Non-fatal self-poisoning in Sri Lanka

Abstract

Non-fatal self-poisoning is a significant public health problem in Sri Lanka. Hospital admission rates due to non-fatal self-poisoning in Sri Lanka have increased since the 1990s, while rates of completed suicides have decreased. Pesticide ingestion among males was the most common pattern of self-poisoning, but recent studies suggest that this is changing. However, little current data is available on non-fatal self-poisoning in Sri Lanka. Psychosocial factors such as psychiatric morbidity, suicide intent, and the likelihood and predictors of recurrence have not been extensively investigated. Accordingly, the aims of this thesis on non-fatal self-poisoning in Sri Lanka are to: 1) investigate the associated socio-demographic factors, substances ingested, psychiatric morbidity and level of suicidal intent; 2) investigate why people carry out acts of non-fatal self-poisoning; 3) describe the longitudinal sequelae over one year, in terms of repetition and suicidal ideation; and, 4) examine potential methods for minimizing rates of non-fatal self-poisoning in Sri Lanka. To achieve these aims, this research program is organized into several sections as follows: A systematic review of 27 studies of non-fatal self-poisoning in Sri Lanka; semi-qualitative interviews of 24 persons who had recently carried out acts of non-fatal self-poisoning; a large cross-sectional survey of 949 persons admitted to hospital after non-fatal self-poisoning, conducted over 14 months; and a one-year follow-up survey of 335 participants. Ethical approval for the study was obtained from the Australian National University and the University of Peradeniya, Sri Lanka. Several key findings emerged overall. Non-fatal self-poisoning in Sri Lanka has begun to resemble the pattern of Western countries, in that most who attempted poisoning were young (majority below 25 years), female, and the most commonly ingested substance was medicinal drug overdoses. One-third of males had ingested pesticides. As described previously in the literature, most acts of non-fatal self-poisoning occurred in the context of distress associated with recent interpersonal conflict; the desire to escape, or to die, emerged as motivational themes. A new finding was that over 50% admitted to hospital after non-fatal poisoning were depressed, and almost one-third of males had alcohol misuse. Male gender, a history of prior suicide attempts, depression, and hopelessness were significant predictors of high suicidal intent. Most participants endorsed potential preventive strategies such as talking to a close friend or family member, distraction activities and recollection of the adverse consequences of the index self-poisoning attempt. Contrary to expectations, the rate of repetition at one year was low, being only 2.7%. These findings suggest that non-fatal self-poisoning should be a national priority in Sri Lanka and that an integrated, multi-level approach towards prevention should be implemented. In particular, the data suggest that primary prevention programs are required to increase community awareness and primary-care treatment of depression, promote safe drinking, and help young people develop interpersonal skills and distress tolerance. Secondary prevention might include screening and targeted management of high-risk individuals who have attempted self-poisoning. Restriction of access to pesticides should be continued. Further research is needed to explore the effectiveness and acceptability of preventive strategies.