Almost 1 million people die from suicide worldwide and 10–20 times more attempt suicide each year and the numbers are increasing “www.who.int/mental_health/management/en/SUPRE_flyer1.pdf” (1, 2). When comparing the distribution of suicides, the largest numbers are found in low and middle income countries where most people live, whereas suicide rates are generally higher in high and middle income countries “www.who.int/mental_health/management/en/SUPRE_flyer1.pdf” (1, 2). Good estimates of the burden of suicides and suicide attempts are difficult to obtain as they are associated with poor reporting practices often linked to taboos (1–3).
Whereas females attempt suicide more often than males in any region of the world, males dominate suicides with a male-to-female ratio of 2–4/1 in high income countries, but with less gender differences in low income countries (1, 2). In some middle and low income countries, more young females than males are committing suicide and very high suicide rates are reported among young married women in various Asian countries (4–6). Suicide attempts are often seen in younger age groups (7–10) and suicides in older age groups, although within the past decade there has been a change with a decreasing mean age among suiciders (1, 2).
Access to methods for suicide often determines the method chosen (2). In the USA, where firearms are easily available they are used in most suicides, whereas in low and middle income countries pesticides are easily available and here ingestion of pesticides is the most common method and accounts for an estimated one-third of all suicide attempts and suicides worldwide (11–14). Ingestion of toxic substances is reported to be most often used by women for suicides, whereas violent methods such as hanging, jumping, and shooting are used more frequently by males (2, 14).
At the global level, psychiatric disorders are believed to be present in 90% of suicide cases (2), whereas evidence from low income countries suggests that suicide attempts and suicides are not necessarily as strongly associated with mental illness (15–17). The majority of risk factors seem to be universal and suicide attempts and suicide are often a reaction to several combined factors, such as family problems, problems with partners, psychiatric illness, economic problems, and alcohol or drug abuse causing a cumulative effect (2, 16, 17).
This study describes cases of suicide attempts and suicides in Bolivia with a focus on age, gender, methods, and background, and information needed to inform the discourse in Bolivia and to prioritize preventive strategies.
Data were gathered from four different sources from 2007 to 2012. Two of the datasets are based on clinical records from hospital emergency and psychiatric wards, one set of data from the National Statistics on Crime, and one set of data based on the content of newspaper articles.
In 2008, data on self-poisoning from eight hospitals in Cochabamba County was gathered by reviewing the emergency ward statistics from the year 2007. The hospitals were selected in connection with a toxicology course for doctors, where the participants returned to their work places to collect the information. Out of nine hospitals eight were willing to participate.
In 2012, data from psychiatric ward registrars from July 2011 to July 2012 on suicide attempts in the capital of La Paz were gathered by medical staff and an anthropologist reviewing inpatient statistics.
In 2012, suicide data were obtained from the National Statistics on Crime from the years 2010 and 2011 by request to the police.
In 2012, articles from 21 Bolivian nationwide newspapers printed in Spanish covering the period February 2009 to April 2012 describing cases of suicide attempts and suicides were reviewed by an anthropologist. The articles had been collected by CIDEM, an NGO working to prevent violence among women in Bolivia.
The hospital data contained information on age, gender, suicide attempt methods, and outcome, whereas the crime statistics only contained information on gender and age groups. The newspaper data varied in amount and quality of information but most often contained data on age, gender, method used, supposed reason, and outcome.
Data were entered in Excel and analyzed using IBM SPSS version 21. In the Cochabamba County hospital emergency wards, 595 poisoning cases were recorded of which suicide attempt by poisoning accounted for 421, accidental poisoning for 171, and occupational poisonings for 3 cases – only the attempted suicides were included in the analysis. From the psychiatric ward in La Paz, all 236 registered cases of suicide attempts were included in the analysis, as well as the 295 suicides registered in the National Statistics on Crime, and the 172 suicide attempts and suicides reported in the newspaper articles. The newspaper cases might be overlapping with some of the cases recorded from the other sources, but as they are only used for describing methods and background for the acts this poses no problem to the interpretation of data.
The following age groups were created in the datasets: adolescents aged 10–19 years, young adults aged 20–29 years, and older adults aged 30 years and above. No mean age could be calculated from the Crime Statistics data as data were reported, as belonging to a certain age group and not with individual age. In the newspaper data on method used, a variable on violent methods comprising hanging, jumping, firearms, explosives, and sharp devices were created, as well as a variable of non-violent methods comprising ingestion of different chemicals and drugs.
As the data came from different areas and years, comparisons with age and gender distribution in the general population were done by extracting population data from the corresponding area and year in the Institute of National Statistics. However, as no significant differences were observed whether using the population in the different areas or the general population data, the general data from the whole of Bolivia from the year 2010 were used for comparison with the different groups.
Data on suicide attempts and suicides from the hospital wards and Crime Statistics were pooled for comparison of age and gender differences. The newspaper articles were used only for analysis of methods applied and the background for suicide attempts and suicides.
Ethical approval was received from the Medical Ethical Committee of Bolivia. The study was non-invasive; all the collected data were treated with confidentiality and registration was anonymous.
Gender and age
Hospital data showed more females (403/657, 61%) than males (254/657, 39%) attempting suicide. The emergency ward data on suicide attempts by poisoning showed a female proportion of 273 out of 421 (64.8%), and the psychiatric ward data on suicide attempts showed a female proportion of 130 out of 236 (55.1%). In contrast to this, the Crime Statistics on suicides showed that males were more numerous than females accounting for 208 out of 295 (70.5%) vs. 85 out of 293 (29.5%) cases (Table 1). The gender distribution between suicide attempts and suicides differed significantly (χ2-test, p<0.00). The gender distribution in both groups also differed from the gender distribution in the general population with 50.3% females vs. 49.7% males above the age of 10 years (www.esa.un.org).
The mean age of cases of suicide attempts from the emergency wards and the psychiatric ward varied from 23.77 (SD=11.17) to 24.84 (SD=11.86) years of age, with females being notably younger than males in both datasets, 21.75 (SD=8.32) to 23.00 (SD=10.7) vs. 27.09 (SD=12.85) to 27.50 (SD=14.39). No cases were reported below the age of 10 years.
|Emergency wards: Suicide attempt by poisoning 2007, n=421||Psychiatric ward: Suicide attempt 2011–2012, n=236||Crime statistics: Suicides 2010–2011, n=295|
|Males||148 (35.2%)||106 (44.9%)||208 (70.5%)|
|Females||273 (64.8%)||130 (55.1%)||87 (29.5%)|
|Gender distribution in age classes|
|10–19||52 (35.1%)||31 (29.2%)||30 (14.4%)|
|20–29||55 (37.2%)||44 (41.5%)||100 (48.1%)|
|>29||41 (27.7%)||31 (29.2%)||78 (37.5%)|
|10–19||141 (51.6%)||72 (55.4%)||20 (23%)|
|20–29||100 (36.6%)||34 (26.2%)||40 (46%)|
|>29||32 (11.7%)||24 (18.5%)||27 (31%)|
The largest proportion of suicide attempts in the hospital data was observed among females in the age group 10–19 years, with a declining trend towards the oldest age group above 29 years of age, a trend not observed among males (χ2-test, p<0.00; χ2-test linear by linear association p<0.00), see Table 1 and Figure 1. The largest number of suicide cases was observed in the older age groups of 20–29 years and above 29 years with no significant gender differences, see Table 1 and Figure 1.
When comparing suicide attempts with suicides with regard to gender and age groups, there was a significant difference among females with a larger proportion of suicide attempts compared with suicides in the age group of 10–19 years and a smaller proportion of suicide attempts compared with suicides among the two adult age groups (χ2-test, p<0.05). The same differences were observed for males, but it was significant only for the age group 10–19 years (χ2-test, p<0.05), see Figure 1.
Pesticides were the most frequent method for suicide attempt (Table 2). The emergency ward self-poisoning cases included poisoning with carbamates (178 cases), organophosphates (60 cases), paraquat (32 cases), pyrethroids (14 cases), coumarins (7 cases), glyphosates (4 cases), and organochlorines (1 case). In the psychiatric ward, organophosphates was the most common group of pesticides used accounting for 90 out of 101 registered pesticide poisonings, followed by coumarins (7 cases) and unspecified pesticides (4 cases). Among pesticide poisonings in the newspapers, 40 used organophosphates, 21 coumarins, and 4 an unknown pesticide. Other poisons used included caustic soda, CO, cocaine, thinner, gas, poisonous plants, and household chemicals.
|Methods used||Emergency wards: Suicide attempt by poisoning 2007, n=421||Psychiatric ward: Suicide attempt 2011–2012, n=236||Newspaper data: Suicide attempt and suicides 2009–2012, n=172|
|Pesticides||299 (70.5%)||101 (42.8%)||65 (37.8%)|
|Medicine||38 (9.0%)||18 (7.6%)||7 (4.1%)|
|Other/unknown poison||67 (15.8%)||15 (6.4%)||12 (7.0%)|
|Other violent methods (firearm, dynamite, cutting, burning)||–||2 (0.8%)||14 (8.2%)|
|Unknown||20 (4.7%)||100 (42.4%)||11 (6.4%)|
In the newspaper data on suicide attempts and suicides, non-violent methods accounted for 84 (48.9%) cases and violent methods for 77 (44.8%) cases; the description of method used was missing for 11 (6.4%) cases (Table 2). When comparing age groups, young people seemed to practice more violent methods, such as hanging and jumping, whereas older age groups used firearms, dynamite, cutting, and burning, although there were relatively few cases. Older people generally used less violent methods, especially pesticides (Table 3). The only significant differences were observed for jumping and firearms/explosives/burning/cutting (χ2-test, p<0.05), although several others showed nearly significant differences. No gender differences in the choice of methods were observed among the 134 females and 22 males from the newspaper articles.
|Age 10–19 years|
|Age 20–29 years|
|Age >29 years|
|χ2-test for linearity|
|Violent methods||36 (56.3%)||20 (40.8%)||11 (37.9%)||0.14||0.07|
|Hanging||23 (35.9%)||16 (32.7%)||6 (20.7%)||0.34||0.17|
|Firearm, dynamite, burning, cutting||1 (1.6%)||4 (8.2%)||5 (17.2%)||0.02||0.01|
|Non-violent methods||28 (43.7%)||29 (59.2%)||18 (62.1%)||0.14||0.07|
|Pesticides||22 (34.4%)||23 (46.9%)||15 (51.7%)||0.21||0.09|
|Medicine||4 (6.3%)||3 (6.1%)||0||0.39||0.25|
|Other poisons||2 (3.1%)||3 (6.1%)||3 (1.3%)||0.37||0.16|
In the emergency wards 2 cases died, whereas no dead cases were recorded in the psychiatric ward data. In the newspaper data, 105 (60.9%) cases died, with significant higher mortality reported for those using violent methods (65/77, 85.1%) compared with self-poisoning cases (43/84, 51.9%) (χ2-test, p<0.00).
The motives for suicide attempt and suicides mentioned in the newspaper articles are presented in Table 4. Problems with partners, economic problems, and depression were increasingly mentioned as a motive with growing age, whereas problems with family and mobbing were decreasingly mentioned as a motive with growing age. In the newspaper stories, details were mentioned such as unfaithfulness, violence, lack of understanding, abuse, and lack of respect. Economic problems were often due to a sudden debt that the family could not pay back. Unwanted pregnancies were described among young women and teenagers, where the partner denied being the father or the girl could not face telling her parents about her pregnancy. It was described in several cases that the suicide attempt action took place a short time after a confrontation within the family or relationship. Many suicides seem to be hidden due to the fact that the family could not give their deceased relative a religious burial if it came out that the person died due to suicide, as referred to in several articles.
|Reasons mentioned||Age 10–19 years|
|Age 20–29 years|
|Age >29 years|
|χ2-test for linearity|
|Problems with partner||6 (12.5%)||12 (34.3%)||10 (43.5%)||0.01||0.00|
|Problems in family||20 (41.7%)||7 (20%)||3 (13%)||0.02||0.01|
|Depression||3 (6.3%)||5 (14.3%)||5 (21.7%)||0.16||0.06|
|Economic problems||3 (6.3%)||3 (8.6%)||5 (21.7%)||0.12||0.06|
|Unwanted pregnancies||4 (9.1%)||6 (21.4%)||0||0.06||0.60|
|Mobbing/school problems||7 (14.6%)||1 (2.9%)||0||0.04||0.02|
|Other reasons||4 (8.3%)||1 (2.9%)||0||0.25||0.10|
Suicide attempt sometimes also includes homicides, and in the newspaper data 15 mothers and 1 father either killed or tried to kill their own children before attempting suicide.
In this study, suicide attempts seem to be more prevalent among young people and especially in females, which is in line with a study from Bolivia in 2010 where Vazquez-Machado and Guarachi-Catari found that suicide attempts were more common among females and younger people aged 15–25 years (7). Another study by Dearden et al., from 2005 among Bolivian college students, showed that 8.9% of boys and 26.5% of girls had been engaged in some form of suicide attempt (18). Similar trends are observed in other parts of the world where young females tend to perform suicide attempts more often than males do, although different patterns are observed in different areas (8, 10, 19). With regard to suicides, as observed in our study and other studies, males tend to dominate the statistics, apart from some reports from Asia where female cases were found to be more prevalent than males in certain areas and age groups (1, 2, 4–6, 20, 21).
In this study, adults are the most abundant among suicide cases, and a similar trend of older age groups is also observed in other studies, although the median age seems to be declining over the past couple of decades, especially in low income countries (1, 2, 20).
Pesticides were found to be the most used method in our study, consistent with the Vazquez-Machado and Guarachi-Catari study reporting that 67.8% of self-poisoned patients had ingested organophosphates (7). This might be due to accessibility as pesticides are easily accessible in rural settings with higher rates of suicides with pesticides found (2, 22–24). In Bolivia, pesticides are cheap, can be bought without restrictions, and are often kept unlocked at home, and thus are easily accessible (7, 25, 26). Our finding that more young people tend to jump and hang themselves compared with older people who more often use pesticides, firearms, and dynamite might also be due to accessibility, as most young people have less access to cash and thus tend to choose the cheapest methods available. Another explanation could be a higher degree of low planned acts among young people and women where hanging and jumping are easily available methods (21). In our study, we did not find a gender difference with regard to method used, which is contrary to other studies that found women used less violent methods than men (14). The use of less violent methods among women might explain why women are leading in suicidal attempts and male suicides.
The reasons behind the acts found in this study were in accordance with the former study of Vazquez-Machado and Guarachi-Catari where acts of suicide attempt were most often found to be due to a conflict with a partner (42.6%) or conflict within the family (37%) (7). Risk factors of suicide attempt reported from other low income countries include acute depressive symptoms, somatic illnesses, recent negative life events, unhappy love affairs, arranged marriages, unwanted pregnancies, and domestic violence (15, 16, 27). Although studies from Europe and the USA report that psychiatric disorders are present in 90% of suicide attempt actions (2), evidence from low income countries suggests that suicide attempts are not as strongly associated with mental illness (15, 16). The reasons for the acts that are more often reported to be connected to partner problems, depression, and economic problems among older people probably reflect the fact that these problems are not yet introduced to adolescents. The reason for young people reporting unwanted pregnancies as a frequent reason reflects that women dominate the younger age groups and fertility declines with age. Problems with family is more often mentioned among adolescents and young adults which might be due to older adults dominating their family, and thus they are the ones creating the problems for the younger family members.
To prevent suicide attempt and suicides, restriction of access to the most popular methods such as pesticides and firearms has proven effective (23, 27, 28), and as pesticides are the most popular method around the world it has been advocated for many years that a minimum pesticide list with the banning of the most toxic pesticides be implemented (29).
Better medical treatment of psychiatric illnesses and an improved acute diagnosis and handling of cases is a requirement and would save lives (2, 30, 31), which might also be the case for Bolivia where a former study showed scarce knowledge on pesticide toxicity, diagnosis, and treatment of intoxication among healthcare workers (32). Discussions on the issue in schools might result in less taboos around suicides, which might help to obtain focus on the problem and implement preventive measures (2).
This study has weaknesses primarily due to the lack of reliable data. Hospital data are of less value for calculating incidences on suicide attempts and especially on suicides, as many cases never reach hospitals for treatment because they die before reaching the hospital and therefore are never registered. Suicide cases are investigated by the police and thus appear in their Statistics on Crime, but an important reason for underreporting also in hospital data might be that many of the acts are hidden because of the taboo related to it, as reported in our newspaper data and in other papers including studies from Latin America (1–3, 31). A weakness in both the hospital and Crime Statistics is that the reasons and methods used are not systematically registered, thus we rely on newspaper articles, which by nature are not so reliable and possibly twisted due to selection bias due to the focus on female violence of the NGO having collected the articles.
Acts of suicide attempt were found in all age classes and among both genders, but young females dominated the statistics. Suicide cases were older and more often observed among males. The most popular method was ingestion of chemicals especially pesticides, but violent methods such as hanging and jumping were also observed. The reasons for suicide attempts included problems with a partner, problems within the family, psychiatric illness, economic problems, and unwanted pregnancies.
To prevent acts of suicide attempt, access to means for committing suicide attempt should be restricted and an appropriate treatment of cases on somatic and psychiatric wards would improve survival and prevention. Increasing awareness of the importance of culture and religion in the general population and in schools could minimize any taboos making preventive measures more likely to succeed.
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