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Suicidal Attempts Admitted to a General Hospital in the Western Galilee: an Inter-Ethnic Comparison Study

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Suicidal Attempts Admitted to a General Hospital in the Western Galilee: an Inter-Ethnic Comparison Study Isr J Psychiatry Relat Sci Vol 43 No. 2 (2006) 137–145 Suicidal Attempts Admitted to a General Hospital in the Western Galilee: An Inter-Ethnic Comparison Study Khalid Ashkar, MD,1 Carlos Giloni, MD,2 Alexander Grinshpoon, MD, MHA,3 Nabil Geraisy, MD, MPAH,4 Eli Gruner, MD,4 Rami Cohen, MA,5 Oshra Paryente, RN, MPA,6 Faris Nassar, MD,7 and Alexander M. Ponizovsky, MD, PhD3 1 Department of Family Medicine, Technion, Clalit Health Services, Haifa and Western Galilee District, Israel 2 Psychiatric C-L Service, Western Galilee Hospital, Nahariya, Israel 3 Mental Health Services, Ministry of Health, Jerusalem, Israel 4 Northern District Office, Ministry of Health, Israel 5 Association for Public Health Services, Jerusalem, Israel 6 Clinical Superviser, Western Galilee Hospital, Nahariya, Israel 7 Department of Medicine E, Western Galilee Hospital, Nahariya, and “Bruce Rappaport” Faculty of Medicine, Technion Institute of Technology, Haifa, Israel. Abstract: Background: Deliberate self-harm is a relatively frequent cause of consultation in the emergency room of gen- eral hospitals. Despite its importance, few epidemiological studies of self-injury in Israel have been carried out, and of these, they mostly covered selected population groups. Objectives: To provide epidemiological data on self-harm in pa- tients examined in the emergency room of a general hospital in the Western Galilee, with special emphasis on differen- tial sociodemographic and clinical characteristics of the Arab and Jewish subjects. Methods: Demographic, clinical, and self-harm characteristics were extracted from hospital files for people aged 18 years and older admitted to the gen- eral hospital in Nahariya, Western Galilee, over a 24-month period (January 1996 to December 1997) following a sui- cidal attempt. Chi-square statistics, two-tailed t-tests, and logistic regression analyses were used to test the significance of inter-ethnic differences in risk factors. Results: The overall incidence rate of suicidal attempts was 16.7 per 100,000 population of Northern District in 1996 (Arabs, 24.4 and Jews, 11.0); or 37.6 per 10,000 admissions (Arabs, 44.2 and Jews, 30.3). Among the Jewish male subjects, attempts rose markedly after the age of 40, while among their Arab coun- terparts the age distribution was even throughout all age groups. Among Jewish females, admissions for self-harm rose gradually with age, while among the Arab women there was a peak at the 20–29 year age group. Both ethnic groups dif- fered significantly in their sociodemographic and clinical profiles, but they shared common characteristics with re- gard to the attempt. Conclusions: Our findings suggest differential ethnic patterns of risk factors for self-harm. Further in-depth investigation of deliberate self-harm is warranted to better explore these factors. Introduction up studies have found that between 3% and 10% of self-harm patients whose first attempt was by self- Deliberate self-harm, often a clinical precursor of fu- poisoning eventually kill themselves (5–7). The inci- ture suicide, constitutes both an expression of severe dence of deliberate self-harm has increased in the psychological distress and a wish to escape from a U.K. (8, 9), other countries of Europe (10, 11), in the troubling situation (1). Although most attempts in- U.S.A. (12, 13) and in Australia (14). In addition, the flict little actual physical harm to health (1, 2) and do gender and age distribution for suicidal behavior has not come to the attention of medical services (3), changed, with marked increases in both suicide and more serious attempts are a relatively frequent cause self-harm in young men and a reduction in the fe- of consultation to the emergency room of general male/male ratio for deliberate self-harm (8,15). hospitals (3, 4). Of the means of attempts, self-poi- There are few epidemiological studies of self-in- soning has potentially serious consequences: follow- jury in Israel (16); most of them deal with adolescent Address for Correspondence: Alexander M. Ponizovsky, MD, PhD, Mental Health Services, Ministry of Health, 2 Ben Tabai St., Jerusalem 93591, Israel. E-mail: [email protected] 138 SUICIDAL ATTEMPTS IN A GENERAL HOSPITAL populations (16–20). These studies reported that mission by a psychiatrist using ICD-10 criteria and self-poisoning constituted about 90% of the pre- previous contact with psychiatric services were ex- ferred means of attempt. Attempts occurred most tracted from the records. frequently in depressed females during the high school years, usually in the context of family dys- The setting. The hospital that participated in this function. studyisamodernpublicgeneralhospital.Itislo- Despite the public health importance of at- cated in Nahariya, the Western Galilee Health Au- tempted suicide, we identified only one epidemio- thority area, and covers a population of over 600,000 logical study published 20 years ago (21) on the individuals, of whom 67% are Israeli Arabs. The population of the city of Haifa. This survey was Nahariya hospital has 609 medical beds and 20 spe- based on data collected at the Rambam Medical cialized wards. The research project received ap- Center during 1977–1979. They found a relatively proval from the ethics committee of the hospital. high incidence rate, an average of 84 per 100,000 population aged 15 and older. The rate was found to Analysis increase up to 170/100,000 in “areas of social dis- Because suicidal attempters could be hospitalized as tress” and declined to 56/100,000 in areas labeled as a result of their action in at least two other hospitals advantaged. The high-risk population included that also serve the Northern District inhabitants, we women below age 29 years; of Oriental origin; with calculated the incidence rates of suicidal attempts elementary education; living in lower class areas; and using different denominators. The first denominator with mental, family, environmental and social prob- was defined as the number of inhabitants of the lems. Although Haifa is an ethnically mixed city, the Northern District area (Arab Israelis and Jewish Is- study did not include Arab-Israelis. Thus, inter-eth- raelis, separately) in 1996 and 1997, separately; this nic differences that may account for a substantial provided a picture of the likelihood of a person in the variance in suicidal behavior (22, 23) have not yet general population who attempted suicide. The sec- been explored in Israel. ond one was defined as the number of people who The objective of this study was to describe se- were admitted to the given hospital during the same lected epidemiological features on patients who at- time periods (Arab Israelis and Jewish Israelis, sepa- tended the emergency room of a general hospital in rately); this provided a picture of the likelihood of a the Western Galilee following self-harm, with special person under the care of the given health service emphasis on the differential socio-demographic and who attempted suicide. Chi-square statistics and behavioral characteristics of the Arab and Jewish two-tailed t-tests were used to test the significance of subjects. differences in proportions and means and standard deviations, respectively. A probability level less than 0.05 was chosen to indicate statistical significance at Methods bivariate level of analysis. In addition, logic regres- Data source. The data for this study were gathered sionanalysiswasperformedwithethnicityasthe from hospital records for people aged 18 years and dichotomic dependent variable (Arab/Jewish) and older (excluding those serving in the Army) who putative risk factors as independent variables. These were admitted to the emergency department of the included the variables that did differ significantly be- general hospital in Nahariya on account of self- tween the groups at bivariate level: gender, age harm. Self-harm attendances were defined as those group (18–20, 20–29, 30–39, and 40 years and older), resulting from an injury or harm of any kind that was marital status (married vs. unmarried), history of reported by the patient or by an accompanying per- contact with mental health services (yes/no), diag- son as self-inflicted or as ascertained as such by the nostic category (mood/anxiety disorders, schizo- medical staff. The period of observation covered 24 phrenia, personality disorders, no diagnosis), and months from January 1, 1996 to December 31, 1997. communication of suicidal intention (others present, Demographic information on the subjects, previous others expected to appear, unknown). Education was self-harm episodes, and diagnosis made upon ad- notincludedduetomultiplemissingdataonthis KHALID ASHKAR ET AL. 139 variable among the Arab group. In addition, gender Arab and Jewish groups. Statistical significance in by age interaction was entered in the regression the logistic regression models was assessed using the model. Backward stepwise selection was carried out Wald statistic model. All analyses were performed on each model with variable removal p-values of .10 using the STATISTICA-6.0 software packet to find the most parsimonious reduced model for the (StatSoft, Inc., Tusla, OK, USA). prediction of differences in risk factor between the Table 1. General hospital patients who attempted suicide by ethnic, sociodemographic and clinical characteristics Characteristic Jewish Patients Arab Patients Total (N=89) (N=86) (N=175) N% N% N% Gendera male 38 42.7 25 29.1 63 36.0 female 51 57.3 61 70.9 112 64.0 Age,b yr., mean (SD) 44.1±20.8 27.7±7.6*
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