	24.2
		Divorced	12	3.5
		Widowed	2	0.6
4	Level of Education	No Education	41	11.9
		Primary school	106	30.7
		Secondary school	139	40.3
		Collage	54	15.7
		Postgraduate	5	1.4
5	occupation	Unemployed	37	10.7
		Government employed	69	20
		Merchant	56	16.2
		Farmer	28	8.1
		Students	78	22.6
		Day labor	18	5.2
		Housewife	29	8.4
		Other	30	8.7
6	Income /ETB/	< 500	226	65.5
		500–1000	3	.9
		1000–2000	31	9.0
		> 2000	85	24.6
7	Living status	With Family	268	77.7
7	Living status	Alone	78	22.6
8	Social Support	Good	256	74.2
8	Social Support	Poor	89	25.8

Clinical characteristics and epilepsy-related factors

More than two-thirds (78.6%) of the participants had a diagnosis of Generalized Tonic-Clonic seizure (GTC)( Table 2). The mean age of onset of epilepsy (± SD) was 16.06 (± 9.5) years. Almost half (45.8%) of the participants were living with epilepsy for more than 10 years. About three- fourth (73.9%) of the participants took Anti-Epileptic Drugs (AED) over 2 years. About 37 percent of the participants were using more than one AED. The majority of the participants (45.8%) were living with epilepsy for more than 10 years. The magnitude of depression was 27%.

Table 2

Clinical characteristics and epilepsy-related factors among people attending care at neurologic OPD
no	Variable		Number (n = 345)	percentage (%)
1	Types of Epilepsy	Focal Seizure	51	14.8
		Generalized Seizure (GTC)	271	78.6
		Unknown	23	6.7
2	Age on the onset of epilepsy	Under 18 years	231	67
2	Age on the onset of epilepsy	Above18 years	114	33
3	Duration of Epilepsy	Under 2 years	39	11.3
		2–5 years	67	19.4
		5–10 years	81	23.5
		Above 10 years	158	45.8
4	Number of AED therapeutic use	1 AED used	217	62.9
4	Number of AED therapeutic use	More than 1 AED used	128	37.1
5	Duration of AED use	Less than 2 years	90	26.1
5	Duration of AED use	Above 2 years	255	73.9
6	Depression	No Depression	252	73
6	Depression	Depression	93	27

Prevalence of suicidal and non-fatal self-harm behaviors

The lifetime prevalence of suicidal thoughts among the respondents was 21.2% (N = 73/345)( Table3). Among the study participants, 63 (18.3%) had a plan to commit suicide, and about 12% had non-fatal self-harm behaviors. Of those with self-harm behaviors, more than half (55.8%) had attempted to commit suicide only one time in their lifetime. The most common reason for suicidal thoughts and non-fatal self-harm behaviors are comorbid mental illness (32.4%) or low financial income (32.4%). The majority of suicide attempts were by poisoning (39.5%).

Table 3

lifetime prevalence of suicidality and non-fatal self-harm behaviors among patients attending neurology clinics
no	Variable		Number (n = 345)	percentage (%)
1	Thoughts of suicide	Yes	73	21.2
1	Thoughts of suicide	No	272	78.6
2	Plan to commit suicide	Yes	63	18.3
2	Plan to commit suicide	No	282	81.7
3	Attempted Suicide	Yes	41	11.9
3	Attempted Suicide	No	304	88.1
4	Number of suicide attempts	Once	24	55.8
		Two times	16	37.2
		Three times or more	3	7.0
5	Methods used to commit suicide	Poisoning	17	39.5
		Hanging	22	51.2
		Sharp objects	1	2.3
		Other methods/ jumping from heights/	3	7.0
6	Reason for attempting suicide	Family disputes/ conflict/	5	12.1
		Poverty	3	7.3
		Death of loved ones	2	4.9
		Low income	14	34.2
		Mental illness	14	34.2
		Physical illness	3	7.3

Factors associated with suicidality and non-fatal self-harm behaviors.

Out of the 345 participants enrolled in the study, Factors that fulfilled the minimum requirement using binary logistic regression (p-value < .2) were re-entered into multivariate logistic regression. Multivariate logistic regression showed that married people living with epilepsy (AOR 0.16, 95% CI = 0.37, 0.76; p = 0.02) had only non-fatal self-harm behaviors as compared to single divorced/ widowed/ separated ones. Those who were living alone had three to five times more likely to have suicidal ideation(AOR 4.6, 95% CI = 1.99, 10.6; p < 0.001), plan (AOR 4.8, 95% CI = 2.02, 11.54; p < 0.001) and non-fatal self-harm behaviors (AOR 3.32, 95% CI = 1.28, 8.23; p = 0.01) than those living with families. In addition to these respondents with poor social support had seven times more to have suicidal ideation and 4.5 times more to have a suicidal plan (p < 0.001) (Table 4)

The presence of moderate to severe depression was strongly associated with suicidal ideation (AOR 6.93, 95% CI = 3.19, 15.07; p < 0.001), plan (AOR 9.29, 95% CI = 3.4, 21.64; p < .001) and attempt (AOR 7.84, 95% CI = 3.20, 19.15; p < 0.001) respectively. Concurrently Generalized tonic-clonic types of epilepsy were more likely associated with suicidality (AOR 4.58, 95% CI = 1.05, 19.88; p = 0.04) than those with focal types of epilepsy. People living with epilepsy had an increased risk of a suicidal plan within 2–5 years of being diagnosed with epilepsy (AOR 5.08, 1.2,21.51 P = 0.027) Factors such as duration of epilepsy, age at onset of epilepsy, and duration of AED therapeutic use didn’t show any significant association with suicidality and non-fatal self-harm behaviors. However, those who were taking 2 or more AED showed statistical association with suicidal ideation (AOR 0.45, 95% CI = .21, .97; p = .041) and suicidal plan (AOR 0.36, 95% CI = .162, .815; p = 0.014) respectively.

Table 4

Multivariate analysis between some of the selected factors and suicidal ideation, plan and non-fatal self-harm behaviors
Characteristics (independent variables)	Thoughts of committing suicide in the past		plans of committing suicide in the past		suicide attempt/ Non-fatal self-harm behaviors in the past/
	Adjusted OR	(95% Confidence interval) (P-Value)	Adjusted OR	(95% Confidence interval) (P-Value)	Adjusted OR	(95% Confidence interval) (P-Value)
Marital status
Married	1		1		1
single	0.45	(.15, 1.309) (P = .14)	0.358	(.10,1.12) (P = .09)	0.16	(.037,.76) (P = 0.02)
separated/divorced/ widowed	2.19	(.29, 16.45) (P = .45)	3.218	(.41,25.56) (P = .27)	1.51	(.145,15.80) (P = .73)
Education
No Education	2.24	(.15,33.25)(P = .55)	2.56	.16,41.78 (P = .508)	0.22	(.01,3.32) (P = 0.27)
Primary school	7.14	(.52, 97.68) (P = 0.14)	14.75	.986,220.57 (P = 0.051)	1.5	(.103,22.03) (P = 0.77)
Secondary school	6.6	(.49,88.08) (P = .15)	6.96	.45,97.92 (P = .15)	1.42	(.10,19.36) (P = 0.79)
Collage	4.86	(.32,73.23) (P = .25)	10.05	.56,168.35 (P = .12)	1.37	(0.8,22.42) (P = 0.82)
Postgraduate			1		1
living status
with family	1		1		1
alone	4.6	(1.99,10.62) (P < 0.001)	4.83	(2.02,11.54) (P < 0.001)	3.32	(1.28,8.23) (P = 0.014)
social support
good	1		1		1
poor	7.27	(3.27,16.11) (P < 0.001)	4.56	(1.95,10.56) (P < 0.001)	1.72	(.68,4.38) (P = .25)
Depression
Yes	6.93	(3.19, 15.07) (P < 0.001)	9.29	(3.4,21.64) (P < 0.001)	7.84	3.20,19.15 (P < 0.01)
No	1		1		1
Types of epilepsy
Focal	2.84	(.55,14.52) (P = .21)	7.12	(1.27,39.8) (P = .025)	3.08	(.41,23.52)(P = .27)
Generalized tonic-clonic	4.58	(1.05,19.88) (P = .04)	6.92	(1.6,29.90) (P = 0.01)	2.95	(.50,17.30)(P = .23)
unknown	1		1		1
Age at onset of epilepsy
< 18	1.25	(.48, 3.26) (P = .65)	2.3	(.78,6.73) (P = 0.12)	1.42	(.466,4.32)(P = .54)
> 18	1		1		1
Duration of epilepsy
< 2	4.61	(.50,42.06) (P = .17)	4.57	(.49,42.58)(P = 0.18)	2.92	(.30,28.31)(P = .35)
2–5 y	3	(.85,10.58) (P = .86)	5.08	(1.2,21.51)(P = 0.027)	5.01	(.93,27.07)(P = .06)
5–10 y	1.36	(.54,3.34)(P = .52)	1.4	(.53,3.73) (P = 0.5)	1.02	(.37,2.86) (P = .96)
> 10 y	1		1		1
AED > 2 yrs.
yes	1.41	(.48,4.14) (P = .527)	1.82	(5.67,5.83) (P = .32)	1.61	(.43,6.09)(P = .48)
No	1		1		1
Quantity of AED
1 AED	1		1		1
2 or AED	0.45	(.214,.97) (P = .041)	0.36	(.162,.815)(P = 0.014)	0.507	(.21,1.24)(P = .14)

In this facility-based cross-sectional study lifetime prevalence of suicidality and non-fatal self-harm and its associated factors were assessed among people living with epilepsy. The study revealed that the magnitude of suicidality was higher as compared with facility-based studies done in high-income countries such as New York USA ideation (12–14%)(16). Although comparable results were seen in similar studies done in Egypt 23.5% (17), and a meta- Analysis on global lifetime prevalence 18% (95% CI: 14.2–22.7%) for suicidal ideation(18), as well as studies in Ethiopia ( 14.1%, 10.1%) for non-fatal self-harm behaviors(3, 19), there are variations in the magnitude of suicidality between studies. This discrepancy could be due to sampling design, study participants, or incidence of risk factors.

The presence of depression was strongly associated with people with epilepsy, which is consistent in various studies done globally(19–21). The explanation proposed for the increased risk of depression among PWE is various; 1) profound perceived stigma of epilepsy leads to psychological distress, 2) bidirectional causation between suicidality, depression, and seizures explained that one causes the other or vice versa (ie seizure alone may be a single risk factor for depression and suicidality or depression and suicidality may increase the risk for new seizure) (6). In this study, a strict cutoff score (10 or more) of PHQ-9 was used to assess depression which resulted in a magnitude of 27% among PWE. Similar studies showed comparable results(22, 23). In addition to this people with poor social support were associated with a higher rate of suicidality and non-fatal self-harm behaviors. This is consistent with studies done in New Zealand (31%). Despite the strong association between poor social support and suicidality, cultural and ethnic differences, as well as study designs, could contribute to the discrepancy in the magnitude of the association (18, 23, 24). In Ethiopia possible social factors that trigger suicidality could be family disputes, financial problems, stigma, and discrimination(2).

The association between married PWE and suicide attempts was inconsistent with other studies. Despite these very few studies were done in rural Ethiopia (22) and the Sodo region of Ethiopia (25), as well as a Korean study (p = 0.001) (26), which showed a similar association. The possible explanation can be a rising marital dispute either because of direct stigma and discrimination from spouses or less proportion of PWE to get married as compared to the general population. However, this theory needs further study to reach on conclusion.

Methods used to attempt suicide were also consistent with other studies. Poisoning using chemicals or AED was the most common method used in Asian studies(30) and New Zealand studies(24). Similarly, in a study done in South Africa, 44% (26), and Indian 93.1% (27) of youths and adolescents also show self-poisoning was the predominant method followed by hanging. However, studies done in Europe (28) and western nations(29) identify completed suicide or attempt is mostly carried out by hanging or using sharp objects/rifles. Such differences in the method could be due to accessibility of the method, knowledge of how to use it, and cultural acceptability.

In our study, Generalized-tonic clonic seizure was the most diagnosed type of epilepsy (78.6%). Other studies done in Ethiopia also showed a similar magnitude (77.6%- 93.0% ) (20, 22). The possible explanation for this is that any convulsive type of seizure with loss of consciousness can be given an automatic diagnosis of GTC by clinicians, underdiagnosing other focal seizures with discognitive features. The other explanation could be because of the skill gap in the diagnosis and lack of investigating modalities such as EEG. Our result also showed those diagnosed with GTC type of epilepsy had a significant association in both suicidal ideation and plan as compared to focal seizure types. This is a rather inconsistent association as compared with other studies done in western nations. One review study highlights that suicidality is increased by 6–25 fold for TLE/ a type of focal seizure/ than GTC type of epilepsy (12). Other studies however didn’t find any association between the types of seizures (13, 30). The possible explanation for this could be the presence of a common mechanism of pathogenesis between suicide, depression, and epilepsy types (13)

Regarding the duration of epilepsy, our result showed a significant association with a suicidal plan. This is consistent with other studies where the risk of self-harm is increased in the two years of epilepsy diagnosis (IRR, 3.1– 4.5) (10). Despite this other studies done in Japan (31) and Ethiopia (22) didn’t show any significant association. This could be because of the complex behavior in the association between Suicidality and epilepsy per se. Apart from this most studies didn’t find any association between factors such as the early onset of epilepsy and duration of AED use that is consistent with this study (3, 20).

Different studies indicate that people who are taking 2 or more AED are at increased risk of suicidality and non-fatal self-harm behaviors. A study done in England showed an increased risk of suicidality for two AED with (OR 1.84, 95% CI 1.33–2.55) or three or more AEDs (OR 2.44, 95% CI 1.51–3.94) (10, 23). similarly, trials on 11 types of AEDs from a pharmaceutical company on 28 000 patients showed a risk increase by almost 2 times (OR 1.8 95% CI, 1.24–2.66) (6, 32).

The study showed the magnitude of suicidal ideation, and non-fatal self-injurious behavior among people with epilepsy is high. Poor social support, living alone, presence of comorbid depression, are significantly associated with suicidal ideation, plan, and or non-fatal self-harm behaviors. The association between suicide, depression and epilepsy could be bidirectional relation where similar pathophysiological mechanisms that lower the seizure threshold and increase the risk for psychiatric disorders and suicidality is suggested. Those taking 2 or more AED showed a significant association between suicidal ideation and plan only.

AED:- Anti Epileptic Drugs
AMSH:- Amanuel Mental Health Specialized Hospital
CIDI- Composite International Diagnostic
CSSRS:- Colombia Suicide Severity Rating Scale
FDA:- Food and Drug Administration
HIC:- High-Income Countries
ILAE:- International League Against Epilepsy
LMIC:- Low and Middle-Income Countries
PHQ-9:- Patient Health Questioners-9
PLWE:- People living with Epilepsy
SPHMMC:- St. Paul’s Hospital Millennium Medical Collage
SPSS:-Statistical package for social sciences
WHO:-World Health Organization
ZMH:- Zewditu Memorial Hospital

Ethics approval and consent to participate

The study was conducted after ethical clearance is approved by the ethical committees of the Public Health Department of St. Paul hospital millennium medical college, Addis Ababa regional Health buero, and Amanuel mental specialized Hospital. All methods were performed in accordance with the relevant guidelines and regulations from the ethical committees.

Written informed consent was also obtained from each respondent to participate in the study and a detailed explanation about the objectives, purposes, and benefits of the study were given by the trained data collectors.

Consent for publication

Not applicable

Availability of data and materials

All databases will be available in an electronic version of SPSS upon the request of the corresponding author.

Competing interests

The authors declare that there are no competing interest

Funding

No funding was received from any institution/government.

Authors contributions

Mohammed N.Anbessie was involved in data acquisition, analysis, interpretation, review, and critique of the study. Ewnet Gebrehanna was involved in the analysis, interpretation, review as well as critique. Yared Z. Zenebe and Biniyam A. Ayele were involved in the review and critique. All authors’ read and approved the final manuscript.

Authors information

*Mohammed N. Anbessie, (MD, MPH ), Atlantic fellow, Global brain health Institute, San Francisco, California, Department of Psychiatry, Amanuel Mental Specialized Hospital, Addis Ababa Ethiopia
Ewnet Gebrehanna, (MD, MPH) ,Department of Public health St. Paul millennium medical college, Addis Ababa Ethiopia
Yared Z. Zewde (MD) Atlantic fellow, Global brain health Institute, San Francisco, California. Department of Neurology, Addis Ababa University, Addis Ababa, Ethiopia
Biniyam A.Ayele (MD) Atlantic fellow, Global brain health Institute, San Francisco, California. Department of Neurology, Addis Ababa University, Addis Ababa, Ethiopia

Acknowledgments

We would like to express our appreciation and gratitude to the Department of Public health at St.Paul Hospital Millenium Medical Collage, Amanuel Mental Specialized Hospital, and Zewditu Memorial Hospital. We are also thankful to the study participants for their cooperation during the data collection process.

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No competing interests reported.

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Suicidality and Non-Fatal Self-Injury Behaviors Among Epileptic Patients in Neurology Clinic at Zewditu Memorial Hospital and Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, a Cross-Sectional Study

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Abstract

Background

Methods

Study design and setting

Study Population And Sampling

Data Collection And Quality Assurance

Data Management And Analysis

Result

Clinical characteristics and epilepsy-related factors

Prevalence of suicidal and non-fatal self-harm behaviors

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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