Suicidality and non-fatal self-injury behaviors among people living with epilepsy attending neurology clinic at Zewditu memorial hospital and Amanuel mental specialized hospital, Addis Ababa, Ethiopia: A cross-sectional study

doi:10.21203/rs.3.rs-2500461/v1

Download PDF

Research Article

Suicidality and non-fatal self-injury behaviors among people living with epilepsy attending 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-2500461/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

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

Methods: A facility-based cross-sectional study with 345 randomly selected epileptic patients who attended the outpatient neurology treatment service at Amanuel Mental Specialized Hospital and Zewditu Memorial Hospital 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. The association between outcome variables and selected independent variables was tested using a logistic regression model.

Results: The magnitudes of suicidal ideation, suicide planning, and nonfatal 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, suicide planning, and nonfatal self-injury behavior. Individuals who were taking two or more anti-epileptic drugs also showed a statistical association with suicidal ideation (AOR 0.45, 95% CI=.21,.97; p=0.041) and suicide planning (AOR 0.36, 95% CI=.162,.815; p=0.014).

Conclusions: The prevalence of suicidal ideation and nonfatal self-injury behavior among PWE 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 nonfatal self-injury behavior. Strong social support also helped prevent suicide and improve quality of life.

Suicidal ideation

Suicide planning/intent

Suicide attempt

nonfatal self-injury behaviors

Epilepsy

Ethiopia

Suicide remains one of the major public health burdens and primary psychiatric emergencies in the world. Suicide is the 15th leading cause of death globally, with one death occurring every 40 minutes. It is the second leading cause of mortality in 15- to 29-year-olds. Approximately 75% of all suicides are estimated to occur in lower- and middle-income countries (LMICs) [1]. A recent review on suicidal and nonsuicidal 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 nonfatal suicidal self-injurious behavior was 7.9%, with a higher magnitude of 10.3% in health facilities [3].

The risk of suicide among people living with epilepsy (PLWE) is at least twice that of 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 PWE [6]. The relationship between epilepsy, depression, and suicidality has raised a complex phenomenon known as the “bidirectional hypothesis”, which means that epilepsy can be a risk factor for depression/suicide and that 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 (AEDs) are at increased risk of suicidal behavior compared with those not taking AEDs [9]. In particular, a patient taking 2 or more AEDs may have increased suicidality, with a likely explanation that seizures not controlled by a single AED usually indicate 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 underrecognized 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 in hindering help-seeking behaviors in people living with epilepsy, which in turn leads to an increased risk of suicidality and self-harm behaviors [10, 14].

There have been a limited number of studies conducted in Africa and Ethiopia to examine 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 nonfatal self-injury 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 (AEDs), type of epileptic seizure, and social disadvantages, which could contribute indirectly to increased suicidality or nonsuicidal 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 that serve patients referred from throughout the country. AMSH provides services in two major specialties, namely, psychiatry and neurology. The neurology service is an outpatient service that 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 serve 6–10 patients per clinic a day. The clinic provides services to epileptic patients 3 times per week. Neurologists lead the care of patients at both sites, each accommodating an average of 7 trained professionals.

Study population and sampling

Data were collected from PLWE who were seen at the outpatient epilepsy clinics at these two hospitals over a period of 2 months. Adult patients over the age of 18 with a clinically confirmed diagnosis of epilepsy who were able to give consent were eligible. 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 used to calculate the sample size [15]. Using a finite population correction formula and a 10% nonresponse rate, the final sample size was 354.

The total monthly number of epileptic patients attending outpatient services at the study sites was taken from the respective outpatient directorates. Samples that were eligible based on the inclusion criteria were randomly selected until the proposed sample size was reached. Patients were invited for an interview following 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 and at ZMH to be 60 per day, the total sample for AMSH would be 253 and for ZMH, 101.

Data collection and quality assurance

Relevant information about the participants was collected using interviewer-administered questionnaires, classified into three sections. The first section was a semistructured 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 number of current AEDs used for the management of epilepsy were collected from a review of the patient’s medical chart. The types of epilepsy were based on the 2017 International League Against Epilepsy (ILAE) classification [1]. Depression was screened using the Amharic version of the Patient Health Questionnaire-9 (PHQ-9), which is a validated tool used to screen the presence of depression and measure its severity. A cutoff value of PHQ-9 ≥ 5 was used to identify depression. The severity scores consisted 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 experiences of suicidality and nonfatal 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 for population-based studies.

Data were 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 conducted through face-to-face interviews. The second section of data collection was performed using a data abstraction format from the medical chart review after face-to-face interviews with the participants.

Data management and analysis

The collected data were 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 suicide attempts were identified using binary logistics, and those that showed statistically significant results were re-entered for a multivariate logistic regression test to identify independent factors. The 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 participants’ ages ranged from 18 to 67 years, with a median age of 28 years (Table 1). 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 monthly income, more than half of the participants earned less than 500 ETB per month. Most of the participants lived with their families and had good social support.

Table 1

Sociodemographic 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
		Student	78	22.6
		Day laborer	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 had lived with epilepsy for more than 10 years. Approximately three-fourths (73.9%) of the participants had taken (AEDs for 2 years. Approximately 37% of the participants were using more than one AED. The majority of participants (45.8%) had lived with epilepsy for more than 10 years. The magnitude of depression was 27%.

Table 2

Clinical characteristics and epilepsy-related factors among neurologic OPD patients
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 at Onset of Epilepsy	Under 18 years	231	67
2	Age at 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
		More than 10 years	158	45.8
4	Number of AEDs	1 AED	217	62.9
4	Number of AEDs	More than 1 AED	128	37.1
5	Duration of AED use	Less than 2 years	90	26.1
5	Duration of AED use	More than 2 years	255	73.9
6	Depression	No Depression	252	73
6	Depression	Depression	93	27

Prevalence of suicidal and nonfatal self-harm behaviors

The lifetime prevalence of suicidal thoughts among the respondents was 21.2% (N = 73/345) (Table 3). Among the study participants, 63 (18.3%) had a plan to commit suicide, and approximately 12% had nonfatal self-harm behaviors. Of those with self-harm behaviors, more than half (55.8%) had attempted to commit suicide only once. The most common reasons for suicidal thoughts and nonfatal self-harm behaviors are comorbid mental illness (32.4%) and low socioeconomic status (32.4%). The majority of suicide attempts were by poisoning (39.5%).

Table 3

Lifetime prevalence of suicidality and nonfatal 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	Plans to commit suicide	Yes	63	18.3
2	Plans 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 attempt 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 nonfatal 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 nonfatal self-harm behaviors compared to single divorced/widowed/separated individuals. Those who were living alone were three to five times more likely to have suicidal ideation (AOR 4.6, 95% CI = 1.99, 10.6; p < 0.001), plans to commit suicide (AOR 4.8, 95% CI = 2.02, 11.54; p < 0.001) and nonfatal self-harm behaviors (AOR 3.32, 95% CI = 1.28, 8.23; p = 0.01) than those living with their families. In addition, respondents with poor social support were seven times more likely to have suicidal ideation and 4.5 times more likely to have a suicide plan (p < 0.001) (Table 4).

Table 4

Multivariate analysis between selected factors and suicidal ideation, suicide planning and nonfatal self-harm behaviors
Characteristics (Independent variables)	Thoughts of committing suicide in the past		Plans to commit suicide in the past		Suicide attempts/ Nonfatal 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)
College	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, .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 (years)
< 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	3	(.85, 10.58) (P = .86)	5.08	(1.2, 21.51)(P = 0.027)	5.01	(.93, 27.07)(P = .06)
5–10	1.36	(.54, 3.34)(P = .52)	1.4	(.53, 3.73) (P = 0.5)	1.02	(.37, 2.86) (P = .96)
> 10	1		1		1
AED > 2 years
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 AEDs
1 AED	1		1		1
2 or more AEDs	0.45	(.214, .97) (P = .041)	0.36	(.162, .815)(P = 0.014)	0.507	(.21, 1.24)(P = .14)

[Insert Table 4 here]

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), suicide planning (AOR 9.29, 95% CI = 3.4, 21.64; p < .001) and suicide attempts (AOR 7.84, 95% CI = 3.20, 19.15; p < 0.001). Concurrently generalized tonic‒clonic types of epilepsy were more likely to be associated with suicidality (AOR 4.58, 95% CI = 1.05, 19.88; p = 0.04) than focal types of epilepsy. PLWE had an increased risk of planning a suicide 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 did not show any significant association with suicidality and nonfatal self-harm behaviors. However, taking 2 or more AEDs showed a significant association with suicidal ideation (AOR 0.45, 95% CI = .21,.97; p = .041) and suicide planning (AOR 0.36, 95% CI = .162,.815; p = 0.014).

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

The presence of depression was strongly associated with PWE, which is consistent with various studies performed globally [19–21]. The explanation proposed for the increased risk of depression among PWE varies: 1) profound perceived stigma of epilepsy leads to psychological distress, and 2) bidirectional causation between suicidality, depression, and seizures explains that one causes the other or vice versa (i.e., 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 the 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, people with poor social support were associated with a higher rate of suicidality and nonfatal self-harm behaviors. This is consistent with studies performed 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 methods used to attempt suicide were also consistent with those used in other studies. Poisoning using chemicals or AEDs was the most common method found in Asian [27] and New Zealand studies [24]. Similarly, in a study performed in South Africa, 44% [26], and in India, 93.1% [28] of youths and adolescents also showed that poisoning was the predominant suicide method, followed by hanging. However, studies performed in Europe [29] and Western nations [30] have identified that completed suicides or suicide attempts are mostly carried out by hanging, stabbing, or gunshot. 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 seizures were the most diagnosed type of epilepsy (78.6%). Other studies performed in Ethiopia also showed a similar magnitude (77.6%- 93.0%) [20, 22]. A 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 a skill gap in making the diagnosis and a lack of investigative modalities such as EEG equipment. Our results also showed that those diagnosed with the GTC type of epilepsy had a significant association with both suicidal ideation and suicide planning compared to focal seizure types. This is a rather inconsistent association compared with other studies performed in Western nations. One review study highlights that suicidality is increased 6- to 25-fold for TLE, a type of focal seizure, compared with the GTC type of epilepsy [12]. Other studies, however, did not find any association between the types of seizures [13, 27]. A 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 results showed a significant association with plans to commit suicide. This is consistent with other studies where the risk of self-harm increases in the two years after epilepsy diagnosis (IRR, 3.1–4.5) [10]. Despite this, other studies performed in Japan [31] and Ethiopia [22] did not 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 did not find any association between factors such as the early onset of epilepsy and duration of AED use, which is consistent with this study [3, 20].

Different studies indicate that people who are taking 2 or more AEDs are at increased risk of suicidality and nonfatal self-harm behaviors. A study performed in England showed an increased risk of suicidality for PWE taking two AEDs (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 for 11 types of AEDs from a pharmaceutical company including 28,000 patients approximately doubled the risk (OR 1.8, 95% CI, 1.24–2.66) [6, 32].

The study showed that the magnitude of suicidal ideation and nonfatal self-harm behavior among people with epilepsy is high. Poor social support, living alone, and the presence of comorbid depression are significantly associated with suicidal ideation, planning to commit suicide, and/or nonfatal self-harm behaviors. The association between suicide, depression and epilepsy could be bidirectional, wherein similar pathophysiological mechanisms that lower the seizure threshold and increase the risk for psychiatric disorders and suicidality are suggested. Individuals taking 2 or more AEDs showed a significant association between suicidal ideation and planning 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
LMICs:- Low and Middle-Income Countries
PHQ-9:- Patient Health Questionnaire-9
PLWE:- People living with epilepsy
SPHMMC:- St. Paul’s Hospital Millennium Medical College
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 was 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 was 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 interests.

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 and critique. Yared Z. Zenebe and Biniyam A. Ayele were involved in the review and critique. All authors read and approved the final manuscript.

Acknowledgements

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

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

World Health Organization. Preventing suicide: full report. WHO Libr Cat Data. 2014;89.
Quarshie ENB, Waterman MG, House AO. Self-harm with suicidal and non-suicidal intent in young people in sub-Saharan Africa: a systematic review. BMC Psychiatry. 2020;20:1-26.
Fekadu A, Medhin G, Selamu M, Shiferaw T, Hailemariam M, Rathod SD, et al. Non-fatal suicidal behaviour in rural Ethiopia: a cross-sectional facility- and population-based study. BMC Psychiatry. 2016;16:1-9.
Josephson CB, Jetté N. Psychiatric comorbidities in epilepsy. Int Rev Psychiatry. 2017;29:409-24.
Minghui R, Kestel D, Wiebe S, Brodie M. A public health imperative. 2014;8.
Bell GS, Sander JW. Suicide and epilepsy. Curr Opin Neurol. 2009;22:174-8.
Castro SCC, Baroni GV, Martins WA, Palmini ALF, Bisol LW. Suicide risk, temperament traits, and sleep quality in patients with refractory epilepsy. Epilepsy Behav. 2018;80:254-8.
Hesdorffer DC, Ishihara L, Mynepalli L, Webb DJ, Weil J, Hauser WA. Epilepsy, suicidality, and psychiatric disorders: a bidirectional association. Ann Neurol. 2011;72:184-91.
Bagary M. Epilepsy, antiepileptic drugs and suicidality. Curr Opin Neurol. 2011;24:177-82.
Gorton HC, Webb RT, Pickrell WO, Carr MJ, Ashcroft DM. Risk factors for self-harm in people with epilepsy. J Neurol. 2018;265:3009-16.
Kalinin VV. Suicidality and Antiepileptic Drugs. Drug Saf. 2007;30:123-42.
Kanner AM. Suicidality and epilepsy: a complex relationship that remains misunderstood and underestimated. Epilepsy Curr. 2009;9:63-6.
Kanner AM. Epilepsy, suicidal behaviour, and depression: do they share common pathogenic mechanisms? Lancet Neurol. 2006;5:107-8.
Stefanello S, Marín-Léon L, Fernandes PT, Li LM, Botega NJ. Psychiatric comorbidity and suicidal behavior in epilepsy: a community-based case-control study. Epilepsia. 2009;51:1120-5.
Tegegne MT, Mossie TB, Awoke AA, Assaye AM, Gebrie BT, Eshetu DA. Depression and anxiety disorder among epileptic people at Amanuel Specialized Mental Hospital, Addis Ababa, Ethiopia. BMC Psychiatry. 2015;15:210.
Hesdorffer DC, French JA, Posner K, DiVentura B, Pollard JR, Sperling MR, et al. Suicidal ideation and behavior screening in intractable focal epilepsy eligible for drug trials. Epilepsia. 2013;54:879-87.
Hamed SA. Risks of suicidality in adult patients with epilepsy. World J Psychiatry. 2012;2:33.
Lim K-S, Wong CH, McIntyre RS, Wang J, Zhang Z, Tran BX, et al. Global lifetime and 12-month prevalence of suicidal behavior, deliberate self-harm and non-suicidal self-injury in children and adolescents between 1989 and 2018: a meta-analysis. Int J Environ Res Public Health. 2019;16:4581.
Haile K, Awoke T, Ayano G, Tareke M, Abate A, Nega M. Suicide ideation and attempts among people with epilepsy in Addis Ababa, Ethiopia. Ann Gen Psychiatry. 2018;17:1-8.
Zewudie A, Mamo Y, Feyissa D, Yimam M, Mekonen G, Abdela A. epilepsy treatment outcome and its predictors among ambulatory patients with epilepsy at Mizan-Tepi university teaching hospital, Southwest Ethiopia. Neurol Res Int. 2020;2020:1-8.
Baldin E, Hesdorffer DC, Caplan R, Berg AT. Psychiatric disorders and suicidal behavior in neurotypical young adults with childhood-onset epilepsy. Epilepsia. 2015;56:1623-8.
Tsigebrhan R, Hanlon C, Medhin G, Fekadu A. Help seeking and suicidality among people with epilepsy in a rural low income country setting: cross-sectional survey. Int J Ment Health Syst. 2017;11:1-9.
Christensen J, Vestergaard M, Mortensen PB, Sidenius P, Agerbo E. Epilepsy and risk of suicide: a population-based case–control study. Lancet Neurol. 2007;6:693-8.
Beautrais AL, Joyce PR, Mulder RT. Youth suicide attempts: a social and demographic profile. Aust N Z J Psychiatry. 1998;32:349-57.
Fekadu A, Medhin G, Selamu M, Hailemariam M, Alem A, Giorgis TW, et al. Population level mental distress in rural Ethiopia. BMC Psychiatry. 2014;14:1-13.
Madu SN, Matla MP. The prevalence of suicidal behaviours among secondary school adolescents in the Limpopo province, South Africa. S Afr J Psychol. 2003;33:126-32.
Nilsson L, Tomson T, Farahmand BY, Diwan V, Persson PG. Cause-specific mortality in epilepsy: a cohort study of more than 9,000 patients once hospitalized for epilepsy. Epilepsia. 1997;38:1062-8.
Alexander D. Adolescents and young adults: overview. Prev Med. 1994;23:653-4.
Stenbacka M, Jokinen J. Violent and non-violent methods of attempted and completed suicide in Swedish young men: the role of early risk factors. BMC Psychiatry. 2015;15:1-9.
Ojima T, Nakamura Y, Detels R. Comparative study about methods of suicide between Japan and the United States. J Epidemiol. 2004;14:187-92.
Hara E, Akanuma N, Adachi N, Hara K, Koutroumanidis M. Suicide attempts in adult patients with idiopathic generalized epilepsy. Psychiatry Clin Neurosci. 2009;63:225-9.
Mentari E, Hughes A, Iii JF, Stone M, Ware J. Statistical review and evaluation: antiepileptic drugs and suicidality. Food and Drug Administration, Center for Drug Evaluation and Research; 2008.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Suicidality and non-fatal self-injury behaviors among people living with epilepsy attending neurology clinic at Zewditu memorial hospital and Amanuel mental specialized hospital, Addis Ababa, Ethiopia: A cross-sectional study

Status:

Version 1

Abstract

Background

Methods

Study design and setting

Study population and sampling

Data collection and quality assurance

Data management and analysis

Results

Clinical characteristics and epilepsy-related factors

Prevalence of suicidal and nonfatal self-harm behaviors

Factors associated with suicidality and nonfatal self-harm behaviors

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1