The Magnitude of Suicidal Behaviour among People Living with Diabetes Mellitus Attending an Outpatient Department of Alamata General Hospital, Mekelle, Tigray, Ethiopia 2019: a Cross-Sectional Study


 Background

Globally, suicide accounts 75% in low and middle-income countries (LMICs).Though the magnitude of suicidal behaviour in high- income countries (HIC) is higher relative to the general population, limited studies had explored about suicidal behaviour among medical outpatients in middle-income countries (LMICs) including this locality. Suicidal behaviours among people with the chronic medical illness are one of the commonest psychiatric emergencies that demand a major health concern by researchers and mental health task forces. People with the chronic medical illness show suicidal ideation and attempt which are fatal problems to end life. Therefore, this study will address the gaps by determining the magnitude of suicidal behaviour among Diabetes Mellitus patients in an outpatient setting of Alamata General Hospital (AGH).
Methods

Institution based cross-sectional study was conducted among medical patients attending a chronic care clinic in Alamata general Hospital from May to June 2019. A sample of 146 DM patients who were attending an outpatient chronic care clinic was included in the study. Patients’ data on socio-demographics, clinical factors, substance use and other information's were collected using a pre-tested structured questionnaire through face to face interview. Suicidal behaviour was used assessed by WHO suicidal behaviour assessment. The collected data were coded, entered and analyzed using frequency, cross-tabulation analysis by SPSS Version 23.
Result

The magnitude of suicidal behaviour among DM patients at AGH is 30.8%.
Conclusion

This study demonstrated that suicidal behaviours common problem in diabetic patients was high magnitude.


Abstract Background
Globally, suicide accounts 75% in low and middle-income countries (LMICs).Though the magnitude of suicidal behaviour in high-income countries (HIC) is higher relative to the general population, limited studies had explored about suicidal behaviour among medical outpatients in middle-income countries (LMICs) including this locality. Suicidal behaviours among people with the chronic medical illness are one of the commonest psychiatric emergencies that demand a major health concern by researchers and mental health task forces. People with the chronic medical illness show suicidal ideation and attempt which are fatal problems to end life. Therefore, this study will address the gaps by determining the magnitude of suicidal behaviour among Diabetes Mellitus patients in an outpatient setting of Alamata General Hospital (AGH).

Methods
Institution based cross-sectional study was conducted among medical patients attending a chronic care clinic in Alamata general Hospital from May to June 2019. A sample of 146 DM patients who were attending an outpatient chronic care clinic was included in the study. Patients' data on sociodemographics, clinical factors, substance use and other information's were collected using a pretested structured questionnaire through face to face interview. Suicidal behaviour was used assessed by WHO suicidal behaviour assessment. The collected data were coded, entered and analyzed using frequency, cross-tabulation analysis by SPSS Version 23.

Result
The magnitude of suicidal behaviour among DM patients at AGH is 30.8%.

Conclusion
This study demonstrated that suicidal behaviours common problem in diabetic patients was high magnitude.

Background
Suicide is a fatal act of terminating one's own life and it is a complex process that involves a series of pathways and mechanisms from initiation of ideation, to planning, and finally to attempting suicide (1). Some plan for days, weeks or even years before acting, while others take their lives seemingly impulse without premeditation (2). Suicidal ideation is an important phase in the suicidal process.
Preceding attempted suicide; which the major risk factors for completed suicide, and is also potentially fatal events (2,3).
Diabetes mellitus is a metabolic disorder of multiple etiological factors characterized by chronic hyperglycaemia with disturbance of carbohydrate, fat and protein metabolism which resulted from either insufficient Insulin secretion, resistance to the action of Insulin or both (4). It is a chronic disease that has become a serious public health problem worldwide (5)(6)(7). Several studies support that DM has profound effects on physical and emotional health. Furthermore, DM has been associated with many adverse health effects including reduced life expectancy, increased risk of various complications, decreased quality of life, and even death (5,(7)(8)(9). On the other hand, it has been reported that patients with chronic medical conditions such as type 2 diabetes mellitus (T2DM) are more likely to manifest psychiatric traits when compared with healthy individuals (10)(11)(12)(13). Up to today, the cause and effect relationship between these entities is not clear yet; we do not know whether diabetes increases the risk of psychiatric traits as depression, or whether psychiatric traits increase the risk of diabetes (14)(15)(16). It is known that suicidal ideas and suicide attempts occur more frequently in patients with DM than in the general population (6,(17)(18)(19). Nonetheless, differences have been reported between patients with type 1 or type II diabetes. For instance, a recent study of people who died by suicide in Finland reported that the proportion of patients with type II diabetes who completed suicide was twice the proportion of patients with type 1 diabetes who completed suicide (20). Other authors indicate that risk factors of suicidal behaviour such as depression, anxiety or hopelessness are present in patients with type 2 diabetes (11,21).
Suicide is an important public health issue; which is the 10th leading cause of death worldwide, a second leading cause of death among those aged 15-29 (22) Suicidal ideation is highly prevalent in the community ranging from 10 to 14% across a lifetime, 2.3 to 14.6% within 12 months of the survey and has a close link completed suicide (2,22). An estimated number of more than 804,000 suicide bases occurred worldwide in 2012 and represents 1.8% of the global burden of disease (23). It is estimated to contribute more than 2.4% the global burden of disease by the year 2020 and the rate of death due to suicide will be increased to one every 20 seconds(3).
Suicidal behaviours in DM are higher in those with low-level education, female, gender in the USA (30), alcohol use and cigarette smoking in the USA (31).
Week family and peer relationship, female sex, lack of social support, stigma related to TB, HIV coinfection, substance abuse, depression, duration of the illness, having other comorbid medical illness associated risk factors suicidal behaviour with CMI. (30,32) In Ethiopia magnitude of suicidal ideation and attempt among patients with severe mental illness is shown as;23.3% for major depression 23.8% bipolar disorder and 13.1% for schizophrenia (32).
Despite the high magnitude of suicidal ideation and attempt among the different chronic medical population in different countries, no data is showing such impact in Ethiopia. Therefore, the aim of the study is to assess the magnitude of suicidal behaviour among patients with DM visiting chronic illness clinic at AGH, Tigray, Ethiopia.
Diabetes Mellitus is one of the most psychologically-demanding chronic diseases, where patients show greater loss of motivation, worse future expectations and a decrease in their quality of life. One study observed that the magnitude of suicidal behaviour in patients with type 2 diabetes was higher than the two-fold observed in the Mexican population (11.6% in patients with diabetes versus 5.2% in the general population) (33). The results were similar to previous reports showing that diabetes increases the risk of death by suicide (34,35). It was found that suicide attempters with T2DM showed higher levels of blood glucose than those without a history of suicide. Since glucose is the human brain's primary source of cellular fuel, psychological processes such as self-control, decision making, and other emotion regulations depend heavily on intracellular availability of glucose in the brain (36,37). Nevertheless, when performed a logistic regression model, glucose levels did not maintain a statistical significance. It was observed that patients in the suicide attempt group, were younger than the control group (44.75 ± 14.01 P = 0.001). In this sense, the results showed that younger patients had a three-fold increase in attempted suicide in comparison to the older population. These data indicate that old age can be a protective factor for suicidal behaviour, as suicidal behaviour magnitude decreases with age (38, 39). The article suggests that younger individuals have more responsibilities and are under more stress than older individuals (40). Gender may be involved as a possible moderator in suicidal behaviour; for example, a study found a statistical relation between obesity and suicide risk in a group of young adult women, but not in men (41). Another hypothesis is that glucose homeostasis may cause mental disorders (42)(43), regardless of the bodyweight; for example, the group of Bendix M. confirmed that higher insulin and lower glucagon plasma levels are associated with SB (44). Then, it is considered that psychological and psychiatric assessments should be performed in diabetic patients before depressive symptoms appear which could prevent suicidal behaviour (45). Also, it is necessary to review studies that have evaluated the use of antidepressants in patients with depression and type 2 diabetes (46). In this sense, a common method of suicide attempt in T2DM patients is the use of high doses of insulin and other medications for treating diabetes (47,48). Therefore, it is supported to have a regular screening and prompt treatment of suicidality, or other psychiatric traits in patients with diabetes (49).
The magnitude of suicide following chronic medical illness varies according to the developmental level of the country, the timing of assessment, sex of victims and classification of chronic medical illness (3). WHO reports shows that an estimated 804,000 suicide death occurred worldwide in 2012, representing an annual global age-standardized suicide rate of 11.4 per 100,000 populations (15.0 for male and 8.0 for female). WHO from the general population shows that globally suicides account for 50% of all violent deaths in men and 71% in women (1,3). Across sectional study conducted in Korea to assess a one-year magnitude of suicidal ideation in adults older than 20 years of age with DM and depression by taking 17065 subjects. Suicidal ideation was assessed by the self-administered question have you ever had any suicidal thought over the past year? And the result shows that 51.4% of patients had suicidal ideation (26).
Deaths from hanging have increased from 16-24%. Most of these (suicide) deaths were male in the 20 to 30 years age group. Deaths due to poisoning have increased from 4-28% over the past 8 years, with males predominating over females. Gunshot related death has also increased from 14% in 1996 to 25% in 2000.Over the same period, student enrolment at the University of Transkei has decreased from 7038 in 1996 to 3783 in 2000, a drop of nearly 50% (24).
Even though, the magnitude of suicide on the medical patient is not studied more in our finding in Ethiopia study from general population shows high magnitude as follows; cross-sectional survey among 2499 adults, using standardizing, and interview-based measures for suicidality (items on suicide from the CIDI) shows that overall 12-month magnitude of non-fatal suicidal behaviour, consisting of suicidal ideation, plan and attempt was 7.9% with magnitude significantly higher in the facility sample 10.3% compared with the community sample 6.3% (24).Retrospective analysis of mortality patterns from the communicable and non-communicable disease in 43 hospitals of Addis Ababa indicates that, of the total 47,153 samples, about 1.9% of deaths attributed to suicide (25).
Another cross-section studies conduct in South Korea assessed the one-year magnitude of suicidal ideation in adults older than 20 years of age with both diabetes and depression. it was found that suicidal ideation was higher among those who are older than 50 years of age, less educated, divorce separated\widowed and suffering from a co-morbid medical condition (26). Similar studies South Korea shows that insulin therapy duration diabetes greater than or equal to 5 years of poor glycemic control [FBS ≥ 126mg\dl] were significantly associated with suicidal attempt (30).
Suicidal ideation was found higher among females patients (p = 0.002) but there was no difference in rates of comorbid infectious between both sexes (30). A history of alcohol abuse, another drug dependency major depression past suicide attempts, and diagnosis of personality disorder have also been associated with suicide risk (30).

Methodology Study design and period
The institution-based cross-sectional study was conducted from May to June 2019 G.C.

Source Population
All DM patients who were attending AGH .

Study Population
All DM patients who were attending Alamata General Hospital during the study period were included.

Inclusion Criteria
All DM patients who were 18 years old or above and attending at AGH were included in the study.

Exclusion Criteria
Those who were seriously ill, under the age of 18 and those with physical disabilities (unable to communicate).

Sample Size Determination
The sample size was determined using a single population proportion formula by Then we added 10% of the Nf for non-response rate 132+14=146 is the sample size we used to conduct our study

Sampling Techniques
Convenience random sampling technique was used to select each study participants from the AGH and the data was collected until the quota was full.

Dependent Variable
Suicidal behaviour.

I. Socio-demographic factors
Age, Sex, Religion, Ethnicity, Marital status, Educational status, Occupational status, Residence, Living condition, Income

Social support
Depression and anxiety

Data collection method and instruments
The study questionnaire had five components. Socio-demographic characteristics were collected by structured socio-demographic questionnaires. Depression and anxiety were collected by using HADS of seven stage questions and substance-related factors were collected by substance-related questionnaires. Social support was assessed by Oslo-3 item social support scale. It is 3 item questionnaires, commonly used to assess social support and it has been used in several studies, Outcome variables, suicidal behaviour were assessed by using a structured questionnaire the data was collected by face to face interview. There were 2 data collectors from fourth-year psychiatric nursing students. Data was collected in the AGH from May to June 2019.

Data quality control
To control the quality of data the questionnaire was designed and modified appropriately. The questionnaire was pre-tested one week before the actual data collection on 5% (8)  Current users: when individuals or study subjects used specific substances like alcohol, smoking cigarette and khat currently.
Ever users: when study subjects or individuals used specific substances like alcohol, cigarette, and khat even once in their lifetime.
Never users: when study subjects or individuals no use specific substances like coffee, alcohol, cigarette, and khat even once in their lifetime.

Ethical consideration
Ethical clearance was obtained from the ethical review committee of Mekelle University. A formal letter of permission was obtained from MU and was submitted to AGH. Confidentiality of respondents was maintained. Informed written consent was obtained from each respondent and anyone not willing to take part in the study had full right to do so. Participants in the study who are highly suicidal were referred at the hospital for the assistant.

Dissemination and utilization of a result
After the data is analyzed, based on the findings obtained, conclusions and recommendations were made. Then the results of the study were submitted to AGH, Mekelle University, College of health science for future planning in routine assessments of mental health particularly suicide for a patient with DM in AGH.. Moreover, the findings of the study disseminated to regional health bureau.

Socio-demographic characteristics
The study compromised 146 Diabetic patients; of whom 113(77) were Males. Majority 46(31.5) of the patients were between the age of 46-55 and mean age was 44.91, 100(68.5) of them were orthodox  Table 2).

Discussion
Suicide is a fatal act of terminating one's own life and it is a complex process that involves a series of pathways and mechanisms from initiation of ideation, to planning, and finally to attempting suicide (1). The finding of this study showed that the overall magnitude of suicidal behaviour among diabetes mellitus patient in Alamata General Hospital was 30.8%, which is within the range of study performed in the USA which was as high as 58.5%(24) and 13.3% (25) respectively in the USA. Similarly, our finding was nearly similar to a study performed in the USA which was found to be 26.5% (27). A crosssectional study conducted in Korea to assess a one-year magnitude of suicidal ideation in adults older than 20 years of age with DM and depression by taking 17065 subjects. Suicidal ideation was assessed by the self-administered question have you ever had any suicidal thought over the past year? And the result shows that 51.4% of patients had suicidal ideation (26) which was significantly higher than our finding this might be due to cultural difference, lack of religiosity which is one of a protective factor of suicide, lifestyle and psychosocial stressors. Our finding was significantly different from a finding in Australia which was 20% and this might be due to better living standard, better management of the illness, less psychosocial stressors compared to Ethiopia. One study observed that the magnitude of suicidal behaviour in patients with type 2 diabetes, 11.6% in patients with diabetes (33) which is significantly different to our finding and this might be due to difference in the study design which was case-control and it also might be due to the study only includes T2DM patients. Suicidal behaviours in DM are higher in those with low-level education, female, gender in the USA (30), alcohol use and cigarette smoking in the USA (31) which was like our finding.
Another cross-section studies conduct in South Korea assessed the one-year magnitude of suicidal ideation in adults older than 20 years of age with both diabetes and depression. it was found that suicidal ideation was higher among those who are older than 50 years of age, less educated, divorce separated \widowed (26) which is like our finding.
In this study out of female 66.7% have suicidal behaviour. In this study, 100% of those who are above

Conclusion
This study demonstrated that suicidal behaviour problem in diabetic patients was high magnitude.

Recommendation
Based on this we recommend For Tigray Regional Health Bureau; They in addition to medical care provided to DM patients they must have the plan to have mental health service converge like mental health care facility and community care facility that provides services with those who have suicidal behaviour due to DM.
For different organization working in DM & psychiatric program; they should have the plan to work integrate mental health services with diabetic management and care service. Also, mental health especially suicidal behaviour assessment should be done for diabetic patients.
For Mekelle University College of health science psychiatry unit; they should also provide awareness services to the diabetic patients by giving health education on prevention and treatment services with coordination other responsible body to the higher risk groups to suicidal behaviour like a female, older patients, uneducated, widowed, those who have poor social support and substance users For researcher; to see in-depth and it needs further study in this idea.

Strength of the study
Strength of this study is that the tools we used are standardized and internationally recognized screening tool is used with high reliability to screens suicidal behaviour.

Limitation of the study
The study, however, could suffer from the following limitations. This study was a cross-sectional study design; it didn't allow establishing a cause and effect of the case.
The study was institution based which could limit it's generalizability to the normal population