Defined as a suicide attempt and deliberate self-harm inflicted with no intent to die, parasuicide1 is a public health concern in some parts of the world.2 The emergency unit at Brits Hospital receives many of these cases. For the past five years on average 10–15 parasuicide cases per month were reported in some months of the year. The frequency of the phenomenon explains the initiation of the current study aimed on determining the profile of parasuicide cases attending Brits Hospital, North West Province of South Africa, from 2013–2018.
Different methods, e.g. ingestion of a product, as well as injury, have been applied in parasuicide,3 referred to as an apparent attempted suicide without the actual intention of killing oneself.1,3 Parasuicide, as presented in the literature, has a prevalence that continues to increase every year.3
In Europe, the multicentre study on parasuicide conducted by the World Health Organization (WHO) focussed on two axes, one the epidemiologic monitoring of the problem and the second on the prediction of repetitive attempts at parasuicide.4 Data collected from 15 centres on the continent showed that the incidence of the phenomenon differs according to location as well as to gender. There were more males, 414 per 100,000 in Helsinki, capital of Finland while Leiden, in the Netherlands, had a lower total of 61 per 100,000. Statistics for women show that Pointoise, a town in France, had 595 versus 95 in Guipuzcoa, a municipality in Spain. Females are experiencing parasuicide to a greater degree than males do on the continent, with incidences respectively at 222 versus 167. With regard to age, a high incidence rate was noted among people aged 15–34 years while a low rate was observed among those aged 55 and older. Looking at the second axis of the study, the incidence of repeated crises also differs according to location, although there were no significant differences between the two genders.4
The Edinburgh, United Kingdom study showed some trends regarding parasuicide rates. There was an increased rate among young, working-class people, especially for men, as well as women, with a history of alcoholism and psychotropic drug use. There was no change in other variables, e.g. repetition rates, use of non-prescribed drugs, etc. Hence the issue of changing trends in parasuicide remains questionable.5
General practitioners (GPs) have a crucial role to play in the management of parasuicide patients in Australia. Thirty-eight percent of the Australians who present for parasuicide at the emergency units of public hospitals have consulted their GP during the previous week. Women younger than 35 years of age, with a history of parasuicide, constitute the major proportion of this group in emergency units. They consult a GP for somatic issues and a few days later present to a public hospital with a history of parasuicide. The Australian study revealed that only 2.3% of this age group had presented at the GP consultation with symptoms related to parasuicide. As a result, it is difficult for a GP to recognize the phenomenon at an early stage. These patients use medication prescribed by a GP to overdose themselves. The study analysis showed no significant differences between females and males or between young and older males. To minimize the problem in the entire region, GPs’ training in parasuicide behaviours has to be given careful consideration.6
In an Islamic country such as Pakistan, three-and-a-half-year retrospective case reports revealed that young adults and married women were the most vulnerable. Marital conflicts appeared to be a weighty cause of stress for women in this country. Self-poisoning with benzodiazepines was the main method used to commit parasuicide in this part of the world. Parasuicide as an act is considered a criminal offence and condemned by the Islamic religion.7
A combined retrospective and prospective study was conducted in one of the Egyptian poisoning centres. A total of 244 self-poisoning participants were enrolled and subjected to clinical, toxicological and psychiatric assessment. The target was to identify the various signs that could lead to parasuicide, to determine the most common toxic agents used in the parasuicide act and to put in place measures and strategies that would prevent parasuicide, considered as non-fatal suicidal behaviour. Results indicated that adolescents (19 years), single, female, unemployed, with familial problems, exposed to emotional situations with a secondary or tertiary level of education were those most vulnerable to parasuicide. Looking at the seasons, more cases were registered during spring, followed by summer with winter last. The methods used were self-poisoning with a pesticide in 95% and drugs in 5%.8
A quantitative study targeted 169 youths of parasuicide cases attended to in Chegutu, Zimbabwe. The youths were investigated in order to determine the risk as well as the protective factors associated with parasuicide in that area of the African continent. Analysis indicated that 39% of the youths presented with risk factors such as hopelessness, signs of illness, e.g. depression, alcohol and substance abuse, as well as stressful life events and family issues. Some protective factors were also revealed in association with the phenomenon of parasuicide in this study, i.e. religious beliefs, social support from peers and others. Further research was encouraged in order to cast more light on the question of risk versus protection regarding parasuicide.9
After applying the suicidal ideation questionnaire to 214 adolescents in the Western Cape province of South Africa, only participants with high scores were considered. Various risk factors associated with suicidal behaviour were identified, i.e. drug use, negative emotional experiences, lack of self-esteem, negative family atmosphere, conflict in family relationships, stressful life events, peer group pressure, romantic relationships and socioeconomic factors.10
While looking for the motives that led to parasuicide in Limpopo province, South Africa, a list comprising unemployment, poverty, domestic violence, mental health conditions including depression, other medical conditions such as HIV/AIDS, and accusation of witchcraft was established, following an unstructured in-depth interview. From the association of these motives, an emotional state of living a meaningless life transpired. The suicidal ideation was gaining ground in the minds of nearly all respondents in this study. The methods used in different cases varied, based on knowledge and the determination to die.11
Nearly 10% of unnatural deaths among young people in South Africa are related to suicidal behaviour affecting almost all social demographic groups. This suicidal behaviour is increasing in prevalence and there are more suicide attempts with non-fatal outcomes than those with fatal outcomes. The ratios vary from 20:1 to 40:1. A study in Durban where these observations were made, showed that females, single, unemployed with low education, low- income level and part of the younger age group, were the most vulnerable when considering suicidal behaviour and, as a result, exposed to parasuicide. Depression seems to be a risk factor associated with suicidal behaviour. A screening strategy to diagnose depression may be considered in the comprehensive management of our patients, in order to prevent or reduce the parasuicide phenomenon.12
A one-year retrospective and descriptive study using patients’ records was conducted in northern KwaZulu-Natal, South Africa. Only patients who presented at the casualty department of the hospital and had deliberate self-harm (DSH) as diagnosis qualified for this study because the target was to determine the profile of the patients and the reasons for DSH. The study results showed that the parasuicidal behaviour was affecting young, single, black women with a secondary level of education and those with relational problems more than other groups. Looking at the result (78% parasuicide), a tool for the identification of clients at risk, as well as community intervention addressing the DSH issues, are needed in order to reduce the prevalence of this phenomenon in that area.13 A chart review of intentional self-poisoning cases was retrospectively studied over a period of six months in Khayelitsha Hospital, Cape Town (South Africa). As a result, 68% of women with mean age of 27.3 years were affected; HIV infection was the comorbidity. The main method of this intentional self-poisoning was the ingestion of pharmaceuticals, e.g. paracetamol. Few benefited with N-acetylcysteine (NAC) and benzodiazepines while 7.3% of the patients went to the high-level hospital and a death rate of 2% was registered.14
In a general hospital in South Africa, looking at the profile of 100 parasuicide patients referred to psychologists, the results showed that the most vulnerable were students and those who were unemployed, at rates of 79% and 16% respectively. The method used for parasuicide was ingestion of substances, e.g. paraffin, pesticides or battery acid. The precipitating factors were family conflicts, academic failure, teenage pregnancy, fear of Aids and mental illnesses.15