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Analysis of Suicidal Patients Admitted to The Emergency Rooms and Their Intensive Care Requirements, A Double-Center Study in Turkey

Purpose In the present study, the clinical and socio-demographic data of the patients who admitted to the emergency department due to suicide attempt, the duration at the emergency department, and hospitalizations are examined. Requirement of intensive care and duration of hospitalization are investigated in the patients with suicide attempt. Methods Patients who were admitted to the emergency department of the hospitals after suicide attempts between 2015 and 2017 and earlier 2018 were included in the retrospective study. Reason for suicide, suicide modality, duration between the suicide attempt and arrival to the emergency department, suicide time, first treatment at the emergency department, hospitalization, mortality, and the levels at the intensive care unit (ICU) were retrospectively reviewed and analyzed. Results In the present study, 428 patients were included. Ratio of the female to male patients was 319/109. The mean age of the patients was 29.18±10.48. Most of the patients were single. The patients were mostly unemployed. Ninety-four (22.87%) patients were diagnosed with a psychiatric disorder. Four hundred twenty-two (98.59%) of the patients were attempted suicide with drugs/toxics. One hundred ninety-seven patients (49.75%) reported domestic violence and family issues reasons for suicide. Mean duration between the time of suicide and the time to arrive to the emergency department was 100.53±91.82 minutes. One hundred thirty (30.5%) patients were transferred to ICU, and 45 (10.5%) patients were followed in clinical departments. One hundred twenty (92.3%) patients hospitalized in the first-level ICU, 4 (3%) in the second-level ICU, and 6 (4.6%) in the third-level ICU. The mean ICU stay was 2.37±1.48 days. Conclusion The suicide attempts were prominent in acute poisoning cases. Majority of the patients stated domestic violence and family issues as a reason of suicide. They were discharged mostly from the emergency department and 10.5% of the patients were kept under surveillance in the departments. When the suicide attempts were evaluated in terms of their time, they were observed during day time at a higher rate.


Conclusion:
The suicide attempts were prominent in acute poisoning cases. Majority of the patients stated domestic violence and family issues as a reason of suicide. They were discharged mostly from the emergency department and 10.5% of the patients were kept under surveillance in the departments. When the suicide attempts were evaluated in terms of their time, they were observed during day time at a higher rate.

Introduction:
Suicide is a public health problem that concerns communities, provinces and all the countries. More than 800.000 people die each year due to suicide. Suicide is the second most important cause of death between 15-and 29-years old patients worldwide (1). Methods of suicide attempt vary according to the countries. The most frequent suicide methods are overdosage, hanging themselves, asphyxiation, jumping out, pesticide poisoning, and use of firearms (2). Pesticide intake is one of the most common methods of suicide attempt globally (1) Most frequently used two methods of suicide leading to death in Turkey are hanging oneself and the use of firearms (3).
The patient with suicide attempt can be discharged or hospitalized based on the examination. The need for medical attention and interventions after a suicide attempt varies from 22% to 88% (4). Treatment settings include the department, intensive care unit, and the outpatient treatments. Severe suicide attempts, refusal of treatment, or mental state changes with metabolic, toxic, infectious situations or any other etiology generally require hospitalization (5). In Nordic countries, the rate of the patients requiring intensive care only after overdose varies between 3% and 15.7% (6). There is a limited number of studies in which suicidal attempts and the follow-up of the treatment at the intensive care unit are considered and there are no large-scale studies including the interventions at the emergency department and the follow-ups at the intensive care unit in Turkey.
In the present study, the clinical and socio-demographic data of the patients with suicide attempt who admitted to the emergency department, duration of admission to the emergency department, and hospitalizations are examined. Requirement of intensive care and duration of hospitalization are investigated in the patients with suicide attempt.

Data collection
The present study was retrospectively conducted at Adana State Hospital and Sanko Patients who were admitted to emergency departments of the hospitals after suicide attempts between 2015 and 2017 and earlier 2018 were included in the study. The names, phone numbers and epicrisis of the patients were retrospectively screened from the archives of the hospitals.
Age, gender, relationship status, employment status, alcohol or substance abuse, history of psychiatric disorders, history of chronic illnesses, reason for suicide, suicide modality, previous suicide attempts, history of suicide in family members, duration between the suicide attempt and arrival to the emergency department, suicide time, initial treatment at the emergency department, hospitalization, mortality, and intensive care unit (ICU) levels were retrospectively reviewed and analyzed. If the answers for the said elements were not present in the hospital registries, the patients were called, and the missing questions were asked. Some of the patients did not want to talk or some of them could not be reached, and therefore, they were recorded as missing data. The ratios of the columns are compared with each other and expressed according to the Bonferroni corrected p value results. Quantitative variables were shown as mean ± SD (Standard Deviation) and median (Minimum/maximum) and categorical variables as n (%) in the tables. The variables were examined at confidence level of 95% and p value less than 0.05 was accepted as significant.

Results
In the present study, 428 patients were included. Ratio of the female to male patients was 319/109. The mean age of the patients was 29.18±10.48. Most of the patients were married (n=189) and single (n=205) and others were widow (n=20) or divorced (n=14). The patients were mostly unemployed. One hundred nine patients were housewives (n=109), 103 were working in a job, 58 were students and 3 were retired. Four hundred twenty-two of the patients were attempted suicide with drugs/toxic substances. Of these patients, 3 attempted suicide with cutting tools, 2 by jumping over (1=4 th floor, 1=2 nd floor), and 1 by blowing his/her brain out (died within 12 hours). The reasons for attempting suicide were analyzed, and 396 patients specified the reason, but 32 patients did not want to give information. In the said 396 patients, majority stated the reason as domestic violence and family issues (n=197) followed by chronic illnesses, (n=64) and others specified the reason as communication problems (n=46), sexual problems (n=28), economic problems (n=18), loneliness (n=12), alcohol/substance abuse (n=9), parental conflicts (n=8), exams (n=8), death/lost (n=6), juvenile problems (3), and school (n=2). Table 3 shows the suicide modality of the patients.    Table 7. Relationship between suicide reasons and gender, relationship status, occupying *p<0.001

Discussion
It is critical to understand the extent of suicide attempts in order to develop the protection and intervention programs. The present study contributes to the literature regarding the suicide modalities, duration between the suicide attempt and arrival to the emergency department, time of the suicide attempt, first treatment at the emergency department, hospitalization, and the intensive care unit (ICU) stages in order to monitor suicide-related treatment level.
Previous studies found that suicide attempts are higher in females and males are more likely to have completed suicide (7,8). Similarly, in the present study, the number of suicide attempts were higher in women than in men and 1 person who died due to a suicide attempt was male. Also, being single acts as a risk factor for a suicide attempt (9). Consistently, it was found that suicide attempts were higher in singles.
In the present study, the predominant method for suicide attempt was drug intoxication, and the second reason was slitting his/her wrists. Only 3 patients attempted suicide by slitting their wrists. This frequency is compatible with the previous studies regarding suicide attempt (8).
The results of the studies regarding the times of suicide attempt are not consistent. In the present study, the highest incidence rate for suicide attempt was the day time The patients who needed intensive care due to suicide attempts were also examined.
In a previous study, it was determined that 12.8% of the patients, who applied due to suicide attempt, were admitted to ICU (16). In the present study, 130 (30.5%) patients were transferred to ICU. According to the classification of the ICU levels, 120 patients with suicide attempts, who took drugs, were kept in ICU at first level, 4 patients at the second level (one needed CPAP ventilation, two needed hemodiafiltration, 1 had a Glasgow coma scale of 10). Mechanical ventilation was required for 6 patients, so they were accepted as the ICU level 3. Two of these patients jumped from a high place, 1 attempted suicide with a gun, and 3 had a respiratory failure due to the use of drugs. All the patients in the 1 st level were accepted to ICU due to the possible adverse events like arrythmia, loss of consciousness and respiratory, cardiac, renal or hepatic failures and they were monitored according to the said adverse events as mentioned in the previous studies (6).
In a study in Turkey, it was determined that the rate of deaths caused by the suicide attempts by using drugs is 6%. In another study, this rate was found to be 0.1% (17,18). According to the findings of World Health Organization, mortality rate after a suicide attempt is 11,4 per 100.000 (19). In the current study, it was found that 1 patient died by blowing his/her brains out in a suicide attempt. No patient died due to the suicide attempts by using drugs. The result supports the low mortality rate in the suicide attempts in Turkey.

Conclusion
The suicide attempts were prominent in acute poisoning. Majority of the patients stated domestic violence and family issues as a reason of suicide. They were discharged mostly from the emergency department and 10.5% of the patients were kept under surveillance in the departments. When the suicide attempts were evaluated in terms of their time, they were observed during day time at a higher rate.

Limitation
A major limitation of this study is the retrospective design. There are no detailed psychiatric examination findings in the emergency departments.