Trend of Incidence Rate of Suicide and Associated Factors in 2011 - 2015 in Zarand, Iran

AUTHORS

Behnaz Aflatoonian 1 , Mohammad Reza Aflatoonian 1 , Habibalah Khanjari 2 , Reza Mirzahosini Zarandi 3 , Parisa Divsalar 4 , *

1 Research Center for Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran

2 Zarand Governorship of Kerman, Kerman, Iran

3 HSR Research Committee, Kerman University of Medical Sciences, Kerman, Iran

4 Neuroscience Research Center, Department of Psychiatry, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran

How to Cite: Aflatoonian B, Aflatoonian M R, Khanjari H, Mirzahosini Zarandi R, Divsalar P. Trend of Incidence Rate of Suicide and Associated Factors in 2011 - 2015 in Zarand, Iran, Hormozgan Med J. Online ahead of Print ; In Press(In Press):e103041. doi: 10.5812/hmj.103041.

ARTICLE INFORMATION

Hormozgan Medical Journal: In Press (In Press); e103041
Published Online: November 11, 2020
Article Type: Research Article
Received: March 28, 2020
Revised: June 27, 2020
Accepted: July 21, 2020
Uncorrected Proof scheduled for 25 (1)
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Abstract

Background: The study of suicide and identification of mental health problems, social, cultural, and environmental communities are effective for preventive measures and reducing risk factors.

Objectives: This study aimed to study the epidemiology of suicide and its associated factors over 2011 - 2015 in Zarand.

Methods: In this observational-epidemiological study (cohort study), all people who committed suicide in 2011 - 2015 were recorded on a standardized questionnaire, and demographic data of Zarand were collected by the health center and government. Data were analyzed by SPSS software using descriptive statistics, Chi-square tests, and logistic regression analysis.

Results: During 2011 - 2015, 2,401 persons (372 at one hundred thousand) committed suicide, of whom 33 cases (5.1 at one hundred thousand) died. Chi-square and logistic regression information showed suicide attempt rate in people with middle school education was 15.7 times greater than less or more educated ones; similar results showed the rate of suicide of the people in the age group 15-29 was 6.3 times higher than other age groups, retired, and unemployed 3.1 times more than employed and finally, urban living had suicide attempt rate of 1.6 times higher than rural living.

Conclusions: In Zarand, the incidence of suicide is much higher than the global, country, and province average (more than three to four times), and leading to death was much less than expected. However, there are significant differences in the cause and manner and demographic characteristics with other studies, which require the creation of Suicide Registry Center (SRC) and qualitative studies with form layer analysis of causes in Zarand.

1. Background

The World Health Organization (WHO) describes suicide as a known endeavor with a fatal end attempted by a person aware of this consequence (1). Suicide is a mental health problem, and the third reason for death in the age range of 15 to 44 years old, estimated to be at 1 million people annually (2). From the viewpoint of sociologists and by definition of Emile Durkheim’s–top sociologist- suicide is applied to every case of death, which results directly or indirectly from a positive or negative act carried out by the victim himself, knowing that it will produce this result. In this view, four sorts of suicide based on levels of balance in social force, social solidarity, and moral conscience are assumed. First, egoistic suicide occurred when an individual was detached from others in his/her community. Second, altruistic suicide due to an extreme knit correlation of a person with other society members. Third, anomic suicide occurs when there is a lack of control over society norms and disillusionment. Fourth, fatalistic suicide, which is due to destiny with heavy and permanent limitations that make life fruitless (3).

In contrast to sociologists, psychologists further concentrate on personal characteristics, and they consider suicide’s origin in the psychological state of people (4). Suicide motives are categorized into three areas of mental disorders, social issues, and somatic illnesses, or in illness classification, suicide is in the group of violence and in subgroup of self-directed violence. Based on the outcomes of a person’s action, suicide is classified into two groups of attempted suicide and fatal suicide (5, 6). WHO reports, 804,000 occurrences of suicidal deaths in 2012 when the suicide was regarded as the second cause of death at the age group of 15 to 29 years old worldwide (7). On the other hand, reports of the year 2000 revealed that 1,000 cases of suicidal deaths occurred daily where attempted suicide was 8 to 10 times more. World Health Organization estimates approximately 1,500,000 cases of suicidal death, and 10 to 20 times more than this figure, attempted suicide in the year 2020. This estimation shows that by 2020, suicide occurrence will increase approximately 4 times than the year 2000 (8). Studies associated with suicide in Iran show the prevalence rate of 6.7 cases per 100,000 people; therefore, Iran in WHO reports is considered a country with a low level of suicide (9). Nevertheless, the rate of attempted suicide is estimated to be 60 to 130 per 100,000 persons. The most dominant method of suicide in men was hanging and in women was self-emollition (7), and the most prevalent grounds were low education level, unemployment, and mental disorders (9). The predominant areas were Iran western Kurdish provinces, especially rural areas, as post-war possible complications (10). Most studies in Iran are conducted using a problem-expressing approach and with descriptive studies on personal characteristics (7, 11, 12).

2. Objectives

The suicide rate in Kerman province and Zarand are reported to be 3.1 and 7.3 cases per 100,000 persons, and with an estimated rate of 10 to 20 times, it is expected that attempted suicide in Zarand is something between 70,000 to 140,000 cases. The age group of 20 to 24 years had the most cases, and suicide cases in men were twice more than women (13). In a study on suicide attempts conducted in the city of Jiroft, 95 percent of suicide cases used drugs and poisons; moreover, 48 percent of suicide cases were due to domestic fights and spouse's conflicts, and 30 percent of cases were related to mental disorders (14). The increasing trend of this portentous phenomenon in the country and in province urges further precise and expansive inquiries. On the other hand, it is necessary to advance the studies from a problem-expressing approach to causal layered network and social epidemiology models.

The city of Zarand is located 108 kilometers far from the capital of Kerman province, with a population of 130,000 people, two hospitals, six urban health centers, and nine rural health centers (15). Since Zarand is one of the riskiest areas in suicide; therefore, the current study aimed to determine epidemiologic trends and affecting factors of suicide attempts in the city of Zarand from 2011 to 2015.

3. Methods

This study is an observational-epidemiological study (cohort study). Full particulars of suicide attempters who referred to hospitals, health centers, public and private clinics in Zarand during 2011 - 2015 were recorded using a standard questionnaire. The inclusion criteria were all local people who admitted to having suicide (either themselves or the parents) and non-locals, non-admission of suicide, and the people who pretended to commit suicide by doctor’s diagnosis and people who did not provide information (i.e., why, how, etc.) were excluded from the study. Meanwhile, complete information on all suicide cases referred to hospitals, public and private clinics, and those who did not go to the above-mentioned places, including frequency distribution of suicide cases throughout the years 2011 - 2015 with the support of the governorate of Zarand, were collected. Data included age, sex, education, employment status, marital status, place of residence, date of attempt, reason, and method of suicide. On the other hand, basic population data of the Zarand, including distribution of age, gender, educational level, marital status and residential place in the city was obtained from the national statistics office and census data and city’s health center and estimated according to the growth rate of population in stated years. Data were entered into SPSS software version 22 and firstly analyzed using 4W’s (Who, When, Where, and Why) descriptive statistics. Chi-Square and logistic regression were used to determine the relative risk of affecting factors. Furthermore, the mean and ratio difference were used to compare the incidence rate among groups, including age, gender, occupational, educational, residential place, suicide location, and suicide time. The current study was verified by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.REC.1394, 275), and all necessary prerequisites, regarding the confidentiality and safekeeping of people’s information were taken into consideration.

4. Results

Collectively, from 2011 to 2015, 2041 (372 cases per 100,000) cases of attempted suicide and 33 (5.1 per 100,000) cases of deaths were reported. The annual average rate of suicide attempts was 372 ± 31, and those who led to death were 5.1 ± 1.6 per 100,000 population. The highest rate of suicide attempts and completed suicide were in 2011 and 2013, respectively. From 2011 to 2015, the suicide attempts rate continued to decline, and on average, one in 71 cases of suicide attempt was fatal (Table 1). Analyzing the data using logistic regression was revealed that the number of suicide attempts in the age group of 15-29 years was 6.3 times more than other age groups, retired and unemployed 3.1 times than employed, singles and loners 2.1 times than married, and middle school educated 15.7 times than other education groups (Table 2). Ninety percent of suicide cases were at the age group of 15 to 49 years old, even though with 8.8 cases per 1,000 persons and the highest rate was related to the age group of 15 to 29 years old (884 per 100,000). Furthermore, there was no significant difference among gender groups where men referred slightly more than women. The annual suicide rate among unemployed and retired was 10.4 per 1,000, unaccompanied and single individuals was 7.2 per 1,000 and among persons with middle school educational level was 12.6 per 1,000, which was higher than other similar groups (Table 3). Furthermore, the frequency of distribution in different seasons, months, and days indicated no significant difference (Table 4). More than 82 percent of suicide reasons were declared as unknown, 14 percent was due to family conflicts (71 percent without considering unknown causes), about 10 percent was related to mental disorders, 4.6 percent affection and passionate, and other causes consisted of six percent. Ninety percent of all suicides were through the consumption of pills and poisons, and less than 2.5 percent used harsh, self-injury, self-emollition, hanging, etc. Only 5.6 percent of cases had a recorded history of suicide by either person or his/her family (Table 5). In locational and residential place distribution, the highest annual incidence rate of suicide was in Reyhanshahr and Zarand, with about 509 and 447 cases per 100,000 population, respectively (Table 6). Data analysis with logistic regression revealed that the age group of 15 to 29 years old, unemployed, and retired people, alone and single people, and living in urban areas were 6.3, 3.1, 2.1, and 1.6-folds more at risk for suicide compared with the sum of other similar groups. Those people with middle educational levels had 15.7 times more suicide rate in comparison to peoples with illiterate, low educational, as well as high educational levels (Table 2).

Table 1. Incidence Rate of Suicide Attempt and Completed Suicide from 2011 to 2015 in Zarand
YearPopulation FrequencySuicide AttemptSuicide Death RateRatio of Variables
AmountRate in 100,000AmountRate in 100,000Death/ AttemptNo of Attempts/Death
9012214153243686.51.567
91124585498400541100
9212707649238797.11.855
9312961744034032.30.7143
9413221043933186.11.855
Totala1291042401372665.11.473

aThe population of Zarand in all calculations is 129104 derived from the average of mid periods between 2011 – 2015.

Table 2. Affecting Factors and Relative Risk of Them in Suicide Attempt from 2011 to 2015 in Zarand
VariablesAnnual Incidence RateORLowerUpperP Value
15-30 years old8.8 in thousand4.513.935.160.001a
Retired and unemployed10.4 thousand3.132.623.740.001a
Singles and divorced7.2 in thousand2.061.822.320.001a
High school graduate or drop outs12.6 in thousand14.3712.1517.010.001a
Zarand and Reyhanshahr4.5 in thousand1.61.411.810.001a
Year 2001 - suicide attempt4.4 in thousand1.21.091.320.001a
Year 2003 - fatal Suicide7 in 100 thousand3.62.314.120.001a

aHighly significant values.

Table 3. Frequency Distribution of Population and Suicide Attempt in Relation to Demographic Features from 2011 to 2015
VariablesAverage 5 Years Population (%)Five Years of Suicide Attempts (%)Annual Suicide Rate in 100,000P Value
Age0.001a
< 1023829 (18.5)0 (0)0
10-1410610 (8.2)118 (4.9)222
15-2939488 (30.6)1745 (72.7)884
30-4935269 (27.3)447 (18.6)253
≥ 5019908 (15.4)91 (3.8)91
Total129104 (100)2401 (100)372
Gender0.8
Male64501 (49.96)1257 (52.4)390
Female64603 (50.04)1144 (47.6)354
Employment0.001a
Retired unemployed6272 (4.8)326 (13.6)1039
Age over 19 years, Employed or housewife77165 (59.8)1256 (52.3)402
Under 20 years45667 (35.4)819 (34.1)359
Marital Status0.001a
Married and housewife64737 (50.1)1139 (47.3)352
Single35135 (27.2)1262 (52.6)718
Teenager and other29232 (22.7)--
Education0.001a
Illiterate19991 (15.5)27 (1.1)270
Primary school46418 (36)283 (11.8)122
High school and diploma32280 (25)2034 (84.7)1260
Higher education15288 (11.8)57 (2.4)75
Under 6 years old15127 (11.7)--

aAverage population of a five-year period (mid periods).

Table 4. Frequency Distribution of Suicide Attempt According to Season and Day from 2011 to 2015 in Zarand
No. in Group (%)P Value
Season0.82
Spring665 (27.7)
Summer656 (27.3)
Autumn507 (23.2)
Winter523 (21.8)
Total2401 (100)
Days0.9
First 10 days of the month773 (32.2)
Second 10 days of the month792 (33)
Third 10 days of the month836 (34.8)
Table 5. Frequency Distribution of Suicide Attempt Considering Causes, Methods, and Previous History of Suicide from 2011 to 2015 in Zarand
VariableNo. in groupP Value
Reason0.001
Familial fights336 (13.99)
Mental disorder41 (1.71)
Love19 (0.79)
Imprisoned14 (0.58)
Drug abuse10 (0.42)
Mistaken consumption3 (0.13)
Not known1978 (82.38)
Method0.001a
Pills1835 (76.4)
Poison326 (13.6)
Illicit drugs151 (6.3)
Self-injury58 (2.4)
Other31 (1.3)
Suicide history0.001a
Person94 (3.9)
Family41 (1.7)
No history2266 (94.4)

aHighly significant values.

Table 6. Incidence Rate of Suicide Attempt Considering Residential Place from 2011 to 2015 in Zarand
Place of livingPopulation, No. (%)Suicide, No. (%)Annual Incidence RateP Value
Zarand60915 (47.2)1361 (56.7)4470.8
Reyhanshahr6252 (4.8)159 (6.6)509
Baha Abad8028 (6.2)151 (6.3)376
Village 28320 (6.4)156 (6.5)375
Village 111254 (8.7)192 (8)341
Dasht-Khak3700 (2.9)55 (2.3)297
Khanook3092 (2.4)46 (1.9)298
Jarfafak1145 (0.9)14 (0.6)244
Roohabad10611 (8.2)130 (5.4)245
Yazdanshahr10373 (8.1)106 (4.4)210
Siriz3260 (2.5)31 (1.3)190
Sarbanan1897 (1.5)0 (0)0
Hatken256 (0.2)0 (0)0
Total129104 (100)2401 (100)372

In this table, the significance level was calculated based on being in one of variable groups in comparison with not being in that group. For example, age of 15 to 30 years old people were compared with all people not in 15 to 30 years old group, unemployed and single people were compared others rather than being unemployed or single or people living in the Zarand and Reyhanshahr were compared with those who lived in other areas.

In fact, X variable was tested with no X variable and risk ratio was also obtained in the same way. Another example, those people with elementary up to diploma educational level were 15.7 times more at suicide risk in comparison to those people with diploma and higher education or lower than elementary educational level. In this situation, the middle educational level variable was tested with other educational levels.

5. Discussion

The results of this study demonstrated that the completed suicide rate in Zarand was relatively lower than worldwide, Iran, and even provincial rates; meanwhile, there were differences in 2014 compared to previous years. Almost certainly, higher attention of political, health and treatment authorities had an effective role in decreasing death rates. A decreasing trend of suicide attempt has further complex reasons, which needs a closer look into this study. Collectively, we face 3- to 4-fold more suicide attempt prevalence and incidence rate compared with other reports in Iran and Kerman province (10, 15-18). There may be some features, including environmental, geographical (water, soil, and weather), social, cultural, economic, worldview, unconscious in the city, which may have a role in this phenomenon. Findings revealed that the age of suicide attempt in Zarand was 26.7 ± 7.5 from 2011 to 2015, while the mean age of the covered community in the current study was 29.14 ± 15.6, which is significantly different and demonstrates younger age of suicide attempt compared with the community, although the literature review has not revealed this difference (community and suicide ages), the WHO reports have mentioned mostly the risk of age group of 15 to 29 years old (2, 5), which is consistent with the results of the current study. A study conducted in Iran from 1989 to 2007 introduced the same group as the highest at-risk group for suicide (7). Another finding of the mentioned study concludes illiteracy as one of the main causes of suicide, which is not consistent with the findings of the current study in which the lowest suicide rate was related to illiteracy, elementary, and higher educational level and the highest incidence rate of suicide was related to middle school to high school level with 15.7 times more rate. In fact, from illiteracy to diploma, the incidence rate of suicide rises significantly with the rise of educational level, which is an unexpected result in Iran (9). Interpretation of the reverse relationship between educational level and suicide is very complicated and needs further sociologic investigations. Probably, the heterogeneous development trend of Zarand was without considering social, psychological, and sociological changes due to environmental and physical development. Moreover, the results are consistent with Maynard’s study (19) that attempting suicide is more likely in high school dropouts than their counterparts who graduated from high school after controlling for the effects of age, gender, race/ethnicity, and family income. Another important point of the current study was the lack of significant differences among gender groups regarding frequency, causes, and methods of suicide, which was mostly different compared with other studies (10, 14, 16). Other results, including suicide frequency among unemployed and single young people, were consistent with most of the studies (17, 18, 20, 21). The incidence rate of suicide demonstrated a decreasing trend from 2011 to 2015. Seasonal or time frequency distribution was not significantly different, which was inconsistent in comparison with a study conducted in Kerman (13). Another significant point is the variation in incidence rate in county sections of Zarand, including Reyhanshahr, Baha Abad, and Zarand; however, there was no significant difference in lifestyle in rural or urban areas. High incidence rate in the mentioned areas needs further environmental studies, including water, soil, and, weather as well as nutritional conditions of at-risk populations. Another basic difference in the current study, compared with other studies, was a history of suicide attempts and mental disorders so that in some studies, the portion of mental disorders has been reported to be 50 percent, while the portion of mental disorders in the present study was only six percent. In most studies, 40 percent of the reasons for suicide was due to a history of attempting suicide, while this rate in the current study was only four percent (20-22). It seems that conducting descriptive studies and assessment of general health status, especially about mental disorders, would be necessary for the Zarand. The difference between the current study and other studies may be due to data records, especially the mental health status of these people, which were limited to self-expressing and family interviews. It is necessary to conduct extensive researches using Causal Layered Analysis in Zarand to determine the causality network and the relationship of personal and environmental variables with suicide. In a study on the relationship of masochism behaviors with psychological and environmental factors, the findings revealed a high frequency of non-lethal suicides (suicide gesture), which is congruent with the current study (23). Before conducting any study, it is necessary to determine the relationship of masochism behaviors and suicide pretending with suicide attempts (real intention to suicide) in the Zarand, which necessitates cohort studies and setting up Suicide Registry Centers (SRCs) in this field.

Significant differences in the result of the present study concerning both the rate and the frequency of suicide among age, gender, educational level, residential place groups and of course causes, methods, and previous history of mental health disorders and the result of other studies revealed the structural feature of the view of cultural, social, economic, developmental, and attitude manifest of the population of this city. For preventive interventions in short-term programs, reinforcing mental health units and comprehensive education throughout the city is required also since the suicide attempt rate in high school dropouts is higher than other age groups; therefore, a school-based suicide prevention program is based on theory and evidence seems to be necessary. In order to determine the causality network, it is necessary to conduct social epidemiologic studies and Causal Layered Analysis; so in this context, more precise programs could be prepared with scientific information. It is vital to conduct simultaneous fundamental and practical studies to improve the level of readiness among accident and emergency units, hospitals, doctor’s offices, private clinics, and patient transportation in the city of Zarand. It is recommended to set up SRCs in the city to conduct practical research, leading to preventive actions.

One of the strengths of the current study is its observational cohort approach, which was actively conducted, and patients and families went under psychologists' consultation. One of the probable causes of the decreased level of suicide among those people with a history of suicide was actively following up on the patients. Furthermore, the help and interest of Zarand governors can be regarded as an effective factor in this regard (The governor has an MSc degree in psychology). On the other hand, one of the disadvantages and limitations of the current study was the unavailability of mild suicides. However, a few cases did not refer to therapeutic centers and were treated at home by familiar doctors, or they were referred to the city of Kerman by private vehicles.

Acknowledgements

Footnotes

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