How To, Education & Training

5 pages

Lethality of suicidal organophosphorus poisoning in an Indian population: exploring preventability

Please download to get full document.

View again

of 5
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Background Suicide by organophosphorus poisoning is common in India. Study of factors associated with lethality may suggest methods for prevention. Methods Severity of symptoms, biochemical manifestation of poisoning, degree of lethality and the
  BioMed   Central Page 1 of 5 (page number not for citation purposes)  Annals of General Psychiatry  Open Access Primary research Lethality of suicidal organophosphorus poisoning in an Indian population: exploring preventability NilamadhabKar*  Address: Wolverhampton City Primary Care Trust, Corner House Resource Centre, 300 Dunstall Road, Wolverhampton, WV6 0NZ, UK Email: NilamadhabKar** Corresponding author Abstract Background: Suicide by organophosphorus poisoning is common in India. Study of factorsassociated with lethality may suggest methods for prevention. Methods: Severity of symptoms, biochemical manifestation of poisoning, degree of lethality andthe outcome were studied with an aim to explore the modifiable factors associated with lethalityand to discuss preventability. Clinical variables were collected; symptoms were rated by thephysicians using global impression of severity; and the lethality was assessed by scale for assessmentof lethality of suicide attempt (SALSA), in 100 consecutive patients with suicidal organophosphoruspoisoning attending a medical college hospital in South India. Results: Fatal outcome (n = 26) was significantly associated with higher mean age, lower meanpseudocholinesterase level, longer duration between organophosphorus compound ingestion andspecific intervention. All those who died had respiratory failure. Physicians' assessment of symptomseverity and lethality as assessed by the SALSA could differentiate those succumbed and survivedin a significant proportion. Conclusion: Majority of cases of organophosphorus poisoning were associated with severesymptoms and higher lethality. Intervention facilities decreasing the period between the ingestionof poison and initiation of treatment might prevent many deaths. Measures like restrictingavailability and banning more toxic organophosphorus compounds may help. Background Poisoning is a common method of suicide, especially inthe developing world [1]. In many Indian reports, therates of poisoning as suicidal method range from 20.6%(10.3% organophosphorus) [2] to 56.3% (43.8% organo-phosphorus) [3,4]. It has remained so for almost a cen-tury, 44.2% in 1872-76 and 49.2% in 1972 [5]. Reportedpoisoning rates in the suicide attempters who attend hos-pital varies from around 40% to over 80% [6-8] in many Indian studies. Organophosphorus compounds availableas pesticides are amongst the most common poisons used[3,9-12]. In hospital based studies mortality rates associ-ated with pesticides have been reported up to as high as50–70% [13]. Considerable proportions of children andadolescent attempters, 50% males and 60% females inone study [3], have used this method of attempt. Study of organophosphorus poisoning as a method of suicideattempt, its presentation in hospitals, lethality and out-come following intervention may provide insight for pre- venting death in a proportion of attempters. Published: 21 November 2006  Annals of General Psychiatry   2006, 5 :17doi:10.1186/1744-859X-5-17Received: 05 July 2006Accepted: 21 November 2006This article is available from:© 2006 Kar; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the srcinal work is properly cited.   Annals of General Psychiatry   2006, 5 :17 2 of 5 (page number not for citation purposes) Specific aim of this study was to evaluate suicide attempt by organophosphorus poisoning in an Indian patient population as they present to a hospital, severity of symp-toms as observed by the physicians, biochemical manifes-tation of poisoning, the lethality of the suicide attempt,and the outcome. It also aimed to discuss the possible pre- ventive ways based on modifiable factors associated withlethality. Methods In a prospective study, consecutive 100 patients with sui-cidal organophosphorus poisoning attending a medicalcollege hospital in South India were evaluated. Patients with multiple methods of attempt, including multiplesubstances for poisoning and accidental poisoning wereexcluded. The informed consent was taken from the rela-tives and later from the patient if he/she survived theattempt. Age, gender, clinical variables like intervalbetween ingestion of poison and specific intervention(pralidoxime (PAM) injection for this index study), respi-ratory failure, duration of ventilatory support and mortal-ity were studied. Pseudocholinesterase level was recorded.Manifestations of poisoning were recorded as mild, mod-erate or severe by the treating physicians as a globalimpression of severity of the symptoms.Lethality was considered as the possibility or degree to which any biological change that could have endangeredthe life of the patient if not rescued or resuscitated.Lethality was studied by global impression of lethality item of the scale for assessment of lethality of suicideattempt (SALSA) with 5-levels of lethality (degree of lethality ranged from subliminal to extremely high) [14]. The mode of attempt, rescuability, degree of helprequired, maximum severity of physical symptoms mani-fested and the level of medical intervention required wereconsidered in deciding about the lethality. The statistical tests were done by SPSS package. The cate-gorical data were analyzed by using chi-square tests andthe continuous variables were compared by two-tailed t-tests. Statistical significance was defined at the standard0.05 level. Results  There were 68 males and 32 female attempters (male tofemale ratio 2.1:1). Mean age and standard deviation(SD) of male (31.5 ± 12.37 years) and female (29.7 ±15.62 years) attempters were not significantly different (t:0.55, df: 98, p: 0.58). More women (90.6%) in contrast tomen (70.6%) were married ( χ 2 : 4.93, df: 1, p: 0.026).Out of the 100 attempters 26 died. Nineteen males(27.9%) and 7 females (21.9%) succumbed to their attempt (ratio: 2.7:1); the difference between the propor-tions was not statistically significant. There was no signif-icant difference between the genders regarding the clinical variables studied.Comparisons of clinical variables of attempters who died with those survived their attempt are given in table 1.Mean age of the attempters who died was significantly more than that of who survived. Fatal outcome was signif-icantly associated with lower mean pseudocholinesteraselevel which indicated probability of higher toxicity of ingested substance besides other factors. The duration of organophosphorus compound ingestion and specific intervention was significantly more in those died. Thedelay was due to many factors including lack of interven-tion facility locally and the time for travel. All the persons who died had respiratory failure, compared to 51.4% of the survived.Severity of symptoms and degree of lethality of consider-able proportion of attempts were high. Global impressionof severity of symptoms suggested that amongst those who died 42.3% had moderate and 57.7% had severesymptoms of poisoning in contrast to 10.8% mild, 56.8%moderate and 32.4% severe symptoms of those who sur- vived ( χ 2 : 6.7, df: 2, p < 0.05). Even though 61.5% withsevere symptoms did survive, impression of the physi-cians regarding severity of symptoms significantly differ-entiated the outcome. Evaluation of lethality throughSALSA suggested a trend with higher lethality indicator being associated with higher proportion of death in theattempters; for example, 75% of the attempters withextremely high lethality died compared to 38.1% withhigh and 21.4% of the moderate lethality ( χ 2 : 34.2, df:1,p < 0.000). Discussion  The study tried to evaluate lethality in organophosphoruspoisoning and to explore preventability. As reported inmany previous studies males were more represented inthe suicidal patients seen in a hospital setting [15]. A larger proportion of them compared to females died, but the difference was statistically not significant. Male/female ratio in the committers (2.7.1) is wider than theoverall national ratio of 1.4:1 in suicide [1]; suggesting that in organophosphorus poisoning there is considerablepreponderance of males in hospital setting. It might berelatively easier for men, some as farmers, to avail pesti-cides to use as suicide method as observed in other studies[3]. Concerns regarding increased suicide by farmers inIndia are well known [16,17]. Alarmingly 22% of attempters were 20 years old or less(17% within the age of 18 to 20 years); however all of them survived. It supports the reports that adolescents area major risk group for suicide attempt [18]. Proportions of    Annals of General Psychiatry   2006, 5 :17 3 of 5 (page number not for citation purposes) attempters who died were more in age groups of 31–40 years and 51 years and above, suggesting probability of higher risk of suicidal death in these age ranges. Mean ageof those who died was significantly more than that of sur- vivors.Mean pseudocholinesterase level was significantly less inthose who died compared to survivors. Though there arecontroversies about the correlation between plasmacholinesterase activity and the severity of organophospho-rus poisoning [19], it is a marker of the organophospho-rus intoxication. Number of hours passed betweeningestion of poison and initiation of specific treatment had significantly influence on the outcome. It was signifi-cantly more in those who died. Respiratory failure which was observed in all who died and in 51.4% of survivorsindicated the severity of the attempts and was one of thesignificant indicators for outcome.Lethality is an important clinical variable for both medicaland psychiatric evaluation and management. In contrast to intent-to-die which is a subjective measure, lethality isobjective, more descriptive of the behaviour, and oftencorrelate with the degree of intent [20]. In the index study findings indicated that organophosphorus poisoning inmost attempters was clinically severe with higher degreeof lethality. Physicians' assessment of symptom severity and lethality as assessed by the SALSA were able to catego-rize attempts into different grades of severity and lethality  which could differentiate the outcome in a significant pro-portion.It is presumable that severity of symptoms and toxicity of the compounds are related. In the index study most patients had moderate to severe symptoms, moderate toextremely high lethality and respiratory failure, besidessignificantly lower pseudocholinesterase level in thosesuccumbed to the poisoning. Though toxicity of ingestedsubstances was not directly studied; and many factors con-tribute to severity of poisoning, the above observationsindirectly suggest probability of higher toxicity of ingestedsubstances in most cases. Banning of extremely toxic pes-ticides and restriction of their use have been urged by  World Health Organisation [13]. Restriction of availabil-ity of suicide methods has received some attention as apossible way of suicide prevention [4,21,22], though it is also reported that when one method is restricted then thesuicidal methods change [4]. Legislation on drug availa- Table 1: Clinical variables associated with mortality following suicidal organophosphorus poisoning VariablesnSuccumbed (n = 26)Survived (n = 74)n%n%GenderMale681927.94972.1Female32721.92578.1Age group in years<18500.05100.018–201700.017100.021–30421228.63071.431–4020840.01260.041–506233.3466.751+10440.0660.0Mean Age (SD) a 35.88(13.17)29.02(13.2)Mean pseudocholinesterase level (SD) b 1448.9(1120.9)3165.5(2715.2)Respiratory failure c 642640.63859.4Mean ventilatory duration in hours (SD)7.15(6.01)5.17(7.46)Symptoms of poisoning d Mild800.08100.0Moderate531120.84279.2Severe391538.52461.5Lethality e Subliminal2000.020100.0Low1500.015100.0Moderate28621.42278.6High21838.11361.9Extremely high161275.0425.0Mean PAM interval in hours (SD) f  7.24(6.28)4.37(4.63) a t: 2.28, df: 98, p: 0.024; b t: -3.12, df: 98, p: 0.002; c χ 2 : 19.76, df: 1, p: 0.00001; d χ 2 : 6.71, df: 2, p: 0.034; e χ 2 : 34.16, df: 4, p: 0.00000; f t: 2.47, df: 98, p: 0.015; Percentages are from the number of patients in that category of variable; figures in parentheses are SD.   Annals of General Psychiatry   2006, 5 :17 4 of 5 (page number not for citation purposes) bility and packaging has been effective elsewhere [13,22]. In addition, involving another individual from farmer community in the sale, use and safe disposal of theremaining content of organophosphorus compoundsmay help. Public education in this regard may be needed.Efforts to minimize the period between ingestion of poi-son and initiation of specific treatment may help todecrease the chance of death in some. Most part of theduration from ingestion of poisoning to initiation of treatment was spent travelling/arranging transport to thehospital. In the developing world many attempters arereferred to secondary and tertiary centres for lack of facil-ity locally. It is a common observation that many attempt-ers are brought dead to hospital [8]. Delay in arriving inhospital with facilities seriously curtails their effective-ness. Availability of basic facilities for treatment of organ-ophosphorus poisoning at primary health centres (PHC)and local hospitals may change this negative outcome for many, if not for all. Increasing the ability of the primary care facilities to manage the medical complication of sui-cide attempt is a recognized intervention in China [21].Periodic training to the doctors and other health care staff in community, improving their skills in assessment andmanagement may help in dealing with more cases in com-munity effectively in time before the duration of ingestionand specific intervention gets prolonged. It may help tohave clear protocol and guidelines available for managing poisoning cases. The facilities for initiating treatment sooner and respiratory support locally and while transfer-ring the patient (if needed) may increase the chance of survival for many attempters. However these suggestions would require further focused study for their effectiveness. There are few limitations of the study. The sample wastaken from a tertiary level of health care system. The find-ings in community sample attending primary or second-ary centres may be different. Variables which may beclinically relevant regarding outcome such as existing other morbidities and treatments were not studied. Conclusion In the index study a typical attempter who died wasaround 35 years of age, male, with low pseudocholineste-rase level, respiratory failure, moderate to severe symp-toms, moderate to extremely high lethality and an averageduration of around seven hours from ingestion to specific intervention. Assessments of severity and lethality of theattempts were able to differentiate the attempters from thecommitters in most cases. Suicide prevention is a muchbroader multi-agency issue; and emphasis is given to pre- venting the act of attempt itself. However efforts todecrease the period between the ingestion and initiationof treatment, restricting availability of organophosphoruscompounds, and banning more toxic ones may prevent some suicidal deaths following organophosphorus poi-soning. Organophosphorus poisoning being a very com-mon method of suicide attempt in developing worlddeserves specific attention. Competing interests  The author(s) declares that they have no competing inter-ests. Authors' contributions NK conceptualized, analyzed and interpreted data, and wrote the paper. Acknowledgements Quality of Life Research and Development Foundation supported the study in part. Purusottam Mishra, MD, Associate Professor of Medicine, Kasturba Medical College, Manipal, India helped in data collection. References 1.Vijayakumar L: Suicide prevention: the urgent need in develop-ing countries.   World Psychiatry   2004, 3(3): 158-159.2.Ponnudurai R, Heyakar J: Suicide in Madras.   Indian Journal of Psychi-atry   1980, 22: 203-205.3.Gururaj G, Isaac MK: Epidemiology of suicide in Bangalore. NIMHANS Publication No. 43, Bangalore; 2001. 4.Nandi DN, Mukherjee SP, Banerjee G, Ghosh A, Boral GC, Chowd-hury A, Bose J: Is suicide preventable by restricting the availa-bility of lethal agents? A rural survey of West Bengal.   Indian Journal of Psychiatry   1979, 21: 251-255.5.Nandi DN, Banerjee G, Boral GC: Suicide in West Bengal – Acentury apart.   Indian Journal of Psychiatry   1978, 20: 155-160.6.Badrinarayana A: Suicide attempt in Gulbarga.   Indian Journal of Psychiatry   1977, 19(4): 69-70.7.Kar N: Psychosocial aspects of suicide attempt.    MD Thesis,Utkal University, Bhubaneswar   1996.8.Arun M: A comparative analysis of suicide and parasuicide.  MD thesis, MAHE, Manipal   2002.9.Chugh SN, Aggarwal N, Dabla S, Chhabra B: Comparative evalua-tion of "Atropine Alone" and "Atropine with Pralidoxime(PAM)" in the management of organophosphorus poisoning.  Journal of Indian Academy of Clinical Medicine  2005, 6(1): 33-37.10.Rao CHS, Venkateswarlu V, Surender T, Eddleston M, Buckley NA: Pesticide poisoning in south India: opportunities for preven-tion and improved medical management.   Tropical Medicine and International Health  2005, 10(6): 581-588.11.Eddleston M, Szinicz L, Eyer P, Buckley N: Oximes in acute organ-ophosphorus pesticide poisoning: a systematic review of clin-ical trials.    J Med   2002, 95: 275-283.12.Latha KS, Bhat SM: Suicide attempts among youth: Correlatesof medical lethality.   Behavioural Medicine Journal   1999, 2(1): 21-29.13.Wadia RS: Treatment of organophosphate poisoning.   Indian JCrit Care Med   2003, 7: 85-87.14.Kar N: Scale for Assessment of Lethality of Suicide Attempt  Quality of LifeResearch and Development Foundation, Bhubaneswar; 2002. 15.Arun M, Yoganarasimha K, Palimar V, Kar N, Mohanty M: Parasui-cide – an approach to the profile of victims.    Journal of Indian Academy of Forensic Medicine  2004, 26(2): 58-61.16.Venugopal D, Jagadisha : An Indian perspective of farmer stress – a priority area for future research.   International Journal of Social Psychiatry   2000, 46(3): 231-235.17.Sunder M: Suicide in farmers in India.   British Journal of Psychiatry  1999, 175: 585-586.18.Kar N, Pany M, Mishra BN, Sengupta J, Das I: Risk factors of ado-lescent suicide attempt.    Journal of Eastern Zonal Branch of IndianPsychiatric Society   1996, 1(1): 17-22.19.Nouira S, Abroug F, Elatrous S, Boujdaria R, Bouchoucha S: Prognos-tic value of serum cholinesterase in organophosphate poi-soning.   Chest  1994, 106(6): 1811-1814.20.Hamdi E, Amin Y, Matter T: Clinical correlates of intent inattempted suicide.    Acta Psychiatr Scand   1991, 83: 406-411.  Publish with BioMed Central  and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours — you keep the copyright Submit your manuscript here: BioMed central  Annals of General Psychiatry   2006, 5 :17 5 of 5 (page number not for citation purposes) 21.Phillips M: Suicide prevention in developing countries: whereshould we start?   World Psychiatry   2004, 3(3): 156-157.22.Gunnell D, Frankel S: Prevention of suicide: Aspirations and evi-dence.   BMJ  1994, 308: 1227-1233.
Related Documents
View more...
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks

We need your sign to support Project to invent "SMART AND CONTROLLABLE REFLECTIVE BALLOONS" to cover the Sun and Save Our Earth.

More details...

Sign Now!

We are very appreciated for your Prompt Action!