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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 100-105

Profile and in-hospital outcomes of deliberate self-harmed patients in a tertiary care centre


Department of General Medicine, Government TD Medical College, Affiliated to Kerala University of Health Sciences, Alappuzha, Kerala, India

Date of Submission02-Apr-2022
Date of Decision10-May-2022
Date of Acceptance16-May-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. K P Rashmi
Sreeragam House, Opposite Kuruchi Temple, Kavambhagom PO, Pathanamthitta, Thiruvalla - 689 102, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_33_22

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  Abstract 


Objective: Suicide is an unrecognised and underestimated epidemic of high complexity and accounts for premature loss of at least 1 million lives worldwide, leaving behind irreparable loss and backlash to family, friends and society. This study was carried out with the aim of analysing the clinical presentation, modes of deliberate self-harm (DSH), demographic and biochemical features with outcomes of patients presenting with DSH and admitted through the emergency unit of the medicine department to a tertiary care teaching hospital in South India.
Materials and Methods: The clinical presentation, demographic details, psychiatric evaluation and blood investigations of patients admitted with a history of DSH during the study (2020–2021) were analysed, with special emphasis on serum cholesterol, C-reactive protein (CRP) and thyroid-stimulating hormone (TSH).
Results: In this study, of the 508 patients studied, the most common mode of self-harm was poisoning by drug overdose (32.28%) followed by plant toxin poisoning and rodenticide ingestion-finding different from other studies of South India during this COVID pandemic. Values of TSH, serum cholesterol, CRP and haematogram were normal in majority of patients. All the patients underwent psychiatry evaluation in which substance abuse, adjustment disorders and personality disorders were the most common diagnosis reached.
Conclusions: Clinical profile and methods of DSH have marked regional variation necessitating the need to create a regional database. Serum cholesterol, CRP and TSH are subject to genotypic and regional variations and thus are not reliable as biomarkers of suicidal ideation.

Keywords: Cholesterol, C-reactive protein, demography, psychiatry, self-injurious behaviour, thyrotropin


How to cite this article:
John J, Rashmi K P, Jayachandran R. Profile and in-hospital outcomes of deliberate self-harmed patients in a tertiary care centre. Curr Med Res Pract 2022;12:100-5

How to cite this URL:
John J, Rashmi K P, Jayachandran R. Profile and in-hospital outcomes of deliberate self-harmed patients in a tertiary care centre. Curr Med Res Pract [serial online] 2022 [cited 2022 Aug 12];12:100-5. Available from: http://www.cmrpjournal.org/text.asp?2022/12/3/100/349292




  Introduction Top


Suicidal behaviour is a global health issue and each year, around 10–20 million people attempt suicide with about 800,000 lost lives.[1] Asian countries account for 60% of global suicides and the situation is worsened by inadequate resources, statistics or research. Suicide accounts for the second-most common cause of death in people of 15–29 years and thus has far-reaching economical and socio-political implications.[2]

Suicide and suicidal attempts are a common yet underreported public health problem necessitating evaluation of risk factors and formulation of strategies for prevention and monitoring. The World Health Organization (WHO) recorded 804,000 self-inflicted deaths in 2014 in its 172 member states with an estimated annual rate of 11.4/100,000 and gender-wise, the rates were 15/100,000 in men and 8/100,000 in women.[3] Furthermore, data revealed that the developing countries which have the largest share of the world population, accounted for 75% of self-inflicted deaths.[4],[5],[6]

The epidemiology of suicide is beset by a lack of sufficient data, but the role of culture, ethnicity, gender and age has been evident.[6] Two age groups are vulnerable-youngsters between the age of 15 and 35 years and the elderly above 75 years of age. Suicide rates were 66.9/lakh population in the elderly as against 1/lakh in those between 5 and 14 years of age. Affluent nations had higher male suicide rate while economically constrained nations had 3 times higher suicide rates in females.[7]

The main risk factors related to suicidal behaviour were identified in WHO fact sheet as psychological and existential philosophical problems, environmental, biological, medical or social motivations. Micro-social factors contributing to suicidal behaviour include anxiety and personality disorders, schizophrenia, hopelessness, workplace stress, legal problems, broken or disturbed relationships, social isolation, interpersonal conflicts, personal loss and violence. Stimulants such as alcohol, amphetamines and cocaine are triggers in people with depression, with alcohol being the most common. Personality traits, hypochondriasis, excessive independence or dependency, timidity and seclusion worsened vulnerability in the elderly. Difficulties with parental relationships, physical or sexual abuse, peer group conflicts and loneliness were of importance in childhood and adolescence.[7],[8],[9],[10]

Previous attempts of suicide or having relatives and acquaintances who attempted or committed suicide, exposure to shocking events as a first-hand witness or through electronic media or life stressors are strong predictors of suicidal behaviour. Environmental factors like ease of access to conditions enabling easy attempts such as falling from heights, drowning, firearms, drugs and poisons also contribute to the ideation.[10],[11]

The factors behind suicidal behaviour are multifactorial and incompletely understood. They include psychological as well as genetic and environmental factors. Borderline personality and major depressive disorder are established as risk factors, but newer evidence implicate a much more complex predisposition.[5],[6]

Studies are now focusing on the underlying biological predisposition to suicidal ideation like a dysregulated immune system or a familial predisposition to self-destructive behaviour.[12] Others have proposed suppressed serotoninergic activity causing poorer impulsivity inhibition or an aberrant serotonin type 5A receptor gene variant with high triglyceride levels and lower high-density lipoprotein cholesterol levels.[13]

The last decade has seen many studies in search of biological markers that might clue the treating doctor to an underlying high risk suicidal behaviour in vulnerable people. The list includes but is not restricted to low serum cholesterol and its fractions and proteins such as leptin associated with adipose tissue,[14] C-reactive protein (CRP),[15] thyroid-stimulating hormone (TSH), free T4, inflammatory cytokines like interleukin-6 and tumour necrosis factor.[16] Low levels of leptin and cholesterol were found to be linked to violent suicide attempts. This is interesting as the reverse-metabolic syndrome (obesity, increased waist circumference and hyperlipidaemia) is also seen in people with bipolar mood disorder. Other studies have implicated a dysregulated hypothalamic-pituitary axis with a four-fold increased risk for self-harm when exposed to stressors.[17],[18]

According to the WHO reports, self-harm and suicide attempts are generally under-reported even in countries with robust health information system.[7] Further, it is estimated that only 25% of those attempting self-harm meet the emergency services and of these, usually the most serious cases get attention while the others are treated simply in relation to the injuries caused by the attempt. Further worrying is the finding that out of every three suicide attempts, only one received health services attention.[9],[11]

In our settings, the first place where people who have attempted suicide meet health-care services is the medicine department emergency health unit. Literature also proves that of the people who attempted suicide, at least 10% had been seen by a health-care professional in the emergency department within the previous two months but were not identified to be at risk for suicide.[11] This has thus strategic importance, and merits further characterisations and analysis.

Purpose of the study

  1. To understand the demographic and biochemical profile of people admitted with self-injurious behaviour
  2. To assess the role of TSH, CRP and cholesterol as biomarkers for suicidal ideation.



  Materials and Methods Top


This hospital-based observational study analysed the presentation, mode of self-harm, demographic and biochemical features and outcomes of 508 patients presenting with deliberate self-harm (DSH) during the 1-year study (2020–2021) and admitted through the emergency unit to the general medicine department of a tertiary care teaching hospital in South India. Patients with a primary diagnosis of DSH admitted to the medicine wards/intensive care units and willing to give consent (the primary care giver in case of unconscious patient) were included in this study. Requisite clearances from the Institutional Research Board were obtained and data de-personalisation/confidentiality maintained throughout the study. Informed written consent was taken from the patients included in the trial.

Details about baseline demographic data, details about the self-harm (method, precipitating factors, substance abuse, prior psychiatric illnesses or attempts of self-harm and outcomes), co-existent diseases, regular medications, vital signs like blood pressure, oxygenation status (SpO2) and Glasgow Coma Scale (GCS) at time of presentation, haematological values (complete blood count, lipid profile and TSH) were collected through a structured questionnaire. ten mL of venous blood in fasting state was withdrawn from willing patients, and samples sent to Haematology and Biochemistry Labs to be tested for Complete Blood Count (Mindray bc-1800 Hematology Analyzer), renal function tests, liver function tests, Electrolytes (Vitros 350 Biochemistry Analyzer), TSH (bioMerieux miniVidas Immunoassays), CRP (Afinion CRP) and Fasting Lipid profile (Cholestech LDX Analyzer). The primary outcome was the status of the patient at the end of hospitalisation days while the diagnosis after psychiatry evaluation was taken as the secondary outcome. Data was entered into excel sheets and analysed using SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc. Categorical variables were depicted using proportions and chi-square tests while continuous variables were expressed as mean with standard deviation.


  Results and Discussion Top


In the study, 508 patients were admitted with complaints of DSH. The objective of the study was to analyse the profile of self-harm in a coastal area. The mean age in the group was 33.3 ± 13.8 years [Table 1]. Majority were females and of age <25 years, like other studies from South India.[19] In some other Indian studies, male preponderance was seen, probably because of the regional socio-cultural differences and male financial dominancy.[20] The higher female vulnerability could reflect their economic dependence, domestic abuse, dowry demands or maladjustment.
Table 1: Age distribution in the study group

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In the study group, the unmarried people were equally vulnerable as the married and the 66.92% belonged to <35 years age. People without regular employment and home makers were predominant, followed by students. This contrasts with other studies[19],[20],[21],[22],[23] and could be an effect of the pandemic related financial and social changes which affected the youngsters and the unsalaried class dramatically. Most of the attempts were of low lethality and unplanned. People belonging to nuclear families were more vulnerable (76.96%) when compared to those of joint families [Table 2]. This trend could be attributed to loss of social support and cohesion network in small nuclear families in the more urbanised areas of the district.
Table 2: Other demographic details of the study group for deliberate self-harm

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The most common cited reason was inter-personal issues, and a majority refused to divulge the cause [Table 3]. Alcoholism or some other substance abuse was seen in 30.12% of the group and in males across all age groups. Being a coastal area with deep-sea fishing and weeks spent on trawlers as the main occupation, lower socio-economic neighbourhood, semi-urbanisation, uncertain incomes, alcoholism as well as other addictions are very rampant This can worsen depression, escalate domestic and inter-personal conflicts, psychological or sexual abuse and precipitate DSH both in the person and his family.[10],[24]
Table 3: Causes attributed by patients to the attempt at deliberate self-harm

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Health-related issues were cited by only 4.2% people and 20.1% of people with chronic illnesses attempted suicide. This pattern differs from other studies which showed a 6.4%–8.8% prevalence of suicide attempts across various chronic illnesses.[25] The COVID pandemic and the ensuing lockdown with limited medical access, mobility and loss of personal space might have confounded the data in our study.

The most common methods for self-harm in our study group were drug overdose (Paracetamol, Benzodiazepines and simultaneous ingestion of multiple drugs), plant poisoning (Cerbera Odollum), rodenticide (rat killer) poisoning and pesticides poisoning. Cut injuries were reported in 18 cases while hanging attempts were seen in 19 cases [Table 4]. A history of DSH was seen in only 2.6% cases and this low value could probably be attributed to the social stigma attached to acknowledgement of DSH attempts or unwillingness to divulge past stressors and events.
Table 4: Methods used for the deliberate self-harm attempt

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Our study was carried out during the transition phase of the COVID epidemic with the ensuing lockdown where only essential medical services were available-this could explain the higher rates (8.4%) of Paracetamol(PCM) /Non-Steroidal Anti-inflammatory Drugs (NSAIDS) and other over the counter easily obtainable drugs (32.28%) overdose. Cerbera Odollam -suicide tree – a cardiotoxic plant is a part of our local flora and fauna – this is used very frequently for DSH attempts by the local population (24.8%). This is contrast to other studies where agrochemical poisoning was predominant and plant poisoning rare.[20],[21],[22]

Most of the patients were hemodynamically stable at time of admission and the most common presentation was with abdominal pain, nausea and vomiting [Table 5].
Table 5: Clinical profile at the time of hospitalisation

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The mean cholesterol was 156.68 ± 51.37 mg/dl in females, and 160.4 ± 51.25 mg/dl in males. The mean TSH was 2.12 ± 1.18 mIU/L in females and 1.78 ± 1.14 mIU/l in males with no statistically significant difference between the two genders [Table 6]. Fifty-six and 34 patients were on medications for dyslipidaemia and thyroid dysfunction, respectively.
Table 6: Baseline hematology reports at the time of hospitalization

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The relation of thyroid hormones and serum cholesterol on suicidal ideation is controversial. Cholesterol affects membrane integrity, lipid metabolism and neuromodulation and some reports have noted association between low cholesterol levels and lethal suicide attempts.[14],[17],[18] Similarly, while low TSH itself can cause depression or violent suicide attempts, lower TSH levels could also be sequel to stress-induced hypercortisolemia or a dysregulated hypothalamic–pituitary–thyroid axis.[14],[26] However, the total cholesterol and TSH values were within the normal range in our group. The anticipated abnormal levels could have been offset by the high prevalence of sub-clinical hypothyroidism in coastal areas, increasing prevalence of obesity, use of statins, fortified food or seafood-based local habits.

Most of our patients were stabilised and discharged from the hospital – a finding congruent with other studies.[6],[19],[20],[21],[22] In-hospital death occurred in 16 cases of which 12 were male and 4 female [Table 7].
Table 7: Post-hospitalization outcomes

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Most attempts were impulsive acts (89.96%) and women presented with less lethal attempts (62.01%) as against men who planned and attempted more lethal attempts at DSH where the possibilities of help and resuscitation were not easy. This finding is parallel to other studies which also reported that men tend to attempt suicide in more lethal ways.[21],[27] This could be an after-effect of higher mobility, access to poisons or substance abuse seen in men.

A psychiatric evaluation was sought in all our patients. No psychiatric diagnosis could be reached in 28.4% of male and 52.5% of female patients [Table 8].
Table 8: Psychiatry evaluation and diagnosis during hospitalization

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Alcohol/substance abuse was more common in men while adjustment disorders and mood disorders were seen more in women. These gender differences and increasing prevalence of associated psychiatric comorbidities are more prominent in recent studies,[19],[20],[27] but not reported in the older articles.[4],[23] A more robust and expanding psychiatric evaluation, changing social milieu and gradual recognition of importance of female mental well-being could be the cause for this shift.

Limitations

This was a purely observational study with no comparison group. The data, being sensitive and personal, were subjective and with recall bias.


  Conclusions Top


  1. DSH is an emerging epidemic and people of lower economic strata, younger age group, income-generating and house-making cadre are more susceptible – this needs to be addressed
  2. More research is needed to identify affordable and dependable biomarkers that can help identify this group and personalise treatment and support options
  3. The methods used for attempting suicide have regional differences. Hence, the importance of tailored local legislations to restrict access to toxins, firearms, agrochemicals and substances of abuse and training the emergency responders to the common toxicology patterns. A cohesive effort from the policy makers, emergency physicians, psychiatrists, social workers, family and community members to develop a strong support system is the need of the hour.


Acknowledgement

Patients admitted to Government TD Medical College and Hospital, Alappuzha, Kerala.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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World Health Organization. Suicide: One Person Dies Every 40 Seconds. Available from: https://www.who.int/news/item/09-09-2019-suicide-one-person-dies-every-40-seconds. [Last accessed on 2022 Mar 14].  Back to cited text no. 1
    
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Bhalla K, Harrison JE, Shahraz S, Fingerhut LA; Global Burden of Disease Injury Expert Group. Availability and quality of cause-of-death data for estimating the global burden of injuries. Bull World Health Organ 2010;88:831-8C.  Back to cited text no. 4
    
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World Health Organization. Preventing suicide: A Global Imperative. Published 2014 World Health Organization. ISBN 978 92 4 156477 9. Available from: https://apps.who.int/iris/handle/10665/13105. [Last accessed on 2022 Mar 14].  Back to cited text no. 7
    
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Müller N. Immunology of major depression. Neuroimmunomodulation 2014;21:123-30.  Back to cited text no. 12
    
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Atmaca M, Kuloglu M, Tezcan E, Ustundag B, Gecici O, Firidin B. Serum leptin and cholesterol values in suicide attempters. Neuropsychobiology 2002;45:124-7.  Back to cited text no. 14
    
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Linkowski P, Van Wettere JP, Kerkhofs M, Brauman H, Mendlewicz J. Thyrotrophin response to thyreostimulin in affectively ill women relationship to suicidal behaviour. Br J Psychiatry 1983;143:401-5.  Back to cited text no. 15
    
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Black C, Miller BJ. Meta-analysis of cytokines and chemokines in suicidality: Distinguishing suicidal versus nonsuicidal patients. Biol Psychiatry 2015;78:28-37.  Back to cited text no. 16
    
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Nousen EK, Franco JG, Sullivan EL. Unraveling the mechanisms responsible for the comorbidity between metabolic syndrome and mental health disorders. Neuroendocrinology 2013;98:254-66.  Back to cited text no. 17
    
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Jegaraj MK, Mitra S, Kumar S, Selva B, Pushparaj M, Yadav B, et al. Profile of deliberate self-harm patients presenting to emergency department: A retrospective study. J Family Med Prim Care 2016;5:73-6.  Back to cited text no. 19
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Singh S, Kumar S, Deep R. Patients with deliberate self-harm attended in emergency setting at a tertiary care hospital: A 13-month analysis of clinical-psychiatric profile. Int J Psychiatry Med 2019;54:363-76.  Back to cited text no. 20
    
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Das PP, Grover S, Avasthi A, Chakrabarti S, Malhotra S, Kumar S. Intentional self-harm seen in psychiatric referrals in a tertiary care hospital. Indian J Psychiatry 2008;50:187-91.  Back to cited text no. 21
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Sivanandan A, Abel SR, Sanjay M, Chandran J, Gunasekaran K, Abhilash KP. Profile and outcome of patients presenting with agrochemical poisoning to the emergency department. J Family Med Prim Care 2020;9:1589-93.  Back to cited text no. 22
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Duval F, Mokrani MC, Lopera FG, Diep TS, Rabia H, Fattah S. Thyroid axis activity and suicidal behavior in depressed patients. Psychoneuroendocrinology 2010;35:1045-54.  Back to cited text no. 26
    
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Bose A, Konradsen F, John J, Suganthy P, Muliyil J, Abraham S. Mortality rate and years of life lost from unintentional injury and suicide in South India. Trop Med Int Health 2006;11:1553-6.  Back to cited text no. 27
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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