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Challenges at the Pharmaceutical–Physician Boundary
Quentin Rae-Grant
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Guest Editorial
Suicide: The Persisting Challenge
Isaac Sakinofsky
(PDF)

In Review
The Neurobiology of Suicide and Suicidality
Kees van Heeringen
(PDF)

Assessing Suicidal Youth With Antisocial, Borderline, or Narcissistic Personality Disorder
Paul S Links, Brent Gould, Ruwan Ratnayake
(PDF)

Original Research
Sexsomnia — A New Parasomnia?
Colin M Shapiro, Nikola N Trajanovic, J Paul Fedoroff
(PDF)

A Case–Control Study on Psychological Symptoms in Sleep Apnea-Hypopnea Syndrome
Weihua Yue, Wei Hao, Pozi Liu, Tieqiao Liu, Ming Ni, Qi Guo
(PDF)

Suicide Attempts in Turkey: Results of the WHO–EURO Multicentre Study on Suicidal Behaviour
Halise Devrimci-Ozguven, Is1k Say1l
(PDF)

Review Paper
Adverse Effects Associated With Physical Restraint
Wanda K Mohr, Theodore A Petti, Brian D Mohr
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Insight and Neuropsychological Function in Patients With Schizophrenia and Bipolar Disorder With Psychotic Features
Luca Arduini, Artemis Kalyvoka, Paolo Stratta, Osvaldo Rinaldi, Enrico Daneluzzo, Alessandro Rossi
(PDF)

Time of Day Influences Nonattendance at Urgent Short-Term Mental Health Unit in Victoria, British Columbia
Rivian Weinerman, Vi Glossop, Randy Wong, Lara Robinson, Karen White, Rif Kamil
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Diabetes Mellitus and Impaired Glucose Tolerance in Patients With Schizophrenia
Mythily Subramaniam, Siow-Ann Chong, Elaine Pek
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Language Impairment and Psychopathology in Infants, Children and Adolescents.
Reviewed by
JH Beitchman, MD

Women’s Mental Health: A Comprehensive Textbook.
Reviewed by
Gail Erlick Robinson, MD, DPsych, FRCPC

Psychiatric and Cognitive Disorders in Parkinson’s Disease.
Reviewed by
Erwin K Koranyi, MD

Un jour la santé.
Reviewed by
Paul Beaudry, MD, FRCP

Seeking Safety: A Treatment Manual for Posttraumatic Stress Disorder and Substance Abuse.
Reviewed by
George A Fraser, MD

Treatment-Resistant Mood Disorders.
Reviewed by
Sagar V Parikh, MD, FRCPC

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QTc Prolongation: Chlorpromazine and High-Dosage Olanzapine

Should Lipids be Monitored During the First Year of Treatment with an Atypical Antipsychotic?

Quetiapine May Induce Mania: A Case Report

Insight, Knowledge, and Beliefs About Illness in First-Episode Psychosis

The Symptoms of Atypical Depression

Potential Risk of Diabetes Mellitus With the Use of Atypical Antipsychotic Medication

Clozapine-Induced Aplastic Anemia in a Patient With Parkinson’s Disease

Early-Onset Obsessive–Compulsive Disorder

Treatment Noncompliance With Orally Disintegrating Olanzapine Tablets

Original Research

Suicide Attempts in Turkey: Results of the WHO–EURO
Multicentre Study on Suicidal Behaviour

Halise Devrimci-Ozguven, MD¹, Is1k Say1l, MD²

Suicidal behaviour is identified as a major public health problem and a considerable drain on resources in both primary and secondary health care settings in many European countries (1). Therefore, one of the 12 “health-for-all” targets of the World Health Organisation (WHO), in the context of Global Strategy for Health for All by the Year 2000, is “the reduction of the current rising trends in suicide and attempted suicide” (2). The WHO–EURO Multicentre Study on Suicidal Behaviour was designed as part of the effort to implement the WHO’s 12 health targets. It has provided accurate and continuous information about the epidemiology of attempted suicide in several European countries (1,3–7). Previous articles have described the background and organisation of this study in detail (1,3–7).

Since 1962, the State Institute of Statistics, Prime Ministry, Republic of Turkey has collected and published the suicide statistics for Turkey. The completed suicide rate in Turkey is relatively low. For example, in 1988, the completed suicide rate in Ankara was 5.5 per 100 000, including women and men of all ages (8). However, no systematic records or official statistics are kept specifically on suicide attempts. The only data available on suicide attempts are obtained from hospital and police records, which are not kept systematically. Research data mostly involve small areas and hospital records (9). The 2 most comprehensive studies were carried out by Say2l and others, in Ankara (10,11). These studies retrospectively reviewed the records of the 9 largest Ankara hospitals in 1990 and 1995 and found that attempted suicide rates were 107 per 100 000 in 1990 and 113 per 100 000 in 1995. In addition to the lack of official statistics on suicide attempts, no population-based surveys or long-term studies exist. As part of the WHO–EURO Multicentre Study on Suicidal Behaviour, our study examined the rate and methods of attempted suicides over 4 years in a catchment area in Turkey.

Material and Methods

Catchment Area
Mamak, the Turkish area under study, is a district in the northeastern part of Ankara, the capital and second-largest city of Turkey. Some parts of Mamak are included in the old city, but most of the catchment area is newly settled. There are many immigrants in Mamak, and the area is fast growing into one of Ankara’s most heterogeneous districts, mirroring to some extent the cultural heterogeneity of Turkey as a whole. Most of Mamak’s population are Muslim, as in the other parts of Turkey. Turkey is a secular country wherein women and men have the same human and social rights. We assume that Mamak is representative of the whole country. According to the 1990 census, the district had 410 359 inhabitants, of whom 269 367 were aged 15 years or over (12). As in most developing countries, the birth rate is high. The population is young, aged from 10 to 30 years, and the elderly population is low (Table 1). The population density is 1616 per km². The male–female ratio is about 1 to 1. The age distribution and male–female ratio are similar for Mamak, Ankara, and Turkey as a whole (12).

Instruments
To avoid the limitations of previous studies, to rule out inadequacies from the epidemiologic standpoint, and to ensure identical data collection in all participating institutions, the proposed ICD-10 definition and the international monitoring sheet were used in all centres (3). The international monitoring sheet was translated into Turkish, and then back-translated into English. The document was proofread and then used in the Mamak study.

Data Base
Mamak has 22 Ministry of Health primary care units and 2 general hospitals (one is a state hospital, and the other is affiliated to the Medical School of Ankara University). All admissions to the hospitals and primary care units in the catchment area were screened to identify attempted suicides. In addition to the hospitals and the primary care units in the area, we included 3 more hospitals in the neighbourhood that might have admitted suicide patients from the catchment area.

Nurses in the hospitals and clinics administered monitoring forms to patients being treated for suicide attempts. Four staff members from the Crisis Intervention Centre (CIC) of Ankara University visited these hospitals and clinics once weekly to check the forms, fill in missing information, and collect completed forms.

Training
At the beginning of the study, the CIC staff were briefed on the study and trained to collect data from hospitals and clinics, to check the monitoring forms, to fill in missing information, and to brief and train nurses in administration of the forms. As a precaution against personnel changes and loss of interest, the nurses’ training was repeated every 3 months.

Procedure
We requested nurses working in the emergency and psychiatric wards of hospitals and in outside clinics to administer monitoring forms to all patients treated for attempted suicide. CIC staff visited these centres once weekly to collect completed forms. During these visits, they checked whether any forms were incomplete, in which case they attempted to fill in missing information by asking the nurses or referring to patient files.

Hospital emergency wards have record systems with files on all patients treated. In Turkey, there are also police units on duty in these wards; these units keep files on treated suicide attempters and report the information to the police headquarters of the county in which the hospital is located. In case not all attempted suicides were recorded on the monitoring forms, we checked all medical and police records at all 5 hospitals and at the Police Headquarters in Mamak. In this way, we added cases missing from the data and estimated that 75.34% of all hospital-treated parasuicides were registered on the monitoring forms. We judged that the missing cases were the result of practical difficulties, such as time constraints, working conditions, and different nurse shifts or changes in personnel. The cases missed in the initial data gathering (24.66%) were evaluated retrospectively with monitoring forms and included in the analysis. It is noteworthy that, conversely, the rate was much higher (43.4%) for cases recorded on the monitoring forms but missing from the records of emergency wards, hospital police, and county police headquarters. This suggests that, in Turkey, hospital and police records of suicide attempts are unreliable.

At the end of the first 3 months, we excluded from the study the primary care units and 2 of the 5 hospitals in or near the catchment area, because no suicide attempters from Mamak had been treated in them.

Analysis
The data were gathered during several periods: a 9-month period from April 1 to December 31, 1998; a 3-month period from January 1 to March 31, 1999, and another 3-month period from October 1 to December 31,1999; and the entire 12 months of the years 2000 and 2001. The 6-month break during the study was owing to staff shortages. Estimation factors were calculated to estimate the true suicide-attempt rates. The estimation factor is 1.3 and 2.0 for the years 1998 and 1999, respectively. To compute the rates, we obtained the catchment area demographic statistics from State Institute of Statistics (11). To determine trends, we analyzed the data and computed average decreases or increases.

Results

Table 1 shows the age- and sex-specific suicide attempt rate for the population aged 15 years and over.

Table 1   The suicide-attempt rates according to age groups
Age group (years)	Attempted-suicide rate (per 100 000)
	1998a		1999b		2000c		2001c
	Male	Female	Male	Female	Male	Female	Male	Female
15–19	68.34	151.07	32.35	195.23	105.14	283.55	93.01	390.46
20–24	15.46	184.86	55.49	142.20	43.60	232.26	75.30	289.14
25–29	48.60	88.74	74.78	87.77	56.08	146.28	65.43	112.15
30–34	22.71	65.17	—	37.60	52.40	43.86	69.87	156.65
35–39	9.96	71.29	30.63	—	68.92	70.51	91.90	47.00
40–44	12.91	26.67	79.42	20.51	—	41.03	49.64	61.54
45–49	53.34	—	27.35	27.68	41.03	27.69	27.35	69.21
50–54	45.91	—	—	—	17.66	32.24	17.66	48.36
55–59	—	—	35.49	—	35.49	18.73	17.74	—
Sum	31.86	85.59	38.92	76.56	52.61	126.32	64.15	163.07
aEstimation factor is 1.3; bEstimation factor is 2; cEstimation factor is 1.

We detected 737 suicide attempters in a 4-year-period (514 women and 223 men), with a female–male ratio of 2.3. The mean (SD) age for men was 27.26 (9.91) years, ranging from age 15 to 56 years; the mean (SD) age for women was 23.51 (7.72) years, ranging from age 15 to 56 years. A statistically significant difference was found between the mean age of men and women (t = 5.03, P < 0.000).

In 1998, 120 individuals attempted suicide in the 9 months studied (86 women and 34 men), giving a female–male ratio of 2.5. When all age groups and both sexes over age 15 years were considered, the mean annual event rate for the total group was 57.91 per 100 000 (31.86 and 85.59 per 100 000 for men and women, respectively). The ratio of female–male rates was 2.69.

In 1999, 77 individuals attempted suicide in the 6 months studied (50 women and 27 men), giving a female–male ratio of 1.8. When all age groups and both sexes over age 15 years were considered, the mean annual event rate for the total group was 57.17 per 100 000 (38.92 and 76.56 per 100 000 for men and women, respectively). The ratio of female–male rates was 2.0.

In 2000, 238 individuals attempted suicide (165 women and 73 men), giving a female–male ratio of 2.3. When all age groups and both sexes over age 15 years were considered, the mean annual event rate for the total group was 88.36 per 100 000 (52.61 and 126.32 per 100 000 for men and women, respectively). The ratio of female–male rates was 2.6.

In 2001, 302 individuals attempted suicide (213 women and 89 men), giving a female–male ratio of 2.4. When all age groups and both sexes over age 15 years were considered, the mean annual event rate for the total group was 112.11 per 100 000 (64.15 and 163.07 per 100 000 for men and women, respectively). The ratio of female–male rates was 2.5.

Figure 1 illustrates the mean attempted suicide rates in the 4-year period from 1998 to 2001 according to sex and age group. For the 4 consecutive years, when both sexes and all age groups over age 15 years were considered, the mean annual rate of attempted suicides was 78.89 per 100 000 (46.89 and 112.89 per 100 000 for men and women, respectively). The ratio of female–male rates was 2.4.

Figure 1 The distribution of average rates of suicide attempts determined from 1998 to 2001 according to sex and age

Women aged 15 to 19 years were at highest risk, with an age-specific rate of 255.08 per 100 000, followed by women aged 20 to 24 years, with an age-specific rate of 186.44 per 100 000. Among the male population, the age group with the highest rate was the group aged 15 to 19 years, with an age- specific rate of 74.71 per 100 000, followed by the groups aged 25 to 29 years and 35 to 39 years (with rates of 61.22 and 50.35 per 100 000, respectively). It is noteworthy that no women or men over age 56 years had attempted to commit suicide in Mamak during the study period. There was no significant difference among the groups in terms of event rate when distributed by month, day, and time.

Figure 2 shows the trends in attempted suicide rates between 1998 and 2001. The parasuicide rate increased 93.59% between 1998 and 2001. Between year 1 and year 4, rates increased by 101.35% in men and by 90.52% in women. Most age groups experienced an increase, but the highest average increase was among the groups aged 35 to 39 years and 20 to 24 years for men and the groups aged 15 to 19 years and 30 to 34 years for women.

Figure 2 Rates of suicide attempts determined from 1998 to 2001

In general, the attempted-suicide methods were so-called “soft methods.” Self- poisoning with drugs was the method used most often by both men and women (78.9% for men and 92.7% for women). The second most common method was self-poisoning with other chemicals and jumping from a high place for men (5.4% in each case) and self-poisoning with other chemicals for women (4.1%). Psychotropic drugs were used in suicide attempts by 21.1% of men and 20.6% of women, respectively; 35.4% of men and 50.8% of women, respectively, used analgesics. The use of analgesics in suicide attempts was significantly higher in women than in men (c² = 16.43, P < 0.001). More than 1 method was used by 26% of men and 12.3% of women. The use of multiple methods in suicide attempts was significantly higher in men than in women (c² = 21.77, P < 0.001).

There was a statistically significant difference between men and women in alcohol use as a supplementary method: 20.2% of men and 3.1% of women used alcohol as an additional method of attempted suicide (c² = 62.91, P < 0.001). The use of alcohol in suicide attempts was significantly higher in the middle-aged groups (c² = 46.55, P < 0.001).

Discussion

Compared with the other European research centres participating in the WHO–EURO Multicentre Study on Suicidal Behaviour, attempted suicide rates in the area of Mamak were relatively low (1,5).

The results showed that attempted suicide was common among women, as was the case in the other European centres and in North America (13–15). The female–male ratios in these studies range from 1.0 to 1.8 (1,5,13–15). In Mamak, however, the female–male ratio is somewhat higher. For women, the highest age-specific rate was found to be in the group aged 15 to 24 years, and for men, it was found in the group aged 15 to 29 years. This confirms the common notion that suicide attempts, especially more demonstrative ones, occur most often among teenagers and young adults (13). However, this simple inverse relation between age and suicide attempts appears to be less valid for men. Among men attempting suicide, the distribution of rates according to age groups was more homogeneous. It is noteworthy that no women or men over age 56 years in Mamak ever attempted suicide.

The attempted-suicide rate in the group aged 15 to 19 years was 2.3 times higher than the mean rate of the total female group and 1.6 times higher than the mean rate of the total male group. The greatest difference was found in the younger age groups; the difference diminished with increasing age.

The methods used were primarily “soft” (poisoning or cutting), as is often mentioned in the literature (1,5,14). The drugs most commonly involved were analgesics, followed by psychotropic drugs. Alcohol was not used alone but as a supplementary method, especially among men.

The rate of suicide attempts in Mamak was lower than the rates found in 1990 and 1995 in Ankara (9,10), which is not surprising, because the social structure of Mamak is representative of the country as a whole rather of than the metropolitan area. Ankara is the second-largest city in the country, and the rate of both suicide attempts and completed suicides can be expected to be higher than the national rates. Moreover, the 1990 and 1995 studies were carried out by investigating hospital records. The rates were calculated using the population of Ankara as the base and may be somewhat inflated, because they may have included patients referred from other areas and treated in Ankara.

The finding that individuals attempting suicide tended to be younger and more often women can be explained by the fact that young people and women are more prone to encounter life crises and are more economically dependent (16). Although women have the right to work legally and there are no negative attitudes toward female employment in Turkey, it has been reported before that 57.1% of the women attempting suicide in our catchment area were economically inactive (most of them were students and housewives), while 32.2% of the men attempting suicide were unemployed (17). This finding supports the view that this group is under heavy economic stress. Further, close family ties and lack of autonomy in Turkey may render life more difficult for women and teenagers.

Although no such increasing tendency has been reported in other centres in Europe and North America (5,13,15), the rate of attempted suicide in Ankara increased sharply in 2000 and 2001, especially among women. Because the most recently published statistics on suicides pertain to 1998, it is not yet known whether this increase is reflected in completed suicides. However, it is known that completed suicides in Ankara increased by 25% between 1988 and 1998 (18).

This increased rate in suicide attempts is not attributable to the method of data collection, since the procedure remained the same. The upward trend in suicide rates may be related to the intense economic difficulties, increasing unemployment, and rapid social change experienced in Turkey in recent years. However, it has to be noted that a period of only 4 years is not long enough for an accurate trend evaluation. To interpret accurately, it will be necessary to observe whether this increase continues.

Another limitation of the study is the fact that parasuicide rates were calculated using data from the 1990 census. No census was conducted in 1995 in Turkey, the 1998 census has been reported to be unreliable, and the results of the 2000 census have not yet been published (The provisional census results of the population in 2000 have been published but do not include detailed information about province and districts according to age groups). Thus the most recent reliable data available were from the 1990 census, and possible changes in the population are not reflected in the results. If the possibility that the population may have grown during this period is taken into consideration, attempted suicide rates may be somewhat lower than those calculated. The population growth in Turkey is roughly 18.34%, according to the provisional census results of the population in 2000 (19). It is evident that the 93.59% increase in attempted suicide rates in the past 4 years far exceeds population growth and that it cannot be accounted for by this growth.

Despite its limitations, however, this is the first comprehensive, population-based, long-term study of the epidemiology of suicide attempts in Turkey reporting parasuicide rates and trends in the country.

Acknowledgements

The authors thank all participants, especially Seda Haran, Gulizar Rol, and Tulay Kurum Ozkan, who helped in data collection.

References

1. Platt S, Bille-Brahe U, Kerkhof A, Schmidtke A, Bjerke T, Crepet P, and others. Parasuicide in Europe: The WHO/EURO Multicentre Study on Parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr Scand 1992;85:97–104.

2. WHO-World Health Organisation. Health-for-all targets. The health policy for Europe. Summary of the updated edition. September 1991. Copenhagen: World Health Organisation. EUR ICP HSC 013; 1992.

3. Kerkhof A, Schmidtke A, Bille-Brahe U, De Leo D, Lönnqvist J. Attempted suicide in Europe. Leiden: DSWO Press; 1994. p 3–14.

4. Bille-Brahe U, Schmidtke A, Kerkhof AJFM, De Leo D, Lönnqvist J, Platt S, and others. Background and introduction to the WHO/Euro Multicentre Study on Parasuicide. Crisis 1995;16(2):72–84.

5. Schmidtke A, Bille-Brahe U, De Leo D, Kerkhof A, Bjerke T, Crepet P, and others. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989-1992. Results of the WHO/Euro Multicentre Study on Parasuicide. Acta Psychiatr Scand 1996;93:327–38.

6. Bille-Brahe U, Andersen K, Wasserman D, Schmidtke A, Bjerke T, Crepet P, and others. The WHO/Euro Multicentre Study: risk of parasuicide and the comparability of the areas under study. Crisis 1996;17(1):32–42.

7. Bille-Brahe U. WHO/EURO Multicentre Study on Parasuicide. Facts and figures. 2nd ed. Copenhagen: World Health Organization, 1999.

8. DIE (Devlet statistik Enstitüsü- State Institute of Statistics Prime Ministry Republic of Turkey) Suicide statistics 1998. Ankara: State Institute of Statistics Printing Division; 2000.

9. Say2l I. Review of suicide studies in Turkey. Crisis 1997;18:124–7.

10. Say2l I, Oral A, Güney S, Ayhan N, Ayhan Ö, Devrimci H. A Study on the attempted suicides in Ankara (Turkish). Kriz Dergisi 1993;1(2):56–61.

11. Say2l I, Berksun O, Palab2y2ko—lu R, Oral A, Haran S, Güney S, and others. Attempted suicides in Ankara in 1995. Crisis 1998;19:47–8.

12. DIE (Devlet statistik Enstitüsü- State Institute of Statistics Prime Ministry Republic of Turkey) Census of population social and economic characteristics of population, province Ankara 1990. Ankara: State Institute of Statistics Printing Division; 1993.

13. Kerkhof JFM. Attempted suicide: patterns and trends. In: Hawton K, van Heeringen K, editors. The international handbook of suicide and attempted suicide. West Sussex (UK): John Wiley and Sons Ltd; 2000. p 49–64.

14. Diekstra RFW. The epidemiology of suicide and parasuicide. Acta Psychiatr Scand (Suppl) 1993;371:9–20.

15. Bland RC, Dyck RJ, Newman SC, Orn H. Attempted suicide in Edmonton. In: Leenaars AA, Wenckstern S, Sakinofsky I, Dyck RJ, Kral MJ, Bland RC, editors. Suicide in Canada. Toronto: University of Toronto Press; 1998. p 136–50.

16. Cilingiroglu NE. Some effects of change on women in Turkey (Turkish). In: Women’s status in Turkey. Ankara: Takav Press; 1998. p 135–40.

17. Sayil I, Devrimci-Ozguven H. Suicidal behaviour in Turkey. In: Suicide and suicide attempts in Europe: Finding from the WHO/EURO Multicentre Study on Suicidal Behaviour. Göttingen: Hogrefe and Huber. Forthcoming.

18. Say2l I, Devrimci-Ozguven H. Suicide and suicide attempts in Ankara in 1998: results of the WHO/EURO Multicentre Study on Suicidal Behaviour. Crisis 2002;23(1):11–6.

19. DIE (Devlet statistik Enstitüsü- State Institute of Statistics Prime Ministry Republic of Turkey) Census of population provisional results 2000. Ankara: State Institute of Statistics Printing Division; 2002.

Author(s)

Manuscript received August 2002, revised, and accepted December 2002.

1. Attending Psychiatrist, Department of Psychiatry, Ankara University School of Medicine, Ankara, Turkey.

2. Professor of Psychiatry, Department of Psychiatry, Ankara University School of Medicine, Ankara, Turkey

Address for correspondence: Dr H Devrimci-Ozguven, Ankara Üniversitesi T2p Fakültesi Cebeci Hastanesi, Psikiyatri Anabilim Dal2, Dikimevi, Ankara / Türkiye

e-mail:ozguven@medicine.ankara.edu.tr

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