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Adverse life events risk factors in self-immolation

INTRODUCTION

Self-immolation (self-burning) is among the most violent and difficult acts to understand, 1 and its etiology is as complex and multifaceted as any other suicidal act. Although self-immolation is rare in high-income countries, 2-6 it is reported with surprising frequency in many low- and middle-income countries. 7 Iran is among the countries with the highest rates of self-immolation. In fact, some regions in the west and south of Iran have the highest documented rates of self-immolation in the world

(22.4 per 100,000 person-years). 10, 11, 12

Women are the main victims of self-immolation in Iran. Suicide by self-burning is the third leading cause of Years of Life Lost (YLL) through premature death among women, after disasters and breast cancer. 10, 11 They account for 70% to 96% of all self-immolation admissions to burn centers in Iran and approximately 80% of these

patients die. 1, 7-12

Subsequently, prevention of self-immolation has become a prominent public health concern among professionals in Iran. This aim is well suited within suggested steps for suicide prevention, using a public health approach, which includes a five phase

cycle: 13

  1. Define the problem: surveillance;
  2. Identify the cause: risk and protective factor research;
  3. Develop and test interventions;
  4. Implement interventions; and
  5. Evaluate effectiveness of interventions.

The suicide literature reveals that risk factors of self-immolation differ across different socio-demographic characteristics, psychological predispositions, psychiatric disorders, and experience of adverse life events. 1-14 In Iran and most low and middle income countries, young and adolescent women are over-represented among selfimmolation cases. 15-28 In high income countries, however, the prevalence of selfimmolation tends to be among older male individuals. 5, 16, 29-36 In a recent survey in Iran, adjustment disorders were among the most prevalent psychiatric predisposition factor 1, 24, 37 whereas, western studies tend to report major depressive disorder, psychoses, and alcohol and other drug addictions as the most psychiatric condition related to self-immolation. 16, 38

These risk factors have been reported among a wide range of age groups and types of suicide victims, including younger individuals (e.g., late adolescents and young adults), married individuals, school drop-outs, those will low level of literacy, the unemployed, and housewives. 1, 7-12, 14, 19-22, 24, 28, 37, 39, 40- 45 Data on history of adverse life events among victims of self-immolation is sparse.

Among suicide victims more broadly, however, there is a pattern of high numbers of adverse life events prior to the suicide attempt. Such events include unplanned pregnancy, homelessness, financial hardship, relationship problems with friends, and/or loved ones/spouses, academic problems and/or failures, work-related anxiety, a personal history of suicide attempts, a family history of suicide attempts, diagnosed mental disorders, and/or malignant disease. 46-55 This study aimed to investigate role of adverse life events in presentation of selfimmolation

among patients admitted to regional Burn Centre at Imam Khomeini

Hospital (BC-IKH) in Kermanshah province, in Iran.

Nearly all currently available data on self-immolation in the world is descriptive, limiting one's ability to establish any relationship between variables of interest.1-37, 39- 45 We therefore implemented a case-control design so that we could examine potential associations between variables of interest.

METHODS

Participants:

Adult patients, both male and female, age 18 and older who either confessed to deliberate self-burning or were reported to have done so by a reliable witness, and were admitted to the BC-IKH were eligible to be enrolled in the study. Patients whose suicide seemed suspicious (i.e., those who denied suicidal intent and for whom there were no corroborating witnesses or data) were excluded. Thirty consecutive patients who met the eligibility criteria were enrolled in this study.

The control group was recruited from the community and was matched by living areas (district-county, rural/urban), gender, and age. All three of those demographic characteristics are risk factors for self-immolation, so control of them was deemed important 1, 7-12, 14, 19, 21, 24, 28, 37, 39, 42, 45 All the participants gave their informed consent

to participation in this study.

Protocol:

A trained clinical psychologist interviewed all enrolled patients within the first 24 hours of admission to the Burn Center to administer Adverse Life Event questionnaire. With the exception of three patients (cases) who had severe burn (defined as greater than 90% Total Body Surface Areas (TBSA)) self-reported data were collected. In cases with high TBSA, the questionnaire was completed by the patients' spouses or parents.

The Adverse Life Events questionnaire was created for this study. It included 16 dichotomized items ranging from unplanned pregnancy to having inability and malignant disease with the response categories; “Yes = 1”, and “No = 0” (See Table 1). Most items in the questionnaire are standard items for such measures. We also included two items that previously have not been evaluated in suicide research but play an important sociocultural role in Iran's society, infertility and compulsory

marriage. 46-58

All protocols were approved by the Kermanshah University of Medical Sciences,

Local Research Ethics Committee.

Analytical method:

Data analyses proceed in two steps. First, we examined descriptive statistics for all items in the Adverse Life Events questionnaire, for both the case and control groups. Second, chi-square was used to estimate differences and, where appropriate, the strength of the difference, between the outcome variable (self-immolation) and the risk factor (items in the Adverse Life Event questionnaire) across each group. We use a p-value ≤ 0.10 to identify trends and a p-value ≤ 0.05 and 95% CI to identify significant differences.

Results

Table 2 shows the results of chi square analysis. Three variables emerged as having statistically significant differences between the two groups. Financial hardship (x2 = 5.41, p = 0.02; OR = 3.45; CI = 1.19-9.90), an intimate relationship break-up (x2 = 9.02, p = 0.003; OR = 5.45; CI = 1.20-11.99), and individual history of suicide attempts (x2 = 6.67; p = 0.01; OR = 7.00; CI = 1.38-35.48). Comparisons of other variables were not statistically significant.

Discussion

The primary purpose of this study was to examine the association between adverse life events and self-immolation among a sample of patients admitted to a regional burn center in Iran. Numerous studies indicate adverse life events play an important role in suicidal attempts and death, 46-56 but very few studies use elegant research designs such as case-control research to reach these conclusions; most data were collected in developed countries; 38, 57, 58 and few address self-immolation in particular as a suicide technique. In fact, we were unable to locate any previous case-control studies examining the impact of adverse life events on self-immolation among patients in Iran or any other low- or middle-income country.

Findings from the present study suggest financial hardship, break-up of an intimate relationship, and an individual history of suicide attempts are significant risk factors for self-immolation. This finding is in line with existing suicide literature. Sunnqvist et al., 48 for example, studied the role of stressful life events and biological stress markers in suicide attempts among former adolescent psychiatric inpatients. They found that patients who reported sexual abuse during childhood and feelings of neglect during childhood had significantly higher levels of CSF-MHPG

(cerebrospinal fluid and Methoxy-4-hydroxyphenylglycole) and U-NA/A than those who had not. In another study, Palacio et al. 49 used a case-control design with 108 adult suicide attempters and 108 controls matched for age and gender. Those who reported adverse life events in the last six months, who had a family history of suicide, who were amidst a major depressive episode, and or who expressed a wish to die, had higher risk of suicide.

Another study, by Zhang et al., 50 used a matched case-control group of 215 suicide attempters with major depression (92 male, 123 female). Hopelessness, negative lifeevents, and family history of suicide were risk factors of attempted suicide. Renaud et al. 51 confirmed the existence of a particular clinical profile of children and

improved understanding of the interrelationships between stressors in youth suicidal behavior. In a study of 300 adolescent aged from 14 to 19 years. Marczyńska- Wdówik, 52 found that suicide attempters and adolescents with suicidal ideation had poor social support from parents and experienced more stressful situations and family and school problems which were perceived difficult to solve.

Way et al., 53 reviewed the mental health records of all 76 suicides that occurred between 1993 and 2001 in New York State Department of Correctional Services prisons and that had some contact with mental health services during their incarceration. He found common stressors preceding the suicide were inmate-toinmate conflict, recent disciplinary action, fear, physical illness, and adverse life events such as loss of good time or disruption of family/friendship relationships in the community. Finally, Chiou et al. 54 demonstrated that the most common precipitating characteristics among adolescent suicide attempters who were admitted to an acute psychiatric ward in Taiwan were school stress, parent-child conflict, and psychopathology, including feelings of hopelessness, psychotic symptoms, substance abuse, or panic symptoms.

Prevention strategies

Results of this study support previous findings that self-immolation involves a complex mix of intrapsychic, interpersonal, and environmental risk factors, including adverse life events. Culturally sensitive interventions should be developed to target atrisk individuals and communities for self-immolation prevention. These interventions could develop out of community participatory research to involve key community members and their inputs. It could focus on community outreach activities such as media campaigns, or school-based interventions to reach adolescent population. Local community-action groups and nongovernment organizations are also important entities for self-immolation prevention activities. Interventions aimed at improving mental health through cognitive-behavioral or interpersonal therapy strategies have also shown to reduce the likelihood of suicide in other cultures 1 and are likely to be helpful in preventing suicide by self-immolation in Iran.

Limitations and Future Directions

This study offers several strengths. Most prominently, it is among the first studies to use a case-control design to examine risk factors associated with self-immolation. Further, it was conducted in a region with self-immolation rate that are among the highest in the world. Nonetheless, case-control studies have some inherent limitations. One pertains to the issue of properly matching subjects between the case and control groups. In this study the control group was selected from the same community and matched by age and gender to consecutive-referral cases to obtain accurate matching. It is unknown if other demographic factors, such as income, may have varied across the groups. Another limitation of the study concerns generalizability. The sample for this study was recruited from one region of Iran, and therefore results cannot necessarily be generalized to other parts of Iran or to other nations. We view this work to be a pilot study from which further investigation is warranted.

In Iran and much of the world, suicide is stigmatized and condemned for religious or cultural reasons. In some countries, suicidal behavior is a criminal offence punishable by law.1 Therefore, for various reasons, suicide often is a secretive act that is deliberately hidden and considered taboo. Identification of at-risk populations, which this manuscript contributes to, will provide valuable information for targeted treatment and prevention programs. As discussed in the introduction, future work should begin to move toward treatment and prevention programs.13

Conclusion

The results of this study suggest financial hardship, break-up of an intimate relationship, and an individual history of suicide attempts are risk factors for selfimmolation. Other variables, including unplanned pregnancy, homelessness, financial hardship, relationship problems with friends, and/or loved ones/spouses, academic problems and/or failures, work related anxiety, personal history of suicide attempts, family history of suicide attempts, diagnosed mental disorders, and malignant disease, did not play a role as individually protective or risk factors for self-immolation. Intervention strategies to prevent life adverse events and educate at-risk individuals about problem-solving approaches and coping skills should be developed and implemented.

Acknowledgment

The authors would like to thank all people who participated in this study.

Ethical approval:

All protocols were approved by the Kermanshah University of Medical Sciences,

Local Research Ethics Committee.

Funding:

Financial support of this study was provided by Kermanshah University of Medical

Sciences.

Competing interests

None declared.

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Table 1. Measures of adverse life events risk factors

· unplanned pregnancy(yes vs. no)

· infertility(yes vs. no)

· homelessness(yes vs. no)

· financial hardship(yes vs. no)

· problems with friends(yes vs. no)

· a relationship break-up (with love or spouse) (yes vs. no)

· school or university failure(yes vs. no)

· anxiety about school/university performance(yes vs. no)

· problems at work(yes vs. no)

· compulsory marriage(yes vs. no)

· individual history of suicide attempts(yes vs. no)

· sibling or parents history of suicide attempts(yes vs. no)

· individual history of mental disorders(yes vs. no)

· having inability and malignant disease(yes vs. no)

Table 2. Demographic data of case (n=30) and control (n=30) groups

Variable

Groups

Cases

Control

Total

Gender; N (%)

Male

4 (13)

4 (13)

8 (13)

Female

26(87)

26(87)

52(87)

Marital state; N (%)

Single

12 (40)

10(33)

22(37)

Married

17(57)

19(64)

36(60)

Divorced

1(3)

1(3)

2(3)

Mean of age;(year)

27.5

28.5

28.0

Mean of TBSA*; (%)

60.2

-

-

* Total Body Surface Area

Table 3. Differences  between self-immolation and variables (cases n =30; controls n=30)

x2

p-value a

Odds Ratio

95% CI

Unplanned pregnancy

0.18

0.54

1.11

0.06-16.76

Abortion

0.35

0.50

2.07

0.18-24.1

Infertility

3.16

0.08

1.12

0.23-2.67

Homelessness

1.02

0.31

1.07

0.03-2.79

Financial hardship

5.41

0.02

3.45

1.19-9.90

Problems with friends

2.10

0.15

0.99

0.16-4.58

A relationship break-up (with love or spouse)

9.02

0.003

5.45

1.20-11.99

School or university failure

3.16

0.08

1.51

0.13-2.95

Anxiety about school/university performance

2.96

0.09

4.79

0.75-15.33

Problems at work

0.22

0.64

0.64

0.10-4.15

Compulsory marriage

1.02

0.31

1.00

0.30-3.31

Individual history of suicide attempts

6.67

0.01

7.00

1.38-35.48

Sibling or parents history of suicide attempts

1.00

0.32

1.98

0.51-7.64

Individual history of mental disorders

1.07

0.31

0.31

0.03-3.17

Having inability and malignant disease

1.07

0.30

0.31

0.03-3.17

a.  Fisher's exact test is used when N<5 


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