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Suicide is rated as the ninth leading cause of death in all age groups in the US and the third leading cause of death among adolescents aged 15 to 19 years (1,2). Suicide and homicide rates in a sample of 72 nations were associated with social variables related to economic development, but not to Islamic adherence (3). Inadequate social support, social isolation, family conflicts, interpersonal relationships, unemployment, and school performance have been found to be associated with suicide attempts (4–8). Substance abuse constitutes a particularly significant risk factor (9,10). Strict religious doctrine in Saudi Arabia forbids suicide, providing a significant cultural deterrent, and strong criminal legislation against illicit substance use may contribute to a low rate of drug abuse. Nevertheless, suicide attempts leading to hospital admissions occasionally occur. For a society that abhors and forbids suicide, this subject has not been adequately studied. We delineate the risk factors, the commonly used drugs, and the resulting morbidity and mortality in subjects with a diagnosis of intentional drug overdose for suicidal purpose in Saudi Arabia. Materials and MethodsKing Fahad National Guard Hospital is a 550-bed tertiary care teaching centre in Riyadh, Saudi Arabia. The hospital serves 250 000 Saudi national guards and their dependents. It also serves as a referral centre for patients requiring tertiary care from all areas in the Kingdom. Because patients with intentional drug overdose are usually admitted to our hospital, we conducted a retrospective chart review of all patients admitted over a 3-year period (from 1997 to 1999). We identified applicable cases by a medical record coding of “drug overdose”, “suicide”, or “attempted suicide.” After reviewing the relevant literature (4–7,16,17) investigators designed data collection sheets to include factors specific to Saudi Arabia. For all patients, we collected data on demographic traits, on drugs used, and on social and familial features. Hospital outcome and length of stay were documented. ResultsDuring the 3-year study period there were 84 936 admissions to the hospital (emergency room visits not included), of which there were 79 cases of intentional drug overdose accounting for 0.09% of all admissions. Tables 1–3 show the demographic profiles, risk factors, and drug details of the study subjects. The patients were aged between 15 and 40 years (mean age 22, SD 4.6 years); most (n = 76; 96%) were Saudi nationals; the female-to-male ratio was 4:1; of those who attempted suicide, 75% percent of men and 44% of women were single.
Most of the patients came from large families (that is, more than 5 members). We noticed a seasonal pattern with a peak in the month of September (that is, 20% of total cases). Drug levels were measured in 67/79 patients. In 50/79 patients (63%) , drug levels were either negative or normal. Toxic levels were recorded in 17 patients (22%). Primary elimination of poison was achieved by use of activated charcoal in 56 patients (71%), by gastric lavage in 42 patients (53%), and by specific antidote in 20 patients (25%). Combined interventions were used in 45 patients (57%). Of the 79 patients, 17 (15%) were admitted to the intensive care unit (ICU), accounting for 1% of all ICU admissions during the study period (1702 admissions). Length of stay in the ICU ranged from 1 to 4 days (mean 1.5 days, SD 0.5). In comparison, those admitted to the ward stayed between 2 and 36 days (mean 5 days, SD 3). Most (75%) patients sustained no major morbidity. One patient (who was non-Saudi) stayed in the hospital for 36 days owing to ingestion of an erosive agent. No mortalities were recorded in the chart review. A psychiatrist interviewed all patients during admission and before discharge. DiscussionThe main findings of our study can be summarized as follows: 1) intentional drug overdose is a relatively uncommon reason for hospital admission in Saudi Arabia; 2) young age, female sex, single marital status, and large family size were factors prevalent in victims of drug overdose, and 3) most cases were mild with no mortality, though some cases required ICU admission and (or) prolonged hospital stay. Because our study is hospital-based, not population-based, we cannot make direct conclusions about the incidence of intentional drug overdose. It is possible that some patients with minor drug overdoses were treated in the community and never presented to the hospital. Comparing our results with literature concerning hospital admission reveals that intentional drug overdose is a less common reason for hospital and ICU admission in Saudi Arabia than in other countries, thereby suggesting lower incidence. Also, cases of intentional drug overdose in Saudi Arabia appear to be less severe, compared with reports in other studies. Henderson and colleagues reported that drug overdose accounted for 13.8% of ICU admissions in an Australian hospital, with 2% mortality (11). Gunawardana and colleagues found that drug overdose accounted for 10.2% of ICU admission in Sri Lanka (12). Other studies (13–15) reported mortality rates of 5.8% to 8.0% in patients hospitalized for drug overdose. We note that many of these studies are from the tricyclic antidepressant era in which higher mortality is expected. Similar to reports in neighbouring countries, younger age (mean age 22, range 15 to 40 years) and female sex are predominant traits among subjects who attempted suicide by drug overdose (4–7,16). Only 15% needed ICU admission, and no deaths were reported. Young age, female sex, and normal drug level (traits shown in most patients) may be factors contributing to the mortality rate being 0. Some patients used tricyclic antidepressants, which can be lethal in overdose (18). Our study shows that 16% of patients were in households of not more than 4 members, while 59% were in households with 5 or more members. Although a large household could be a risk factor, it might also permit early discovery of overdose victims, lessening the chance of patient fatality. Family conflicts seemed to play a role in suicide attempts—60% of patients experienced familial discord, and reports from neighbouring Gulf states support the higher prevalence of family conflict in persons who attempt suicide (4–6). Of the 31 married women, 26% were partners of polygamous marriages (this is probably an overrepresentation of polygamy in the general population). School performance constitutes an important risk factor in suicide and attempted suicide (4,6–8). Failure to obtain admission or promotion to an educational institute might explain the higher rate of suicidal attempts in September. However, educational level was not found to be an important risk factor. Forty-one percent of patients had completed high school, while 25% were below high school level. Six patients did not receive any education. Of the study subjects, 23% had previous suicidal attempts, and 25% had unspecified psychiatric disorders. Only 5% admitted to any history of drug abuse. Family size, educational stress, (that is, the pressure of passing school exams and being accepted into university), and polygamous marriage are risk factors seemingly particular to the Saudi population. Illicit drug use was recorded in only 5% of subjects. Although the prevalence of illicit drug use in the Saudi population has not been studied, we expect this figure (that is, 5%) to be higher than the national rates. The risk factors identified in the Saudi patients are similar to reports from neighbouring countries (4–7,16,17) but differ from reports in the Western populations, where psychiatric illness, cohabiting problems, social isolation, drug abuse, and alcoholism appear to be more common (1,8,9,18,19). This hospital-based study is limited in terms of sample size, and our retrospective data collection cannot be generalized; however, we aim to enhance awareness about drug overdose in Saudi society. Public health education is required to address the still-neglected issue of drug overdose, taking into consideration the major risk factors (specifically, family conflicts and school-related stress). A larger, population-based, multicentre study would be useful for increasing our knowledge about this important public health issue. ConclusionDespite religious, cultural, and legal deterrents, occasional cases of drug overdose with suicidal intention do occur in the Saudi population. Raising awareness in the Saudi health care community will help foster the development and application of appropriate solutions through public health orientations and programs. References1. Singh GK, Kochanek KD, MacDorman MF. Advance report of final mortality statistics 1994. Monthly Vital Statistics Report. Volume 45, No 3. Hyattsville (MD): National Center for Health Services; 1994. 2. US Center for Disease Control. Fatal and nonfatal suicide attempts among adolescents–Oregon, 1988–1993. MMWR 1995:312–5,321–3. 3. Lester D. Islam and suicide. Psychol Res 2000;87:692. 4. al-Ansari AM, Hamadeh RR, Matar AM, Marhoon H, Buzaboon BY, Raees AG. Risk factors associated with overdose among Bahraini youth. Suicide Life Threat Behav 2001;31:197–206. 5. al-Ansari AM, Hamadeh RR, Matar AM, Marhoon H, Buzaboon BY, Raees AG. Overdose among youth in Bahrain: psychosocial characteristics, contact with helping agencies and problems. J R Soc Health 1997;117:366–71. 6. Suleiman MA, Nashef AA, Mousa MA, El-Islam MF. Psychosocial profile of the parasuicidal patient in Kuwait. Int J Soc Psychiatry 1986;23:16–22. 7. Cosar B, Kocal N, Arikan Z, Isik F. Suicide attempts among Turkish psychiatric patients. Can J Psychiatry 1997;42:1072–5. 8. Bancroft JH, Skrimshire AM, Simkin S. The reasons people give for taking overdoses. Br J Psychiatry 1976;128:538–48. 9. Moscicki EK. Identification of suicide risk factors using epidemiological studies. Psychiatr Clin North Am 1997;20:499–517. 10. Oyefosott, Ghodsett, Clancy C, Corkery JM. Suicide among drug addicts in the UK. Br J Psychiatry 1999;175:277–82. 11. Henderson A, Wright M, Pond SM. Experience with 732 acute overdose patients admitted to an intensive care unit over six years. Med J Aust 1993;158:28–30. 12. Gunawardana RH, Abeywarna C. Intensive care utilisation following attempted suicide through self-poisoning. Ceylon Med J 1997;42:18–20. 13. Tay SY, Tai DY, Seow E, Wang YT. Patients admitted to an intensive care unit for poisoning. Ann Acad Med Singapore 1998;27:347–52. 14. Stern TA, Mulley AG, Thibault GE. Life-threatening drug overdose. Precipitants and prognosis. JAMA 1984;251:1983–5. 15. Kallenbach J, Bagg P, Feldman C, Zwi S. Experience with acute poisoning in an intensive care unit. A review of 103 cases. S Afr Med J 1981;59:587–9. 16. Khan MM. Suicide and attempted suicide in Pakistan. Crisis 1998;19:172–6. 17. Khan MM, Islam S, Kundi MAK. Para suicide in Pakistan: experience at a university hospital. Acta Psychiatr Scand 1996;93:264–7. 18. Kapur S, Mieczkowski T, Mann JJ. Antidepressant medications and the relative in suicide attempt and suicide. JAMA, 1992;268:3441–5. 19. Holmes EK, Holmes EK, Mateczun JM, Lall R, Wilcove GL. Pilot study of suicide risk factors among personnel in the US Marine Corps (Pacific Forces). Psychology Report 1998;83:3–11. Author(s)Manuscript received September 2003, revised, and accepted January 2004. 1. Pulmonologist, Medicine Department, King Abdulaziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. 2. Internist, Medicine Department, King Abdulaziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. 3. Intensivest, Intensive Care Department, King Abdulaziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. 4. Psychiatrist, King Abdulaziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. Address for correspondence: Dr HH Al-Jahdali, Department of Medicine, Mail Code 1445 King Fahad National Guard Hospital, Riyadh-11426, PO Box 22490, Kingdom of Saudi Arabia 11426 e-mail: jahdali@yahoo.com
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