Heaven can wait: studies on suicidal behaviour among young

Transcripción

Umeå University Medical Dissertations
New Series No 1067 • ISSN 0346-6612 • ISBN 91-7264-213-0
From Department of Clinical Sciences, Division of Psychiatry
Medical Faculty, Umeå University, Sweden
and
Department of Preventive Medicine and
Centre for Demographic and Health Research (CIDS)
Medical Faculty, León University, Nicaragua
Heaven can wait
Studies on suicidal behaviour among
young people in Nicaragua
Andrés Herrera Rodríguez
Umeå 2006
Copyright © Andrés Herrera Rodríguez
Photos: Andrés Herrera Rodríguez
Printed by Print & Media, Umeå University, Umeå, 2006
Original papers
The thesis is based on the following papers.
Paper I
Caldera, T., Herrera, A., Renberg, E. S., & Kullgren, G. (2004).
Parasuicide in a low-income country: results from three-year hospital surveillance in Nicaragua. Scand J Public Health, 32(5), 349355.
Paper II
Herrera, A., Dahlblom, K., Dahlgren, L., & Kullgren, G. (2006).
Pathways to suicidal behaviour among adolescent girls in Nicaragua. Soc Sci Med, 62(4), 805-814.
Paper III
Herrera, A., Caldera, T., Kullgren, G., & Salander Renberg, E.
(2006). Suicidal expressions among young people in Nicaragua - a
community based study. Soc. Psychiatry Psychiatr Epidemiol, 41(9),
692-697.
Paper IV
Herrera A., Caldera T., Kullgren G., Peña R., & Salander Renberg,
E. (2006). Attitudes towards suicide among young people in
Nicaragua: A community based study. Submitted manuscript.
-I-
Abstract
In developed countries, suicidal behaviour is recognised as a significant public
health problem among young people, but there are few studies from developing
countries on this subject. The present thesis aims at estimating the extent of the
problem and at exploring factors related to suicidal behaviour among young
people in a developing country, Nicaragua, using a combined quantitative and
qualitative approach. Three studies were conducted between 1999 and 2006.
In the first study, all hospital admitted suicide attempt cases in the area of León
were assessed over a three year period. Secondly, a qualitative study using
individual in-depth interviews was conducted with eight girls aged between 12
and 19 admitted to hospital after attempting suicide. Thirdly, a study using the
Attitudes Towards Suicide (ATTS) questionnaire was conducted in a community based sample of 278 young people aged 15-24 years to assess own
suicidal behaviour, attitudes towards suicide as well as exposure to suicidal
behaviour among significant others.
The hospital surveillance showed that suicide attempt rates were highest among
females in the age group 15-19 years with a female rate three times that of
males (302.9 versus 98.9 per 100,000 inhabitants per year). Drug intoxication
and pesticides were the most commonly used methods for the attempts. A
consistent seasonal variation with peaks in May-June and September-October
was found in each of the three years, possibly related to exam periods in
schools.
Findings in the qualitative approach led to a tentative model for pathways to
suicidal behaviour based on four main categories: Structuring conditions,
triggering events, emotions and action taken. Dysfunctional families, lack of confidential and trustworthy contacts and interpersonal conflicts followed by
emotions of shame and anger were some important components in the model.
The community studies showed that suicidal expressions (life-weariness, death
wishes, suicidal ideation, suicide plans and suicide attempts) were common
among young people where more than 44.8% of males and 47.4% of females
reported some kind of suicidal expression. Gender differences were small.
Exposure to suicidal behaviour among others was associated with higher levels
of self-reported suicidal behaviour. The attitude study showed that boys had
less pro-preventive attitudes than girls, possibly indicating their higher risk for
completed suicide. Exposure to suicidal behaviour and own suicidal behaviour
showed an association with specific patterns of attitudes.
The findings should be taken into consideration when planning for prevention
of suicidal behaviour among young people in a developing country like
Nicaragua.
Keywords: Suicide attempts; suicidal expressions; attitudes towards
suicide; young people; Nicaragua
- II -
Resumen
El suicidio se encuentra entre las primeras tres causas de muerte en
los adolescentes del mundo con una tendencia creciente. De acuerdo con estimados de la Organización Mundial de la Salud, 100 000
adolescentes se suicidan cada año en el mundo. En Latinoamérica,
según la Organización Panamericana de la Salud, las tasas promedio
de suicidios en los jóvenes (15 – 24 años) por 100 000 habitantes es
de 13.5 mientras que las jóvenes tienen una tasa promedio de 6.6
por 100 0000. Estas tasas aumentan dramáticamente cuando analizamos solamente Nicaragua donde encontramos que la tasa de suicidio entre los jóvenes es de 32 por 100 000 habitantes y entre las
jóvenes es de 23.7 por 100 000 habitantes. Estos datos reflejan que
el comportamiento suicida en adolescentes representa un serio
problema de salud pública en Nicaragua.
Dada la situación de suicidios en Nicaragua, desde 1999 los Departamentos académicos de Salud Pública y Salud Mental de la
UNAN León junto con las autoridades de salud local del municipio
de León, acordaron estudiar los intentos de suicidios registrados
dentro del sistema de vigilancia de lesiones del Hospital Escuela
Oscar Danilo Rosales Argüello (HEODRA).
Posteriormente, en el año 2003 se realizó un estudio comunitario
sobre actitudes hacia la conducta suicida en jóvenes de 15-24 años
utilizado el sistema de vigilancia del Centro de Investigación en
Demografía y Salud de la UNAN León. Estos estudios realizados
tanto a nivel hospitalario y comunitario combinaron abordajes
cuantitativos y cualitativos, teniendo como objetivos los siguientes:
• Evaluar la incidencia de intentos de suicidios e identificar factores de riesgos asociados, en los casos admitidos a través del
sistema de vigilancia hospitalario, proveniente del área urbana de León; dichos eventos fueron monitoreados entre
marzo 1999 y febrero 2002.
• Explorar la conducta suicida utilizando un abordaje cualitativo (entrevistas a profundidad) con ocho mujeres adolescentes entre 12-19 años, que fueron admitidas en el hospital
después que hicieron un intento de suicidio durante mayoagosto, 2001.
• Explorar expresiones de conducta suicida y actitudes hacia la
conducta suicida con relación a factores de riesgos asociados,
y factores socio-demográficos; así como la exposición a conducta suicida entre familiares y otros.
- III -
El último objetivo fue abordado en un estudio comunitario con
278 jóvenes de 15-24 años de ambos sexos utilizándose un cuestionario para medir las actitudes hacia la conducta suicida (ATTS), el
cual fue realizado entre agosto-noviembre, 2003.
El sistema de vigilancia del hospital reportó que la mayoría de los
intentos de suicidios eran mujeres (68.8%), mas jóvenes que los
varones con un promedio de edad de 20.8 años versus 24.6 años.
De éstos, los adolescentes de 15-19 años tuvieron las tasas mas altas
encontrándose que las tasas entre las mujeres fueron tres veces más
altas comparada con las de los hombres (302.9 versus 98.9) por
100,000 habitantes en un año. El estudio reflejó un predominio de
dos tipos de métodos; la intoxicación con fármacos (70.7%) y la
intoxicación con plaguicidas o venenos (19.1%). Más de un 90% de
los intentos de suicidios ocurrieron en la casa y un patrón consistente de dos picos de intentos de suicidios en los meses de mayojunio y octubre-noviembre probablemente relacionados con la finalización de los primeros y segundos exámenes semestrales de las escuelas. Adicionalmente, se reportó que cerca del 80% de los participantes tuvieron contacto previo con los servicios de salud y de este
porcentaje, el 46.5% habían estado en contacto con los servicios de
salud al menos seis meses previos al intento de suicidio.
(Articulo I : Caldera, T., Herrera, A., Renberg, E. S., & Kullgren, G. (2004).
Parasuicide in a low-income country: results from three-year hospital surveillance in
Nicaragua. Scand J Public Health, 32(5), 349-355).
Al explorar la conducta suicida entre las mujeres adolescentes de 1219 años se identificaron cuatro categorías principales: condiciones
estructurales, eventos negativos, condiciones emocionales adversas y
acciones tomadas por las adolescentes en búsqueda de resolver sus
problemas. Esto dio como resultado la propuesta de un modelo
conceptual (presentado en el articulo II), el cual ilustra una interconexión dialéctica entre las condiciones estructurales en que viven
las adolescentes y las acciones que ellas toman para resolver sus
problemas o varias formas de escape que cuando su estrategia fracasa, el resultado puede ser un intento de suicidio. Por tanto, el mal
funcionamiento en la familia, la ausencia de los padres de las
jóvenes, poca integración en la sociedad son algunas de las condiciones estructurales que lideran esta carga emocional estresante. El
abuso emocional, físico y sexual, la muerte de un familiar, las
rupturas de relaciones de parejas con los novios y los suicidios entre
los/as amigos/as actúan como eventos negativos que precipitan la
conducta suicida entre las mujeres adolescentes.
- IV -
(Articulo II: Herrera, A., Dahlblom, K., Dahlgren, L., & Kullgren, G. (2006).
Pathways to suicidal behaviour among adolescent girls in Nicaragua. Soc Sci Med,
62(4), 805-814).
El estudio comunitario revela una prevalencia de cualquier tipo de
conducta suicida en el último año de 44.8% entre hombres y
47.4% entre las mujeres. El 2.1% de los hombres y el 1.5% de las
mujeres reportó algún intento de suicido en los últimos doce meses.
Otras expresiones suicidas como el deseo de morir fue reportada en
un 33.8% de las mujeres y un 20.7% de los hombres; además, el
19.8% de los participantes de ambos sexos reportaron haber tenidos
ideas suicidas en los últimos doce meses. El 5% reportó haber
tenido planes para quitarse la vida en los últimos doce meses previos
al estudio. En otro orden, se constató que estar expuesto a expresiones de conductas suicidas entre familiares y otros, estaba significativamente asociado a expresiones serias de conducta suicida
(ideas, planes e intentos de suicidios) entre los/las participantes. Al
realizarse el análisis específico comparativo por género, esta asociación fue significativa solo para las mujeres comparadas con los
hombres.
(Articulo III: Herrera, A., Caldera, T., Kullgren, G., & Salander Renberg, E.
(2006). Suicidal expressions among young people in Nicaragua - a community
based study. Soc. Psychiatry Psychiatr Epidemiol, 41(9), 692-697.
Finalmente, se reportan nueve factores que describen las actitudes
hacia la conducta suicida de los/as jóvenes, mostrándose diferencia
de género solamente en tres factores. La relación entre características
sociodemográficas y la experiencia de conducta suicida entre familiares y otros, así como, las propias expresiones de conducta suicida
entre los participantes destaca que aquellos que estaban viviendo en
pobreza no estaban tan de acuerdo en que el suicidio es un derechos
de los humanos, de igual manera manifestaron que este es mas un
evento de “llanto por ayuda”. Sin embargo, los que tenían un
amigo/a con expresiones de conducta suicida estaban a favor en
expresar que el suicidio es una conducta normal y común. Las
principales razones encontradas para intentar suicidarse, en el caso
de las mujeres fueron problemas familiares y con su pareja,
mientras que los hombres expresaron razones económicas. Finalmente se analizaron las formas de prevenir las conductas suicidas
donde a pesar de la poca diferencia, hubo una tendencia a que mas
mujeres estuvieran de acuerdo en hacer esfuerzos de prevención a
nivel de las escuelas.
(Articulo IV Herrera A., Caldera T., Kullgren G., Peña R., & Salander Renberg
E. (2006). Attitudes towards suicide among young people in Nicaragua: A community based study. Submitted manuscript)
-V-
En síntesis, el intento de suicidio fue más común entre las mujeres
que asistieron al hospital y mas reportado entre los hombres en el
estudio comunitario de actitudes hacia las conductas suicidas. Los
plaguicidas o venenos son frecuentemente usados como un método
de intentos de suicidio. Según el modelo conceptual propuesto, la
disfunción familiar, ausencia de los padres de las adolescentes y poca
integración social fueron algunas de las condiciones estructurales y
emocionales encontradas entre las mujeres. Cerca de la mitad de
los/as participantes en el estudio comunitario reportaron algunas
expresiones suicidas en los últimos doce meses (gesticulaciones
suicidas, deseo de morir, idea suicida, plan suicida, e intento de suicidio). Además, la presencia de conducta suicida entre familiares y
otros pareciera estar teniendo un efecto de contagio entre los/las
adolescentes y jóvenes en Nicaragua. Sin embargo, comúnmente
los/las adolescentes en Nicaragua tienden a estar en desacuerdo con
las actitudes permisivas hacia la conducta suicida, y a la vez se muestran positivas hacia la posibilidad de prevenir esta conducta.
Estos resultados están indicando que la juventud está demandando
un apoyo institucional pero también sugiere que la conducta suicida
entre adolescentes y jóvenes en Nicaragua es un problema serio de
salud pública y necesita un programa urgente de prevención. Este
programa puede estar encaminado a: limitar la accesibilidad a los
métodos letales como los plaguicidas o venenos (fosfina, gramoxone, organofosforados), impartir consejería y habilidades para la
vida en las escuelas sobre la detección temprana de los signos de
peligros de la conducta suicida, pero también, mejorar el manejo de
los intentos de suicidios a nivel de atención primaria en salud, así
como también, mejorar el manejo de los pacientes con problemas
de salud mental.
En este esfuerzo es bueno visualizar la participación de los padres de
familia, maestros y la comunidad pero sobre todo quienes toman
decisiones claves deberían ser mas beligerantes en promover políticas públicas con indicadores de seguimiento a mediano y largo
plazo: como por ejemplo movilizar recursos económicos y humanos
para mejorar el entrenamiento de los recursos de salud mental,
impulsar una política nacional de salud mental donde se proponga
hacer mejor inversión en salud, además de promover el deporte y la
sana recreación para los/las adolescentes y jóvenes.
Palabras claves: intento de suicidio, conducta suicida,
expresiones suicidas, actitudes hacia la conducta suicida,
jóvenes, sistema de vigilancia, Nicaragua.
- VI -
Contents
Original papers........................................................................I
Abstract ............................................................................... II
Resumen ............................................................................. III
Introduction .......................................................................... 1
Suicidal behaviour – the extent of the problem ..................................... 1
Some factors associated with suicidal behaviour among young people .......... 4
Norms and attitudes towards suicide .................................................. 5
The suicidal process approach.......................................................... 6
The study setting - Nicaragua........................................................... 8
Environment and lifestyles among young people in Nicaragua ................... 10
Health services in Nicaragua ........................................................... 11
Aims ................................................................................. 12
Method .............................................................................. 13
Overall framework and design ......................................................... 13
Study setting.............................................................................. 14
Method - Paper I ......................................................................... 15
Method - Paper II ........................................................................ 15
Method - Papers III and IV .............................................................. 17
Ethical considerations ............................................................ 22
Main results......................................................................... 23
Paper I: Hospital surveillance study .................................................. 23
Paper II: In-depth interviews with girls .............................................. 23
Paper III: Suicidal expressions ......................................................... 24
Paper IV: Attitudes towards suicide .................................................. 25
Discussion ........................................................................... 26
Acknowledgements................................................................ 33
References.......................................................................... 35
Appendix
- VII -
Suicidal behaviour – some definitions
Suicidal behaviour is used as a term covering completed
suicides, suicide attempts and suicidal ideation.
Suicidal expression is used to cover life-weariness, death
wishes, suicidal ideation, suicide plans and suicide attempts.
Suicide can be defined as “an act with a fatal outcome which
the deceased, knowing or expecting a fatal outcome, had
initiated and carried out with the purpose of provoking the
changes he desired” (World Health Organization, 1986).
Suicide attempt and parasuicide are terms often used as
interchangeable. Parasuicide has been defined by WHO and
EURO/Multicentre study as "an act with nonfatal outcome, in
which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause selfharm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which
is aimed at realizing changes which the individual desired via
the actual or expected physical consequences" (Platt et al.,
1992).
Deliberate self harm (DSH) is sometimes used as interchangeable with suicide attempt (Webb, 2002).
Non-fatal suicidal behaviour, with or without injuries is a
more recent term defined as “a non-habitual act with nonfatal
outcome that the individual, expecting to, or taking the risk
to die or to inflict bodily harm, initiated and carried out with
the purpose of bringing about wanted changes.”(De Leo et al.,
2006).
- VIII -
Introduction
Point of departure for the present thesis
Since 1987 there is an ongoing research collaboration between the
department of psychiatry, Umeå University, Sweden, and León
University, Nicaragua. Over the years, several studies have been
conducted on mental health problems among people in the León
region.
During the late 1990s, suicidal problem among adolescents became
a growing concern for all of us in the research group; hospital
admissions of young people after suicide attempt seemed to be
everyday events. To learn more about this problem, a hospital
surveillance system was set up to cover all suicide attempt cases
referred to the sole general hospital in the region. Rates on suicide
attempts were high, in particular among young girls, and this led us
to continue with in-depth interviews with young girls to get a
deeper understanding of pathways to suicidal behaviour. The final
step for this thesis was a community based study among the young
people of León to learn more about suicidal behaviour from a
public health perspective.
Suicidal behaviour can be approached from several different research perspectives such as anthropology, sociology, psychology or
biology. The different perspectives have all contributed significantly
to the scientific literature on suicidal behaviour. In the present
thesis, a psychosocial perspective has guided the studies.
The overall incentive for the present thesis is to lay ground for
future interventions to prevent young people from taking their lives
as symbolised by the title line “Heaven can wait”.
Suicidal behaviour – the extent of the problem
It is estimated that more than 800,000 individuals commit suicide
every year (World Health Organization, 2003), implying that
suicide is a significant global public health problem. Suicide rates
among young people have been increasing during recent years in
several countries and suicide is one of the leading causes of death
among young people in many countries. In a global context, it is
estimated that at least 100,000 adolescents commit suicide every
year (World Health Organization, 2005b). In Europe, high national suicide rates among 15-24 year olds are found in Finland (8.1 per
Andrés Herrera Rodríguez - Heaven can wait
100,000 among females and 31.1 per 100,000 among males) and
Sweden (8.5 and 27.2, respectively). In US the corresponding rates
are 3.1 per 100.00 among females and 17.2 among males (World
Health Organization, 2003).
For Latin America, PAHO/WHO has reported on figures for different countries including Nicaragua as shown in Table 1. Among
young people, the suicide rate in Nicaragua is the second highest in
Central America and only El Salvador has higher rates.
For attempted suicide, it is estimated that worldwide 18 million
people attempt suicide each year, that is, for every committed
suicide there are at least 20 suicide attempts (World Health
Organization, 2006). For obvious reasons, reported figures on
suicide attempt rates are likely to be underestimates, in particular in
cultures where suicide is stigmatized and even prohibited by religion
or law (Bertolote et al., 2005).
School based studies among adolescents in different European
countries have shown prevalences of self-reported suicide attempts
during last year to vary between 1.5% - 5.3% (Tomori et al., 2001;
Buddeberg et al., 1996; Ivarsson and Gillberg, 1997). A national
survey in the United States showed that 8.8% of the students
reported a suicide attempt over the last 12 months (Grunbaum et
al., 2002).
Among other suicidal expressions, suicidal ideation may be considered a primary marker for risk of more serious suicidal behaviours. Studies have reported prevalence figures ranging from
11% to 44% among adolescents (Dervic et al., 2005; Buddeberg et
al., 1996 ; Tomori et al., 2001; Wunderlich et al., 2001).
Suicide plans held over a period of 2 weeks or more have been
reported in a German study by 9.6% among adolescents and in a
US study 15% had made a specific plan to attempt suicide during
recent 12 months (Grunbaum et al., 2002).
-2-
- 17 -
5.3
4.1
0.7
1.4
0.0
1.5
1.1
0.9
9.8
6.1
2.2
2.6
8.2
1.3
2.9
1.3
2.0
1.9
3.5
3.6
3.6
2.4
2.0
8.0
F
4.6
3.5
0.7
1.4
0.0
1.5
1.3
1.0
9.1
6.8
2.2
2.6
8.3
1.4
2.7
1.5
1.9
1.6
3.0
3.5
3.4
2.7
2.1
7.5
Rate*
M
F
17.4
15.1
4.3
7.6
3.9
14.6
5.6
4.0
35.6
12.7
8.8
9.4
19.6
10.5
15.4
6.7
11.8
7.1
10.2
10.3
13.1
6.9
8.0
17.9
Rates
Sources: PAHO/WHO Statistics from the Americas, 2006.
*Rate standardized by age
M = male, F= female
Cuba
Brazil
Argentina
Colombia
Panamá
Nicaragua
Costa Rica
Honduras
El Salvador
Guatemala
Belize
México
M
19.3
17.4
3.6
7.4
3.2
13.3
4.1
3.2
29.1
13.7
9.0
10.3
16.9
9.3
15.1
5.5
11.4
6.9
10.5
10.2
13.7
6.4
7.6
21.2
USA
1984-1986
2000-2002
1984-1986
2001-2003
1984-1986
2001-2003
1984-1987
2001-2003
1984-1986
2001-2003
1987-1988
1989-1990
2000-2002
1984-1986
2001-2003
1984-1986
2001-2003
1984-1986
1999-2001
1984-1986
2001-2003
1984-1986
2000-2002
2001-2003
Countries
Rate
1.1
1.0
0.4
1.1
0.0
0.0
0.4
0.3
0.4
0.7
1.0
0.3
1.5
0.5
0.9
0.6
0.9
0.5
0.9
0.5
1.0
0.3
0.4
0.6
0.4
0.3
0.2
0.7
0.0
0.0
0.2
0.3
0.9
2.7
0.7
0.0
2.4
0.4
0.5
0.5
0.2
0.4
1.4
0.2
0.7
0.4
0.4
0.4
5 to 14
Rate
M
F
20.5
16.8
5.1
11.4
3.9
20.4
7.5
5.2
51.3
14.1
9.6
9.9
32.0
9.6
17.7
7.3
15.4
9.9
14.9
6.7
17.1
6.2
7.8
11.5
4.3
2.9
1.4
2.9
0.0
4.0
2.5
2.3
29.9
19.6
4.6
4.4
23.7
2.6
7.2
3.0
3.1
4.2
7.9
3.4
5.2
3.7
2.8
9.4
15 to 24
Rate
M
F
23.2
21.7
7.0
11.4
9.7
25.0
10.1
6.2
64.5
18.3
13.4
14.1
30.7
15.4
21.6
10.9
16.3
9.7
12.7
10.0
14.5
9.8
12.3
22.3
6.5
5.5
1.1
1.7
0.0
3.3
2.1
1.2
11.5
7.6
2.5
2.6
9.9
1.8
3.6
1.4
2.2
2.0
3.3
3.8
3.3
3.7
3.0
9.0
25 to 44
Rate
M
F
24.5
22.3
5.4
8.6
0.0
16.2
6.1
5.4
38.5
20.4
10.9
14.8
24.1
19.3
23.9
9.3
17.0
11.0
14.2
18.1
19.7
11.8
13.2
27.9
8.4
6.5
0.8
1.4
0.0
0.0
1.0
1.1
3.7
4.2
2.6
4.8
5.8
2.0
2.2
1.9
2.3
1.4
2.3
6.8
5.8
3.9
3.1
11.4
45 a 64
Rate
M
F
43.5
30.9
7.7
12.8
0.0
19.9
6.9
6.5
38.6
21.3
18.2
17.0
18.9
15.9
29.3
10.0
21.8
10.6
20.6
43.6
35.2
14.7
13.4
67.4
7.7
4.0
0.5
1.0
0.0
0.0
1.7
1.0
1.9
2.1
1.7
3.0
1.7
0.0
0.0
2.2
4.2
0.8
1.3
8.9
5.4
3.4
2.5
18.8
64 a +
Rate
M
F
Table 1. Sex and age specific suicide rates by 100,000 inhabitants/year in selected countries in the Americas.
Some factors associated with suicidal
behaviour among young people
There are many social theories about suicidal behaviour, and
changes in the social environment have for instance been regarded
crucial for variation in suicide mortality. Emile Durkheim identified already in his classic contribution on suicide from more than
100 years ago, the crucial effect of rapid modernization (Durkheim,
1995). As further described below, Nicaragua is a society that has
been exposed to rapid political and social changes in the recent
decades.
Social environment in general should maybe be one of the first
dimensions to consider when analysing suicidal behaviour, and
perhaps the individual’s social network is the most crucial aspect.
There are important gender differences in suicidal behaviour among
young people. Completed suicides occur primarily among boys
(World Health Organization, 2003). For suicide attempts, there is
an opposite gender pattern (Alaghehbandan et al., 2005; Wunderlich et al., 2001; Renberg, 2001). For example, in a US surveillance,
11.2% of females students reported a suicide attempt in recent year
compared to 6.2% among male students (Grunbaum et al., 2002).
However, there are indications that suicide attempts are more serious among young men and, for example, male adolescents have
been reported to attempt suicide in places where they were less
likely to be discovered (Hummel et al., 2000). Opposite gender
patterns have been reported in some countries and, for example, in
rural China young women are more at risk for completed suicide
than young men (Phillips et al., 2002).
Previous studies have identified a number of environmental and
life-style factors associated with suicidal behaviour among young
people. Experiences early in life, such as a family history of suicidal
behaviour or childhood sexual abuse, increase the risk of suicidal
behaviour. Life-events, such as loss of a significant other, loss of employment or school failures, financial problems and conflicts with
family or partners, are other risk factors. Among life-style factors,
drug or alcohol related problems, unwanted pregnancies and
sexually related problems may put the individual at risk for suicidal
behaviour. (Fergusson et al., 2003; Buddeberg et al., 1996; Gunnell
et al., 2000; Hulten et al., 2001;Tomori et al., 2001). For an
overview, see DeLeo (2004).
Most of the risk factors mentioned are likely to be unspecific factors
contributing to mental health problems in general. However, there
-4-
are factors more specifically targeting suicidal behaviour. Some
studies have shown that exposure to suicidal behaviour among
significant others are associated with increased own suicidal behaviour (Wong et al., 2005; Kirmayer et al., 1996).
Availability of means for suicide attempts is another example of a
specific risk factor. Pesticides are easily available and also commonly
used as method for suicide attempts in developing countries
(Gunnell and Eddleston, 2003; Conner et al., 2005; Phillips et al.,
2002). Their high lethality makes this in particular cumbersome.
Norms and attitudes towards suicide
Culture and norms play crucial roles in influencing views on
suicidal behaviour among young people. The Catholic Church in
Nicaragua is probably the single strongest force to influence
peoples' norms and values. In Nicaragua, the Catholic Church still
has the tradition, that when someone commits suicide, the dead
body will be buried without any ceremonies in church. This procedure is perceived as very stigmatizing by the family and is likely to
strongly influence popular attitudes to suicidal behaviour.
Norms, culture and attitudes are strongly related phenomena. The
concept of attitude should be viewed as a creation or a construct. It
has been defined as “a tool that serves the human need to see order
and consistency in what people say, think and do, so that given
certain behaviour, predictions can be made about future behaviours” (Henerson et al., 1987). Attitude has also been defined as
“a predisposition to react against an object, rather than an actual
response, that is lasting over time, and results in a consistency in the
behaviour directed against an object” (Summers, 1970). This predisposition might be consciously or unconsciously acquired (Kolb,
1968).
Culture strongly influences norms and attitudes and their associations with actual behaviours are context dependent. This means
that the way, in which suicidal behaviour is perceived and communicated, differs from one cultural context to another. Crosscultural comparisons have also shown attitudes towards suicide to
differ distinctly between cultures, as shown, for example in a study
comparing India and Austria (Etzersdorfer et al., 1998).
The cultural dependence also implies that norms and attitudes, even
if substantially stable, are possible to change over time. These chan-5-
ges are in particular pronounced when characterised as “turning
points” – i.e. changes of crucial importance for the society as a
whole as well as for the single individual (Strauss, 1997).
Young people hold, in general, permissive attitudes towards suicide.
For example, a study performed in New Zealand has shown that the
majority of the youths reported liberal attitudes towards euthanasia
(82%). More than half of the adolescents in another study considered suicide an option when if life becomes too difficult (Beautrais et
al., 2004). Similar findings were reported in a Canadian study
(Singer et al., 1995).
Attitudes towards suicide differ also between males and females.
Pro-preventive attitudes have been reported to be more pronounced
among men. In a Swedish study, males were more inclined to believe in the possibilities to help a suicidal person (Renberg and
Jacobsson, 2003).
A crucial point from a preventive perspective is whether certain
attitudes, for example permissive attitudes towards suicide, are associated with increased risk for suicidal behaviour. Recent studies
from Hong-Kong among young people aged 12-17 years (Wong et
al., 2005) and a community survey from Australia (De Leo et al.,
2005) seem to support such an association. One possible mechanism linking attitudes to suicidal behaviour might be that attitudes
and beliefs support the use of maladaptive coping strategies in response to depression and suicidal thoughts, as suggested in one
study (Gould et al., 2004).
The suicidal process approach
Wasserman has presented a comprehensive model for pathways to
suicidal behaviour based on a stress/vulnerability perspective (Wasserman, 2001). The model suggests that suicide is preceded by a
process, of varying length, in which the dynamics are highly
individual. The process usually stretches over months, but for some
people it lasts more than a year. For patients with severe mental
disorders or substance abuse, it can be a lifelong process but for
young people with, for example adjustment disorders, its duration
may be only a few days or weeks. Propensity for suicide may be
acute, chronic or latent. For long periods, thoughts of suicide may
be entirely absent, only to return in response to new strains as
shown in Figure 1.
-6-
-7-
-8-
5.3
4.1
0.7
1.4
0.0
1.5
1.1
0.9
9.8
6.1
2.2
2.6
8.2
1.3
2.9
1.3
2.0
1.9
3.5
3.6
3.6
2.4
2.0
8.0
F
4.6
3.5
0.7
1.4
0.0
1.5
1.3
1.0
9.1
6.8
2.2
2.6
8.3
1.4
2.7
1.5
1.9
1.6
3.0
3.5
3.4
2.7
2.1
7.5
Rate*
M
F
17.4
15.1
4.3
7.6
3.9
14.6
5.6
4.0
35.6
12.7
8.8
9.4
19.6
10.5
15.4
6.7
11.8
7.1
10.2
10.3
13.1
6.9
8.0
17.9
Rates
Sources: PAHO/WHO Statistics from the Americas, 2006.
*Rate standardized by age
M = male, F= female
Cuba
Brazil
Argentina
Colombia
Panamá
Nicaragua
Costa Rica
Honduras
El Salvador
Guatemala
Belize
México
M
19.3
17.4
3.6
7.4
3.2
13.3
4.1
3.2
29.1
13.7
9.0
10.3
16.9
9.3
15.1
5.5
11.4
6.9
10.5
10.2
13.7
6.4
7.6
21.2
USA
1984-1986
2000-2002
1984-1986
2001-2003
1984-1986
2001-2003
1984-1987
2001-2003
1984-1986
2001-2003
1987-1988
1989-1990
2000-2002
1984-1986
2001-2003
1984-1986
2001-2003
1984-1986
1999-2001
1984-1986
2001-2003
1984-1986
2000-2002
2001-2003
Countries
Rate
1.1
1.0
0.4
1.1
0.0
0.0
0.4
0.3
0.4
0.7
1.0
0.3
1.5
0.5
0.9
0.6
0.9
0.5
0.9
0.5
1.0
0.3
0.4
0.6
0.4
0.3
0.2
0.7
0.0
0.0
0.2
0.3
0.9
2.7
0.7
0.0
2.4
0.4
0.5
0.5
0.2
0.4
1.4
0.2
0.7
0.4
0.4
0.4
5 to 14
Rate
M
F
20.5
16.8
5.1
11.4
3.9
20.4
7.5
5.2
51.3
14.1
9.6
9.9
32.0
9.6
17.7
7.3
15.4
9.9
14.9
6.7
17.1
6.2
7.8
11.5
4.3
2.9
1.4
2.9
0.0
4.0
2.5
2.3
29.9
19.6
4.6
4.4
23.7
2.6
7.2
3.0
3.1
4.2
7.9
3.4
5.2
3.7
2.8
9.4
15 to 24
Rate
M
F
23.2
21.7
7.0
11.4
9.7
25.0
10.1
6.2
64.5
18.3
13.4
14.1
30.7
15.4
21.6
10.9
16.3
9.7
12.7
10.0
14.5
9.8
12.3
22.3
6.5
5.5
1.1
1.7
0.0
3.3
2.1
1.2
11.5
7.6
2.5
2.6
9.9
1.8
3.6
1.4
2.2
2.0
3.3
3.8
3.3
3.7
3.0
9.0
25 to 44
Rate
M
F
24.5
22.3
5.4
8.6
0.0
16.2
6.1
5.4
38.5
20.4
10.9
14.8
24.1
19.3
23.9
9.3
17.0
11.0
14.2
18.1
19.7
11.8
13.2
27.9
8.4
6.5
0.8
1.4
0.0
0.0
1.0
1.1
3.7
4.2
2.6
4.8
5.8
2.0
2.2
1.9
2.3
1.4
2.3
6.8
5.8
3.9
3.1
11.4
45 a 64
Rate
M
F
43.5
30.9
7.7
12.8
0.0
19.9
6.9
6.5
38.6
21.3
18.2
17.0
18.9
15.9
29.3
10.0
21.8
10.6
20.6
43.6
35.2
14.7
13.4
67.4
7.7
4.0
0.5
1.0
0.0
0.0
1.7
1.0
1.9
2.1
1.7
3.0
1.7
0.0
0.0
2.2
4.2
0.8
1.3
8.9
5.4
3.4
2.5
18.8
64 a +
Rate
M
F
Table 1. Sex and age specific suicide rates by 100,000 inhabitants/year in selected countries in the Americas.
The leading reported causes of deaths among adolescent in 1998 in
Nicaragua were deaths associated with natural disasters, pesticide
poisoning, and accidents. Young people between 15-19 years of age
comprised 30% of cases of acute pesticide poisoning (PAHO,
2006a). It is not fully clear to which extent this refers to accidental
poisoning or suicide.
Nicaragua has signed several international conventions, such as
International convention on elimination of all form of discrimination against women (1979), and Convention on the rights of the
child (1989). It seems obvious that signing conventions is not the
same as implementing them.
Women received right to vote in 1955 and in 1990 the first woman
was elected president. However, only 14.3% of officials at government or ministerial level are women.
Nicaragua has no laws regarding mental health and human rights
(United Nations Development Programme, 2005). Furthermore,
the country still lacks a national policy in mental health. Actually,
64% of the countries in the world do not have any mental health
legislation or have legislation that is more that 10 year old (World
Health Organization, 2005a).
As further described in Paper II, the Nicaraguan society has been
characterized by rapid social changes during the last thirty years.
First, after the revolution in 1979, the Sandinistas implemented
many changes such as the agricultural land reform, improved health
access, improved education through national education campaigns,
and strengthened community participation. While people were still
adapting to these social changes, new political events took place in
1990 when the National Coalition was elected to power and reversing changes, particularly those related to popular participation.
Society was once more very rapidly transformed, affecting the social
structure and consequently the adolescents’ situation. Moreover, in
1996 the Liberal Party came to power introducing social changes
that further deepened the social crisis; the already poor conditions
of most Nicaraguan families became worse, people seemed to lose
confidence in political parties, and this disillusionment has been reinforced by an environment of distrust further nurtured by government corruption.
-9-
Environment and lifestyles among young
people in Nicaragua
Environmental factors and lifestyle cannot be viewed as independent phenomena. It has also been argued that “environmental
factors cannot be separated from personality-related characteristics,
and some individuals are more sensitive to environmental factors
than others, where social network, migration, dietary factors may
have protecting or reinforcing influences on stress behaviours”
(Heeringen, 2001).
In Nicaragua there are a number of environmental factors that
interact with life-style factors and are likely to increase the risk for
suicidal behaviours such as poverty, gender inequity and economic
inequalities. Other environmental factors affecting young peoples´
life conditions are lack of food, unemployment, low education and
poor availability of health services (Peña, 1999). For young girls,
who are in focus for the present thesis, several of these factors contribute to unintended pregnancies in very young age, which represents a further burden for both boys and girls (Zelaya et al.,
1997).
Among life style factors, alcohol consumption is a major health
threatening factor. This continues to be a low priority in the health
agendas in Nicaragua and most countries in the region of the
Americas. According to a survey from five cities in Nicaragua,
young people have alcohol drinking patterns that should call for
concern as shown in Table 2 (PAHO, 2006b).
Table 2. Alcohol consumption among young people between 18-24 years in León,
Nicaragua, 2006.
Alcohol habits
Alcohol consumption last
12 months
Drinking alcohol at some
occasions
Drinking more than once
per week
Drinking more than once
per month
Starting to drink before 18
years of age
Problem with alcohol
No
9
Males
%
39.1
Females
No
%
8
14.5
No
17
%
21.8
21
91.3
30
54.5
51
65.4
1
4.3
1
1.8
2
2.5
8
34.7
7
12.7
15
19.2
10
43.4
12
21.8
22
28.0
2
8.6
-
-
2
2.5
Source: PAHO/WHO, Nicaragua, 2006
- 10 -
Total
In addition, Nicaragua is frequently struck by natural disasters such
as volcano eruptions and flood waves which also worsen life conditions. In a previous study, we have reported on severe psychological consequences from the Hurricane Mitch in the rural parts of
the León region (Caldera et al., 2001).
Rapid structural changes in the society have contributed to changing life styles among young people. León has grown from 90,000
inhabitants in 1980 to 170,000 in 1997 accelerated by the immigrations from the rural areas to urban areas with new neighbourhoods being created as informal settlements (asentamientos)
with poor social conditions (Pérez and Barten, 1999).
In recent years, young people have started to demonstrate for their
right to be recognised as full members of the society. This might be
illustrated by the convention in June, 2006, in León, as shown
below, where young people demonstrate for their right to be
listened to; “we are part of the present and not only the future”.
Youth convention in León 2006.
Health services in Nicaragua
Nicaragua has 164 physicians per 100,000 people but health services are mainly concentrated in a few urban areas such as Managua, León and Granada. The Mental health program is very limited,
receiving 1% of the total health budget in the country as compared
to 5-10% in most European countries (World Health Organization,
2005a).
- 11 -
Mental health services in Nicaragua have a structure typical for
developing countries with an old psychiatric hospital in the capital
city of Managua where the majority of the psychiatrists in the
country are working. Efforts have been made to modernise psychiatric services and a ministerial resolution stated already in 1991 that
psychiatric patients have a right to receive treatment in the general
hospitals but still only very limited mental health services are
available in the general hospitals
During the last two decades, community based outpatient services
in mental health (CAPS - Centro de Atención Psicosocial) have
been established in five places (León, Chinandega, Managua,
Granada and Bluefields) but overall it is estimated that mental
health services is available for less than 25% of the population.
Basic mental health care is intended to be provided by primary
health care physicians but regular training of PHC professionals in
the field of mental health is basically absent (World Health
Organization, 2005a).
Table 3. Psychiatric beds and professionals assigned to the national mental
health program in Nicaragua.
Items
Per 10,000
population
Items
Per 100,000
population
Total psychiatric beds
0.34
Number of psychiatrists
0.64
Psychiatric beds in mental
hospital
0.32
Number of psychiatric
nurses
0.045
Psychiatric beds in general
hospital
Not known
Number of neurologists
0.4
Psychiatric beds in other
setting
0.02
Number of psychologists
1.45
Number of social workers
0.71
Source: MINSA, 2005 and WHO, Mental health atlas, 2005
Aims
This is one of the first studies to be performed on suicidal behaviour among young people in a developing country. The literature on attitudes towards suicide is overall scarce and there has been
no community based study outside the developed world on how
young people view suicidal behaviour and on factors associated with
different patterns of attitudes.
- 12 -
The overall aims of the present thesis were to increase knowledge
about suicidal behaviour among young people from different perspectives within a psychosocial frame of reference. The more specific aims were:
•
•
•
•
to assess the rate of hospital admitted suicide
attempts, identify groups at risk and to examine
methods used and time and place for the attempt
to explore pathways to suicidal behaviour among
young women
to examine suicidal expressions among young
people in the community and factors associated
with such expressions
to examine attitudes towards suicidal behaviour
among young people and their relation to sociodemographic factors, own suicidal behaviour and
exposure to suicidal behaviour among significant
others.
Method
Overall framework and design
The research work started in 1999 when a hospital surveillance
system was set up to monitor all cases admitted after a suicide
attempt. All cases admitted during a three-year period were interviewed according to a structured questionnaire. In a second step, indepth interviews were performed with girls, identified by the
surveillance system, to explore their pathways to suicide attempts.
In a third step, a community based approach was chosen, where
interviews were performed according to an attitude questionnaire
with a random sample of adolescents identified from a study base
managed by the Centre for Demographic and Health Research
(CIDS).
The thesis presents a combination of quantitative and qualitative
methods. Quantitative methods were used to assess hospital admitted suicide attempt rates, prevalence of various suicidal expressions,
identify factors associated with such behaviours and to study attitudes among adolescents in the community. A qualitative approach
was added to explore and gain understanding of pathways to suicide
attempts among young girls. In this combined approach three
different sources of information was used as shown in Figure 2.
- 13 -
Database
information
Suicidal behaviour
among young people
Self-reports
In-depth interviews
Figure 2. Methodological approaches: quantitative and qualitative.
Study setting
The municipality of León is located at 90 kilometres from the
capital city of Managua and covers an area of 820 square kilometres. León city is traditionally considered the intellectual and
educational heart of Nicaragua. It is the second largest city in the
country with an estimated population of 195,000 inhabitants
(Peña, 1999). The University of León dominates the city which has
a very young population. In León the health services are relatively
well developed as compared to Nicaragua as a whole, with a general
hospital, PHC-centres in all city districts and a community mental
health team (Centro Atención Psicosocial – CAPS). For the last 26
years, León has had a Sandinista Local Government with a community structure characterised by active popular engagement in
social services.
Fieldworkers discussing problems in data collection with their supervisor.
- 14 -
Method - Paper I
This hospital surveillance study covers the city of León. It includes
all cases referred to the emergency unit of HEODRA hospital. This
is the only general hospital in the area and all cases in need of
medical treatment after a suicide attempt are likely to be admitted
to HEODRA hospital.
All hospital admitted cases of parasuicide living in the study area
were interviewed, following the standardized monitoring procedure
developed within a WHO/EURO multi-centre study (Platt et al.,
1992). During the three-year period a total of 326 persons were admitted to the HEODRA hospital due to a parasuicide act. After exclusion of 17 cases, who eventually died after admission and 76
cases living outside the study area, 233 parasuicide cases were included in the study. Most of the participants 75% (175) were in the
age span 11-24 years old, out of whom 44 individuals were males
(25.1%) and 131 females (74.9%).
Instrument
All cases included were interviewed according to the protocol
applied within the WHO/EURO multi-centre study (Platt et al.,
1992). The questionnaire covers basic demographic information
and information on methods used as well as place and time of the
day when the attempt took place. The questionnaire also included
questions from the Suicide Intent Scale SIS (Beck et al., 1974).
Findings regarding SIS are not reported in the thesis but published
elsewhere (Caldera et al., 2006).
Method - Paper II
Individual in-depth interviews were carried out with eight adolescent girls who had been admitted to hospital between May and
August 2001 after a suicide attempt. The girls were selected from
hospital records of the regional hospital in León based on the
ongoing hospital surveillance (Paper I). Each week, the first girl
admitted to the hospital as a result of a suicide attempt was invited
to participate. On the ward, the researcher contacted them in order
to have an initial contact in close connection to the event, and an
appointment for an interview after hospital discharge was agreed
upon.
- 15 -
Family
Preventive
advices
Childhood
Adolescence
Migration
Life project:
Violence:
plans and dreams
psychological,
physical and sexual
Previous
suicidal
behaviour
Friends
and partners
Community
Alcohol / drugs
Figure 3. Interview guide for the in-depth interviews
The interviews took place at the Department of Public Health at
León University. The semi-structured in-depth interviews lasted
from two to four hours. All interviews were performed by Andrés
Herrera, first author of the paper. The audio-taped interviews were
transcribed and translated to English. The interview guide contained different aspects as shown in Figure 3.
The method used was guided by Grounded theory, i.e. a methodology aimed at illuminating the processes from the perspective of
the interviewee. Grounded theory is a general methodology and a
way of thinking about and conceptualizing data, designed to guide
researchers in producing theories, hypotheses or models (Denzin
and Lincoln, 1994). It provides means for describing the psychological and social processes that have been developed to assist people
in their attempts to make sense of their world (Morse, 1992).
Grounded theory is a methodology that follows data rather than
precedes them. Glaser and Strauss (1967), the creators of grounded
theory, state that a grounded theory is one that will "fit" the
situation being researched, and "work" when put into use. By "fit"
it is meant that the categories must be readily (not forcibly)
applicable to and indicated by the data under study; by "work" it is
meant that they must be meaningfully relevant to and be able to
explain the behaviour under study (Lincoln and Guba, 1985). In
addition, one of the most pronounced ambitions of the Grounded
Theory approach is to discover something new, to generate theory.
The ultimate aim, therefore, is to develop tools to understand new
types of problems and to cope with new situation (Dahlgren et al.,
2004).
- 16 -
Researchers’
pre-understanding
Practical framework
Theoretical framework
Negotiated outcome
Trustworthiness
Path of discovery
Grounded theory
Figure 4. Path of discovery process
Qualitative data analysis is a process where researchers need to
“negotiate on the results”. In this process the first author reads the
entire interviews and then he suggests coding, categories, properties
and dimensions to be discussed with the other researchers in the
team. The process is further illustrated in Figure 4 above.
Method - Papers III and IV
Papers III and IV are based on a community survey among adolescents in León using a questionnaire (ATTS) collecting information
on attitudes towards suicidal behaviour, own suicidal behaviour and
exposure to suicidal behaviour among significant others. The sample was derived from the study base of 9,245 households with
64,728 inhabitants included in surveys conducted in the León area
during 1993 and updated in 2003. Out of those 64,728 individuals, 11,308 were in the age group 15-24 year old and from
those a random sample of 352 subjects was selected. Geographic Information System (GIS) and map was used as tool to locate each
individual in the sample to be interviewed. The map in Figure 5
shows the whole municipality of León and the specific area selected
for the study base.
Eight field-workers and one supervisor were trained for the data
collection. After exclusion of individuals who refused to participate
and those who could not be reached at several home visits, the final
sample consisted of 278 adolescents, 145 males (52.2%) and 133
females (47.8%), giving an overall response rate of 79%.
Instrument
The ATTS questionnaire was developed to measure attitudes towards suicide and to collect information on suicidal expressions
among respondents and significant others. The instrument consists
of three main sections: first, contact with suicidal expressions (ideations, plans, attempted and completed suicide) among significant
others; second, attitudes covering different attitude areas (39 items);
and third, own life satisfaction and suicidal behaviour (Renberg and
Jacobsson, 2003). The attitude items present a view on suicide, for
example, “People have a right to commit suicide” and the respondents were asked to give a response on a five point scale ranging
from 1= Strongly disagree to 5=Strongly agree. The last section on
own suicidal behaviour (expressions) includes questions originally
presented by Paykel and colleagues (Paykel et al., 1974).
1. Have you ever felt that life was not worth living?
2. Have you ever wished you were dead, for instance
that you could go to sleep and not wake up?
3. Have you ever thought of taking your life, even if
you would not really do it?
4. Have you ever reached the point where you seriously considered taking your life, or perhaps made
plans how you would go about doing it?
5. Have you ever made an attempt to take your own
life?
A choice of four responses was given for the first four questions:
often, sometimes, hardly ever, and never. Subjects were asked to
report the occurrence during the past year and earlier in their life.
For the last question on suicide attempts, the response options were
simply “Yes” or “No”. For this study only data relating to the past
year were used. Basic socio-demographic information was collected,
for example age, gender and length of education (number of years
in school: <10, 10-13, >13).
The instrument was translated from English to Spanish and further
revised after discussions with several organizations and professionals
to clarify problematic questions. A pilot study was conducted to
assess the applicability of the instrument among young people in a
Nicaraguan setting (Nielsen, 2002).
- 18 -
Figure 5. Map of León.
- 19 -
Based on this pilot study, we decided to use the questionnaire as an
interview instrument where all adolescents were asked to respond to
the questions in a face-to-face interview. The reason for this
approach was illiteracy problem in this setting and that people in
general are not familiar with self-report questionnaire.
Also, based on experiences from previous studies in this setting, we
decided to match interviewees and interviewers for gender (Olsson
et al., 2000; Zelaya et al., 1996). The interviewers were psychology
and medical students from the last year of the university. They were
trained for one week on how to perform the interviews, and the
interviews were carefully monitored on a daily basis for quality
assurance.
An overview of design, sample and aims of all studies in the thesis is
presented in Table 4.
Youth convention in León 2006.
- 20 -
- 21 -
G., Peña R., & Salander Renberg, E.
(2006). Attitudes towards suicide among
young people in Nicaragua: A community
based study. Submitted manuscript.
IV - Herrera, A., Caldera, T., Kullgren,
G., & Salander Renberg, E. (2006).
Suicidal expressions among young people
in Nicaragua- A community based study.
Soc. Psychiatry Psychiatr Epidemiol, 41(9),
692-697.
III - Herrera, A., Caldera, T., Kullgren,
Community
survey
Community
survey
2003
Qualitative
2001
II - Herrera, A., Dahlblom, K., Dahlgren,
2003
Hospital
surveillance
study
19992002
I - Caldera, T., Herrera, A., Renberg, E.
S., & Kullgren, G. (2004). Parasuicide in a
low-income country: results from threeyear hospital surveillance in Nicaragua.
Scand J Public Health, 32(5), 349-355.
L., & Kullgren, G. (2006). Pathways to
suicidal behaviour among adolescent girls
in Nicaragua. Soc Sci Med, 62(4), 805-814.
Design
Study
year
Papers
to assess the rate of parasuicides in Nicaragua, to identify
groups a risk, and describe the characteristics of
parasuicides.
to explore the motives and processes related to suicidal
behaviour among girls.
233
♂=72
♀=161
8
to examine the prevalence of different types of selfreported suicidal expressions and factors associated with
such expressions.
to examine attitudes towards suicide in the young
population in Nicaragua and their relation to gender and
exposure to suicidal behaviour among significant others.
278
♂=145
♀=133
278
♂=145
♀=133
♀=8
Aims
Sample
Table 4. Study year, design, sample, aims and instrument used for the different studies.
Same as III
Self-report
through lay-men
interviewers
In-depth
interviews
Expert interviews
Methods used
Ethical considerations
The studies have obtained an ethical approval from the Research
ethical committee at the Faculty of Medicine, the University of
León. Participation was voluntary, their information was kept confidential and those in need were offered consultation. Ethical considerations as related to the different papers are shown in Table 5.
Table 5. Ethical considerations in the three studies.
Study
Ethical considerations
Hospital
surveillance
study
Inclusion in the study was based on informed consent. All patients under 15 years old were interviewed after informed consent by relatives or tutor. Twenty-eight patients refused to be
interviewed but accepted inclusion of data from clinical records. The study was approved by the ethical committee at the
Faculty of Medicine of León University. Those in need were
offered consultation.
Qualitative
study
The research was approved by the ethical committee of the
Faculty of Medicine of León University. All of the subjects were
first visited by the first author (Andrés Herrera) while still in
hospital, where they were invited to participate in the study
and informed about its purpose as well as the confidentiality of
the process. In addition, informed consent was obtained from
their adult caretakers for the girls below 15 years of age. According to hospital routines all suicide attempters are referred
to the psychiatric outpatient unit for counselling. In addition,
several of the girls felt that the research interviews per se were
beneficial and supportive for them.
Community
survey
This study was approved by the Faculty of Medicine of León
University. The aims and purpose of the study were thoroughly
explained to all participants. Participation was voluntary and
they were informed about the confidentiality of the process. A
leaflet was given to all participants with information on where
to get support or help for suicidal problems. Interviewees who
were judged to be in need of support or treatment were
offered a treatment contact at primary health care centres or
the psychiatric outpatient unit in León-CAPS.
- 22 -
Main results
Paper I: Hospital surveillance study
During the three year surveillance, 233 cases admitted for a parasuicide act were identified, 68.8% females and 31.2% males. Based
on a recent census, the overall parasuicide rate was estimated to
66.3/100 000 inhabitants per year based on the population of
people ten years of age and older. The highest parasuicide rate
(302.9/100 000 inhabitants and year) was for females in the age
group 15-19 years. In the age groups 10-14 and 15-24 years, male
to female ratios were 1:9.5 and 1:2.7, respectively.
The dominating methods used were drug intoxication followed by
ingestion of pesticide. Almost eighty per cent had had previous
contact with health care, most of them within six months preceding
the attempt. Among females younger than 25 years, 46% had had
contact with health care six months before the attempt. Frequency
of parasuicide acts showed two seasonal peaks, May-June and September-October. Most acts occurred between 11:00 to 13:00 hours
and 19:00 to 21:00 hours, respectively.
Paper II: In-depth interviews with girls
This paper is based on eight individual in-depth interviews conducted with girls aged between 12 and 19 and admitted to hospital
after attempting suicide. Based on this data, a tentative model exploring pathways to suicidal behaviour emerged.
The model aims at illustrating the dialectic interplay between structure and action taken. Our ambition was to present an alternative
framework for understanding suicidal behaviour in the local context
of León. Our finding showed that adolescent girls in León attempted suicide because they could not stand their pain, because
their life situation did not fit their concept of themselves or their
personal ideas and dreams. Their immediate goal seems to in one
way or another escape from a state of traumatic stress, often associated with humiliating experiences. The model consists of four main
categories as is illustrated in Figure 6: structuring conditions, triggering events, emotions and action taken.
- 23 -
'
Figure 6. Model of pathways to suicidal behaviour.
Paper III: Suicidal expressions
In this study close to half of the respondents (46.0%) reported at
least one kind of suicidal expression during recent year, 44.8% of
males and 47.4% of females. More males than females in the 20-24
years age group reported suicidal ideation; however the difference
was not significant.
- 24 -
A suicide attempt in the past year was reported by 2.1% of males
and 1.5% of females. There was no significant gender difference in
reporting of the separate types of suicidal expressions, except for
death wishes, which were significantly more common among females (33.8%) than among males (20.7%). There was a significant
association between being exposed to suicidal behaviour among
significant others and serious suicidal expressions among the
respondents themselves (OR=2.97; 95% CI=1.47-5.30). When
conducting gender-specific analysis, this association was only
significant among females (OR=4.62; 95% CI=1.74-12.31).
Paper IV: Attitudes towards suicide
This study is based in the same population as in paper III. A factor
analysis including all attitude items yielded a 9 factor model explaining for 59.3% of the total variance. Summary scores on the
different factors were compared among males and females. The only
significant findings were that more females than males agreed on
preventability and preparedness to prevent (factor 2) and females
were more likely to consider suicide an incomprehensible problem
(factor 5).
Factors were further examined as related to socio-economic conditions and experience of suicidal behaviours among significant
others and own suicidal expressions. Those in poverty were less
likely to agree that suicide is a human right (factor 1) and less likely
to regard suicide as common and a cry for help (factor 9). Responders who had friends with suicidal behaviour were more inclined to regard suicide as a normal and common behaviour (factor
3). Those who had a family member with suicidal behaviour were
less likely to consider suicide as normal (factor 3). Those with own
serious expressions (suicidal ideation, plans and attempts) were
more likely to consider suicide a human right (factor 1) and a
normal response (factor 3) than those without such behaviours.
Finally, the reported main reasons to commit suicide and ways to
prevent suicide were post-coded and listed. More males reported
that suicide is caused by economic problems whereas females were
inclined to report that suicide is caused by family dysfunctions and
partner problems. Both genders agreed that better access to treatment might be important to prevent suicide.
- 25 -
Discussion
This is the first study on suicidal behaviour among young people in
Nicaragua using standardized methods enabling international comparisons and also one of very few studies on suicidal behaviour in a
developing country. The combined approach used in this setting
with a hospital based surveillance of suicide attempts, in-depth
interviews with girls who had attempted suicide and a community
based study on suicidal expressions and attitudes among young
people, represents a unique approach to study suicidal behaviours
among young people in a developing country.
The extent of the problem
The hospital surveillance (Paper I) shows that parasuicide represents
a significant health problem in Nicaragua. In an international context, parasuicide rates among young females are higher in Nicaragua
as compared to rates from some studies, for instance one Canadian
study (Alaghehbandan et al., 2005) but quite similar to rates reported from some European countries (Schmidtke et al., 1996).
Regarding other suicidal expressions (Paper III), almost half of the
respondents reported some kind of suicidal expression during recent
year including milder expressions, i.e. life-weariness (34%) and
death-wishes (27%) as well as serious expressions, i.e. suicide ideation (20%), plans (5%) and attempts (2%). There are few general
population based studies on milder expressions but a Latvian study,
using basically the same instrument, found similar rates (Rancans et
al., 2003). For serious expressions, there are only few general population studies but several European school based studies report
figures on suicide attempts ranging from 1 to 5% (Tomori et al.,
2001), (Buddeberg et al., 1996; Ivarsson and Gillberg, 1997) and a
US study reported even higher figures (Grunbaum et al., 2002).
Consequently, suicide attempt rates among young people in Nicaragua are in general quite similar to rates reported from Europe and
prevalence of other serious expressions also similar to or in the
lower range of what has been reported in studies from the developed world. These results might seem surprising considering the huge
differences in terms of culture and socio-economic conditions
between Nicaragua and developed countries. An alternative explanation might be an underreporting of suicidal behaviours due to
the condemning attitudes towards suicides.
- 26 -
Regarding gender differences, rates for hospital admitted suicide
attempts in our study had a similar gender pattern as reported from
international studies with highest figures for young girls (Alaghehbandan et al., 2005; Wunderlich et al., 2001; Renberg, 2001). For
self reported suicide attempts in our study (where numbers were
small) there were no gender differences but suicide plans were twice
as common among girls.
The pattern that seems to emerge is that attempts among girls are
more likely to attract attention and end up in hospital, whereas
suicide attempt among boys might be more impulsive and carry
greater risk to end up as a completed suicide. This is in accordance
with, for example, a study showing that young men are more likely
to attempt in places where they are less likely to be discovered
(Hummel et al., 2000).
Attitudes towards suicide and suicidal behaviour
Several previous studies have reported that young people have
overall permissive and allowing attitudes to suicide (Beautrais et al.,
2004; Renberg and Jacobsson, 2003). This has not been confirmed
in our study (Paper IV) where both boys and girls were likely to
disagree to statements presenting permissive attitudes. There were
some small, but still interesting, gender differences. Boys were more
likely to consider suicide to be understandable and less likely to
think that suicide can be prevented. We have no clear explanation
to this set of attitudes among boys, but it might represent a risk
factor for the higher rate of completed suicides among boys. Studies
in other countries have shown an opposite gender pattern regarding
pro-preventive attitudes (Renberg and Jacobsson, 2003).
The pattern among girls, more point in the direction that suicide is
something that you should not do and that it is possible to prevent.
This might relate to the fact that hospital admitted attempts were
most common among young girl and often seemed to be more a
desperate cry for help rather than a wish to die (Paper I and II).
Attitudes towards suicide were further analysed as related to poverty, own suicidal behaviour and exposure to suicidal behaviours
among relatives and friends (Paper IV). Those living in poverty had
a less allowing and less understanding view on suicide. One possible
explanation is that struggling for basic everyday needs for yourself
and your family, leaves little room for thinking about suicide as an
option. Even though we failed to show any association between
poverty and permissive attitudes towards suicide, economic prob-
- 27 -
lems were frequently reported as reasons to commit suicide (Paper
IV).
Permissive attitudes towards suicide were associated with higher
levels of own suicidal expressions among the respondents, similar to
reports from other studies (Wong et al., 2005; De Leo et al., 2005).
A study among Israeli adolescents reported that approving attitudes
towards suicide were associated with a high level of suicidal ideation
(Stein et al., 1998). Due to the cross-sectional design of this study,
the temporal and causal direction of this association must remain an
open question. It might be that permissive attitudes lower the threshold for suicidal behaviour, i.e. constitute a risk factor for future
suicidal behaviour but it might well be that permissive attitudes
serve to relieve the individual who has made an attempt from feelings of guilt. Overall, from a preventive perspective it seems reasonable to consider permissive attitudes as a risk factor for suicidal acts
based on our findings.
Another factor associated with a permissive pattern of attitudes towards suicide, was being exposed to suicidal behaviour among significant others. In this case, the causal direction seems more evident.
Australian and Chinese studies have reported similar findings
(Wong et al., 2005; De Leo et al., 2005). Permissive attitudes might
act as mediator between exposure and suicidal behaviour.
Other factors related to suicidal behaviour
A number of potential risk factors or risk conditions have been
identified in the present study. In the hospital surveillance (Paper I)
the main method used for the attempts were over-the-counter
drugs, such as analgesic and sedative drugs. The easy availability of
such drugs should be considered for prevention.
The second most frequently used method was intoxication with
pesticides. Highly toxic pesticides are easy available in the streets or
at the market in Nicaragua as in many other developing countries.
From China it has been reported that pesticides are frequently used
for suicide, in particular among young women in rural areas
(Phillips et al., 2002). Easy access to pesticides in developing countries combined with ignorance about their lethal effects might turn
less serious suicidal gestures into completed suicides (Conner et al.,
2005). Reduced availability of pesticides and campaigns to inform
about the high lethality should be part of prevention. Local studies
might be useful to convince decision makers to participate in
preventive efforts. For example, the findings from our hospital sur-
- 28 -
veillance facilitated an agreement with the market place to make
pesticides less easily accessible for young people.
A more speculative risk factor suggested in our Paper I, is stress
related to end of school semester. The study showed consistent
peaks in suicide attempt cases in May-June and September- October, which coincides with end of school semester. In Nicaragua each
semester ends with a period when all exams take place. An association between exam periods and suicidal behaviour was further supported by the qualitative interviews, where some of the girls reported school failures as a triggering event for their suicide attempt
(Paper II). Teachers and schools should be invited to discuss ways
to offer better support to students during the exam periods.
Exposure to suicidal behaviour among others was associated with
increased risk for own suicidal behaviour, at least among girls
(Paper III). This has also been reported by other researchers (Kirmayer et al., 1996; De Leo et al., 2005; Wong et al., 2005). This
contagious nature of suicidal behaviour shown in the study should
be considered when planning for prevention among young people.
Another factor, that might be of importance from a preventive perspective, is potential failures in primary health care to identify and
manage young people at risk for suicidal behaviour. León has fairly
well developed primary health care services and young people with,
for example, diffuse somatic complaints possibly indicating mental
health or suicidal problems are likely to consult primary health care.
In the hospital surveillance, almost half of the suicide attempters
had a fairly recent contact with health care services (Paper I). Based
on findings from the in-depth interviews (Paper II) and from a
previous pilot study with focus group discussions with young
people (Kirkbakk and Åsén, 2005), it is evident that young people
distrust primary health care. Lack of confidentiality and time enough for a useful consultation were common complaints. In a previous study in León, we have also shown that primary health care
doctors do not perform well in identifying mental health problems
among their patients (Penayo et al., 1990). The findings call for
engaging primary health care to find better ways to identify and
manage young people at risk for suicidal behaviour.
In the in-depth interviews of girls who had attempted suicide, we
explored pathways to suicidal behaviour to get an understanding of
the process. A model was built based on structuring conditions,
triggering events and subsequent emotions leading to either problem solving or escape, which might include a suicide attempt. The
- 29 -
main components in the pathway leading to suicidal behaviour were
factors linked to dysfunctional interactions in the family and also
lack of relations characterised by trust and confidentiality. Absent
fathers, which is a common phenomenon in Nicaragua, emerged as
one important problem. It is noteworthy, that one study has shown
that females that live fewer years with their fathers attempt suicide
more often (Zayas et al., 2000). Living in chaotic family situations
with single mothers, step siblings and grand-parents were problematic structuring conditions. Several girls commented that there
were “so many people around but no one to talk with.” Conflicts
emerging from distrust and lack of confidentiality in this environment triggered emotions of shame and anger, where a suicide attempt emerged as the only solution from the girls’ perspective
(Paper II). Dysfunctional families as risk factor for suicidal behaviour were also reported by the young people in the community
based study (Paper IV). Previous studies in other countries have
reported similar findings (Moscicki, 1994; Wunderlich et al.,
2001).
Strengths and limitations of the present study
The main strength of the present study is the combined approach
covering hospital admitted suicide attempts, in-depth interviews
with some cases and a community based approach. The studies have
explored not only the occurrence of suicidal behaviour but also tried
to build a comprehensive model of pathways to such behaviours
and attitudes related to suicidal behaviour.
Very high coverage in the hospital surveillance study (Paper I) and a
clearly representative sample with high response rate in the community based studies (Paper III and IV) are additional strengths.
Due to low base rate of serious suicidal expressions and hence low
number, some of the analyses lack power to detect significant associations. Given the resources available for this study, this limitation was difficult to avoid.
Obviously, the studies do not cover all background factors of
relevance for suicidal behaviour. A choice was made to approach
this problem from a psychosocial perspective and, for example,
psychiatric aspects, such as depressive or anxiety disorders are not
included, despite the fact that their importance has been clearly
demonstrated in the literature (Wunderlich et al., 1998).
One factor that should have been included is drug and alcohol use,
which has been too much neglected in our studies. Drug and alco-
- 30 -
hol use is a major public health problem in Nicaragua (PAHO,
2006b) and their association with suicidal behaviour warrants
further research.
In addition, it must be emphasised that León city, though typical
for a university city in countries like Nicaragua, is not representative
for Nicaragua as a whole; poverty and unemployment is less severe
and infrastructure more developed than in the rural parts of the
country.
Some implications for prevention
The studies in the present thesis did not aim at developing and
evaluating interventions to prevent young people from suicidal behaviour – this is on the agenda for future studies. However, the
studies have reported on a number of findings that should be targeted in prevention of suicidal behaviour among young people in a
developing country like Nicaragua:
• Young girls 15-19 years represent a high risk group for
suicide attempts that need hospital admission
• Self-reported suicidal expressions are common among
both boys and girls
• Stressful exam period and school failures were associated
with suicidal behaviour
• Painkillers and other over-the-counter drugs were the
most commonly used method for suicide attempt
• Pesticides are lethal, easily available and frequently used
as method for suicide attempt
• Among girls, exposure to suicidal behaviour among
others increases the risk for suicidal behaviour and was
furthermore associated with permissive attitudes towards suicide.
• More understanding views and less pro-preventive
attitudes towards suicide among boys might be an issue
to address in preventive programs.
• Dysfunctional families with absent fathers, chaotic structure and lack of confidential and trustworthy relationships are related to suicidal behaviour
• Lack of independent supportive structures and lack of
trust in health care settings are perceived as obstacles to
receive help when needed.
All these factors should be considered when planning for interventions on the community level and interventions targeting groups
at risk and those identified with suicidal behaviours. Community,
- 31 -
schools, health services and families must all be involved in the
prevention of prevention of suicide among young people (Figure 7).
School program
Working with
students, teachers,
parents associations
Community
Follow-up
Avoid discrimination
Avoid stigmatization
of suicidal behaviour
Social support
Listening
Understanding
Social support
Health workers
Identification and
treatment of those at risk
Psychological and
medical interventions
Family
Information
Family support
Figure 7. Arenas of importance for prevention of suicide among young people.
- 32 -
Acknowledgements
I would like to thank my main supervisor, Gunnar Kullgren for his
patience and guidance through the whole process of learning how to do
research. It has been a great privilege to have him as a supervisor. I have
always had him by my side from the formulation, data collection, analysis and writing of the manuscripts. His timely and kind way of teaching
me the different approaches for data analysis and interpretation of results
was very important in my development, as well as his enthusiasm to
come to Nicaragua and work with me in this tropical, warm but
beautiful country. I specially thank Gunnar for almost twenty years of
cooperation and for his commitment and great contribution to the
research in the area of mental health at the university in León and in
Nicaragua.
I would also like to thank my second supervisor Ellinor Salander
Renberg for her great support from the very beginning when I started
with the master degree in public health; for her patience when working
with me and for sharing with me the questionnaire on Attitudes Towards
Suicide (ATTS). The dream came through when we decided to translate
it into Spanish and apply this questionnaire to the Nicaraguan context. I
really appreciate the enlightening conversations and our discussions
concerning suicidal behaviour.
Special thanks are due to Lars Dahlgren for sharing with me his experience on qualitative methods. His support was essential in this long
process of learning qualitative methods.
My deepest thanks to my "Nica-supervisor" Rodolfo Peña, He has helped and guided me in performing the study and reviewing the research
proposal.
Particular thanks to my co-authors Dr. Jose Trinidad Caldera Aburto
and Kjerstin Dahlblom for this joint, fruitful and challenging collaboration in an area very much needed in this country. Especially to Kjerstin,
who went with me several times to the country side and shared with me
the peaceful environment of the tropical trees and the happiness of eating
good ripe mangoes under the tree in my backyard. Thanks also for her
skilful editing and layout of my thesis.
Thanks to all teachers at the Department of Epidemiology and Public
Health, Umeå University. Specially to Stig Wall for his generous support
and attention during all these years in Umeå.
I wish to express my heartfelt thanks to the administrators Doris Cedergren and Margaretha Lindh at the Department of Psychiatry, Umeå
University for all their generous support.
Thanks to Elmer Zelaya Blandón for giving valuable comments and
suggestions on this thesis at my "pre-defence" in León.
- 33 -
To our team and field work-mates in Nicaragua: Ingeniero Santos
Betancurt, Aleyda Fuentes Reyes, Lic. Julio Rocha, Dra. Maria L. Palma,
Evert Tellez, Claudia Obando, Rolando Ruiz, Socrates Hermogenes
Muñoz, Denia Dávila, who were enthusiastically collecting the information together with me during 2003. Thanks to the field workers,
they were always able to work any time, any day to make data collection
possible.
I also want to express my deepest gratitude to Dr Ernesto Medina
Sandino, MSc. Edmundo Torres and Dr. Rene Altamirano, Dr. Jorge
Aleman Pineda for their support.
Thanks to the rector Dr. Rigoberto Sampson Granera and the university
council for their support and interest in developing research in our
university.
Thanks to all my colleagues, members of the Department of Preventive
Medicine at León University, particularly to Dr. Nestor Castro G.
Thanks to all my colleagues at CIDS especially to Dra. Elliette Valladares
for her help and for sharing with me classrooms and theoretical
discussions in Umeå. Thanks to Doña Azucena Espinoza and all our staff
and young researchers at CIDS.
My gratitude to my parents María de Jesús Rodríguez and Teófilo
Antonio Herrera, and to my five sisters: Jesus Sabina, Maria Mercedes,
Maria Victoria, Gregoria Victoria and Esperanza Demetria.
I wish to express my profound appreciation and respect to all participants
in the study; without their collaboration these studies could not have
been possible. I am also grateful to the NGO Mary Barreda in León
(Doña Mercedes Toruño), CISAS (Lic. Victor Gutiérrez), CARAS (Dr.
Jairo García), Policía de León, and Alcaldía de León. Special thanks to all
the primary health workers at MINSA, especially Dr. Carlos Fletes, head
of the mental health program in Nicaragua and HEODRA hospital in
León.
This study was supported by a collaborative research grant from the
Swedish International Development Cooperation Agency/ Department
for Research Cooperation Sida/SAREC.
Last but not least, I would like to express my gratitude and appreciation
to the ones that supported me at all times in making this dream come
true. Special thanks to my beloved wife Aurora Aragon and my children
Reynaldo Francisco and Leana Mercedes.
- 34 -
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Appendix
Con todo el poder de la informacíon
SOS por suicidios en León
Impulsan programas de intervención para prevenirlos
* Dramáticas estadísticas: mayoría de personas con conducta suicida,
sobre todo jóvenes, envía mensajes previos a la acción
* Falta de comunicación entre la familia no permite identificar la
necesidad de ayuda
LEÓN -El cincuenta por ciento de trescientos jóvenes, entre 15 a 24
años, han tenido una conducta suicida, según un estudio realizado por
el Centro de Investigación en Demografía en Salud, CIDS de la UNANLeón.
Las dramáticas cifras orientaron a varios organismos de León a unir
esfuerzos y elaborar programas de intervención para prevenir los
suicidios
Suicidios, como epidemias
“Lo primero que estamos haciendo es intervenir en brotes, porque los
suicidios son como una epidemia que contagia a otras personas.
Cuando en un barrio registramos un suicidio, hablamos con la familia,
amigos o bien en los colegios, para evitar una acción en cadena, como
hemos descubierto en nuestros estudios”, indicó el doctor Andrés
Herrera, subdirector del CIDS.
Una de las primeras acciones de la comisión “Por la Vida” es la
capacitación a maestros en centros de estudios a profesionales de la
salud en la región en el tratamiento de personas que quieren quitarse
la vida. Además, están brindando atención psicológica y seguimiento a
pacientes que no consumaron el suicidio.
No obstante, Herrera advirtió que hay una necesidad urgente de
desarrollar programa de intervención a largo plazo que incluya
detención temprana, tratamiento oportuno y actividades de
recreación a los jóvenes, priorizando barrios identificados con mayor
riesgo
Pendiente de los cambios de conducta
Según el doctor Trinidad Caldera, coordinador de la Unidad de Salud
Mental del CIDS, la mayoría de personas con conducta suicidas, sobre
todo jóvenes, envía mensajes previos a la acción, sin embargo, la
falta de comunicación entre la familia no permite identificar la
necesidad de ayuda.
- 40 -
Con todo el poder de la informacíon
“Empiezan a bajar el rendimiento académico, se aíslan, llegan tarde a
la casa y hasta hacen mensajes escritos, pero no estamos atentos. Los
padres tenemos responsabilidad de oír a los hijos y acercarnos a ellos
para escuchar sus problemas”, sostuvo Caldera.
En el hospital de León cada año se atiende un promedio de 100 a 115
casos de pacientes con conductas suicidas, de los cuales mueren entre
15 a 20, es decir, cada mes hay al menos una persona que fallece en
el centro hospitalario por decisión propia
Arrepentimiento sin remedio
La mayoría de las personas una vez que ingirieron la sustancia letal se
arrepiente, no obstante, muy poco se puede hacer para revertir el
daño y muchos mueren conscientes y en pleno juicio, de acuerdo con
las investigaciones realizadas.
Los métodos han cambiado, en la actualidad se usan píldoras
derivadas de Diazepán, las cuales son más manejables desde el punto
de vista médico y hay mayores posibilidades de salvar la vida del
paciente.
La comisión “Por la Vida” ya finalizó un programa de intervención, el
cual fue presentado a la Organización Panamericana de la Salud, con
el fin de conseguir recursos para la ejecución.
Marianela Flores
El Nuevo Diario - Managua, Nicaragua - 8 de mayo de 2006
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•

Heaven can wait: studies on suicidal behaviour among young

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