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Ethics code: IR.YUMS.REC.1403.111
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Received: 2024/12/19 | Accepted: 2025/02/8 | Published: 2025/02/16
Received: 2024/12/19 | Accepted: 2025/02/8 | Published: 2025/02/16
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Zahmatkeshan N, Rastgouyan F, Azmooni M, Zarei Z. Suicide Attempts and Related Factors from 2019 to 2023 in Yasuj, Southwest of Iran. J Clinic Care Skill 2025; 6 (1) :25-32
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1- Department of Operating Room, Faculty of Paramedicine, Yasuj University of Medical Science, Yasuj, Iran
2- Student Research Committee, Yasuj University of Medical Science, Yasuj, Iran
3- Department of Education, Faculty of Paramedicine, Yasuj University of Medical Science, Yasuj, Iran
2- Student Research Committee, Yasuj University of Medical Science, Yasuj, Iran
3- Department of Education, Faculty of Paramedicine, Yasuj University of Medical Science, Yasuj, Iran
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Introduction
Suicide is the intentional act of taking one’s own life, a phenomenon that dates back to the dawn of humanity, and its prevalence is increasing with the industrialization of countries [1, 2]. By definition, attempted suicide is an act, in which a person intentionally engages in abnormal behavior, such as self-harm or taking a substance in greater quantities than prescribed for treatment, with the intention of achieving desired changes [3]. Suicide is one of the most complex and dangerous human behaviors, affecting millions of people worldwide, and it represents a significant tragedy at social, familial, and personal levels [4]. This issue ranks among the ten leading causes of death globally, with 10.6 out of every 100,000 people committing suicide each year [5]. The frequency of suicide varies based on geographical context, with 79% of the world’s suicides occurring in low- and middle-income countries [2, 6]. Although the suicide rate in Iran is lower than that in most Western countries and, according to the World Health Organization’s ranking, it falls within the 15-19 age group among the 90 countries with the lowest suicide rates worldwide, it is higher than in other Middle Eastern countries [7, 8]. According to the Iranian Forensic Medicine Organization, the number of suicide victims increased by more than 4 percent in the first eight months of 2020 compared to the same period in the previous year. Based on this statistic, at least 15 people in Iran lose their lives to suicide every day [9]. Official suicide statistics focus solely on successful suicides, and there are no accurate statistics on unsuccessful suicide attempts. However, to obtain more reliable statistics, it is estimated that for each successful suicide, there are 6 to 8 suicide attempts [5].
Studies have identified various factors that contribute to suicide attempts, including incurable physical illnesses, mental disorders, drug and alcohol abuse, family problems, economic factors (such as poverty and unemployment), social isolation, mourning the loss of loved ones, and demographic factors such as marital status, gender, and religion [1, 4, 10]. Research has also indicated different methods of suicide, with individuals resorting to a wide range of actions to end their lives. For example, in the northeast of Iran, self-harm, hanging, and jumping from heights have been common methods of suicide [11]. In the south of Iran, hanging and self-immolation are more prevalent. Additionally, hanging, self-harm, self-immolation, and jumping from heights are common methods in the west of Iran [12]. In the southwest of Iran, self-immolation and self-harm with sharp instruments have been reported [13]. Although self-immolation is a rare phenomenon in developed countries, it has been reported as one of the three most common methods in countries such as Pakistan, Sri Lanka, Iran, and India [14].
Suicide imposes enormous costs on healthcare systems [11], with estimates in Ireland and Scotland showing that each instance of suicidal behavior costs an average of €1.5 million. These figures are expected to increase if preventive measures and support policies are not implemented [15, 16]. Studies indicate that the number of suicide attempts in Iran is higher than in other Middle Eastern countries [9], and in Kohgiluyeh and Boyer-Ahmad provinces, field surveys reveal a high number of suicide attempts among young women and men relative to the population of this province [17, 18]. Therefore, accurate knowledge of the pattern of suicide occurrences at the national level can significantly contribute to the prevention of this phenomenon. With careful planning to control the influencing factors, the health level of the community and vulnerable groups can be improved [19].
Veisani et al. indicate that during a six-year period from 2011 to 2016, the rate of suicide attempts in men ranged from 177.9 to 172.2 per 100,000 populations per year, while in women, it ranged from 221.1 to 144.9 per 100,000 populations [20]. Additionally, in the study by Mojahedi et al. conducted in the South Khorasan province in Iran, 4,613 cases of suicide attempts and 86 cases of successful suicides are recorded during the years 2014-2019, resulting in an incidence rate of suicide attempts of 111 per 100,000 [21]. In a study conducted in Shahrood City in northeastern Iran, the rate of suicide attempts is 155.84 per 100,000 over two years (from April 2016 to March 2017) [22]. A study conducted in Kohgiluyeh City reports a suicide attempt prevalence of 92.5 per 100,000 people over six months in 2012, with higher rates among women in the adolescent and young adult age groups [17]. Furthermore, the most common causes of suicide included problems in family relationships and physical violence by a spouse [17, 18]. Moreover, in a study in Gachsaran City in Kohgiluyeh and Boyer-Ahmad province, the incidence of suicide attempts is 2.8 per 1,000 people in 2015, with a significant relationship found between male gender, unemployment, and love problems with suicide [17, 18]. The study by Jahani Dolatabad et al. indicates an upward trend in the suicide rate in Iran from 2011 to 2021, with Kohgiluyeh and Boyer-Ahmad province ranking second in this upward trend and third in overall suicide rates in Iran, with an average suicide rate of 0.088 [23]. Suicide has been increasing in Boyer-Ahmad province, and according to the aforementioned study, this province hold the third rank in suicide attempts in Iran, also demonstrating an upward trend. It appears that suicide attempts have become an epidemic, spreading harm to those around the victims, affecting public opinion, and impacting peers of the same age as the victims of this social phenomenon, which causes public distress and depression. This situation significantly involves the active force of society, as indicated by the provided statistics. Moreover, most studies conducted in this province or other cities have been limited to short time frames or previous years, highlighting the need for more recent statistics. Additionally, studies in Kohgiluyeh and Boyer-Ahmad province and other cities in Iran have shown conflicting results regarding the factors associated with suicide, the methods used, and trends in suicide. Therefore, the present study was conducted to determine the frequency of suicide attempts and related factors from 2019 to 2023 in Yasuj, Iran.
Instrument and Methods
The present descriptive cross-sectional study was conducted in Yasuj, Iran. Yasuj City is located in the southwest of Iran, and its population, including the surrounding villages, is approximately 300,000 people. A census sampling method was used. All individuals who attempted suicide between the first of April 2019 and the end of March 2023 and who were referred to medical centers affiliated with Yasuj University of Medical Sciences with a diagnosis of attempted suicide were included in the study.
The inclusion criteria for the study required confirmation of the diagnosis of a suicide attempt by an emergency medicine specialist, along with the recording of the patient’s information in the suicide file. The exclusion criteria included incomplete client information. The sample size consisted of all suicide attempts within a five-year period, which were included in the study using a census method.
After the proposal was approved and the code of ethics in research (IR.YUMS.REC.1403.111) was obtained from the university’s research vice-chancellor, the researchers were introduced to the city health care center. Demographic data, as well as the time, reasons, and methods of suicide, were collected using a form designed based on similar studies. This form included questions about the patient’s demographic information (age, sex, marital status, employment, etc.), as well as factors and methods related to suicide, which were extracted by a researcher from the patient files in a computer information system and maintained in the statistics unit at Yasuj City health center (the Mental Health Unit of the Health Deputy).
The data were analyzed using descriptive statistics, including frequency, percentage, mean, and standard deviation, using SPSS software version 26.
Findings
During the five-year study period (2019-2023), 4,481 suicide attempts were referred to hospitals affiliated with Yasuj University of Medical Sciences, of which 343 (7.65%) resulted in death and 4,138 (92.35%) resulted in recovery. The highest number of suicide attempts occurred in 2021; however, the rate of successful suicides was lower than in other years (19.40%). The lowest number of attempted suicides was recorded in 2022. Nevertheless, there was an increasing trend in suicide attempts in 2023 (Figure 1).
Figure 1. Frequency of suicide attempts among patients referred to the hospitals in Yasuj City by year
Based on the number of patients referred, the estimated incidence rate in 2021, which had the highest number of suicide attempts, was 384.29 cases per 100,000 people. In contrast, in 2022, which had the lowest number of patients, the incidence rate was 226.23 cases per 100,000 people (Table 1).
Table 1. Frequency of suicide rate and consequences during a 5-year period (2019-2023)
According to the results, 2,327 individuals (51.9%) were men, while 2,154 individuals (48.06%) were women. In terms of age group, during the five-year study, the highest percentage of suicide attempts (33.18%) occurred in the 16-20 age group. Most suicide attempts (3,005 individuals, 67%) were among single individuals, while 2,003 individuals (44.69%) were unemployed. Furthermore, 2,723 individuals (60.76%) had completed middle or high school education, and 2,519 individuals (56.21%) lived in urban areas. Regarding the previous history of suicide attempts, only 135 individuals (3.01%) reported a history of previous attempts, and 325 individuals (25.7%) reported a history of substance abuse. The results also indicated that the highest number of suicide attempts occurred in the winter (1,671 cases, or 37.26%), while the spring season had the lowest number of cases, with 621 (13.85%) (Table 2).
Table 2. Frequency of suicide attempts according to demographic factors
Regarding the methods of suicide, the highest number of cases reported was due to drug poisoning in both sexes (3,267 cases (74.66%)). The next categories included suicide attempts by substance abuse (414 cases, or 9.43%), poisoning (372 cases, or 8.54%), shooting with a firearm (295 cases, or 6.72%), self-immolation (18 cases, or 0.41%), and hanging (10 cases, or 0.23%; Figure 2).
Figure 2. Frequency of suicide attempt methods among patients referred to teaching hospitals in Yasuj City by year
Discussion
The present study was conducted to determine the frequency of suicide attempts and related factors from 2019 to 2023 in Yasuj, Iran. The prevalence of suicide among patients referred to hospitals affiliated with Yasuj University of Medical Sciences ranged from 258 to 402 per 100,000 people. Of these cases, 7.65% resulted in death, while 92.34% recovered. In this regard, the incidence of suicide in the cities of Gerash and Khorasan Razavi was reported to be 59.93 and 97.2 per 100,000 people, respectively [7, 24]. Additionally, in the systematic review conducted by Daliri et al., which covered the entire country during the years 2001-2014, the overall estimated incidence of suicide attempts has been 8 per 100,000 people, with this rate reported as 37 per 100,000 people in Kohgiluyeh and Boyer-Ahmad province [25]. The results of this study indicate that this province is one of the regions with the highest prevalence of suicide in the country, which is an important and concerning issue. Furthermore, the incidence of suicide leading to death has been reported to be 2.2% in a study conducted in Mashhad [7], whereas in the present study, this rate was 7.65%. The differences between the results of the present study and those of the aforementioned research may be attributed to climatic and cultural conditions, the demographic distribution of the studied population, and the specific social and economic conditions of this underprivileged province. In this study, the results indicated that the prevalence of suicide attempts in 2021 was higher than in other years. Possible causes for this increase may be linked to the spread of the COVID-19 pandemic, as the consequences of the pandemic have led to greater tensions and an increase in suicide attempts, as noted in another study [26]. Other potential factors may relate to more accurate documentation in hospitals due to the heightened sensitivity during the pandemic, which has contributed to more precise reporting of suicide attempts.
In the present study, men had the highest number of suicide attempts. Generally, the suicide rate among men is higher than that among women worldwide, although it varies significantly across different countries [27]. Consistent with the present study, other research has also found that the prevalence of suicide in men is greater than in women [28, 29]. The results of these studies indicate that men are at a higher risk of suicide due to factors such as greater emotional suppression, the inability to meet desired standards, challenges in fulfilling their own and their families’ demands, and feelings of worthlessness following these failures [27]. However, some studies have reported results that contradict the findings of this study. For example, Rahmani et al. and Piraee et al. conducted in Dehdasht in Kohgiluyeh and Boyer-Ahmad provinces have shown that the prevalence of suicide in women is higher than that in men [5, 17]. Similarly, in the study by Ahmed & Heun in Iraqi Kurdistan and that by Yaseh et al. in Kermanshah, the prevalence of suicide in women has been reported to be higher than in men [13]. The results of these studies identified factors, such as deprivation in the studied areas, identity disorders in women, early and sometimes forced marriages, and restrictions imposed by husbands as significant contributors to the incidence of suicide among women. In addition to these factors, the type of study and the methodology employed may also be considered other reasons for this discrepancy. The findings of the present study indicated that most suicide attempts occurred in the age group of 16-20, followed by individuals over 30 years old. In general, people are more prone to suicide during their late adolescence and early adulthood [29]. The suicide rate is the highest in the world among individuals aged 15-24 years. Psychological crises during adolescence and young adulthood, along with social and cultural issues, poor economic status, and early marriage, are among the influential factors in this regard [30]. Consistent with the results of this study, other studies in Iran and abroad have also reported the highest number of suicide attempts in the age group of 15-34 years [10, 13]. The findings also indicated that a percentage of individuals who attempted suicide were in the age group of 10-15 years, which is lower than the global average and suggests the occurrence of child suicide. Similar results were reported in the study by Piraee et al. in Kohgiluyeh [17]. This decrease in the average age of suicide attempts, particularly in Kohgiluyeh and Boyer-Ahmad province, is a significant and concerning issue that highlights the need to focus on children’s mental health. In general, childhood traumas, especially in girls, can create a foundation for suicide attempts. Issues, such as lack of emotional and social support, poverty, academic failures, parental separation, inappropriate guardianship, and sexual abuse can contribute to this risk [14]. The need for appropriate support for vulnerable children and monitoring their conditions are crucial issues that should be addressed by relevant organizations and policymakers. The results showed that the suicide rate is higher among single individuals of both sexes. Consistent with these findings, other studies have also reported a higher prevalence of suicide among single individuals [12, 31], although some results contradict the present findings. For instance, the study by Rezaeian reported a higher suicide rate among single and divorced individuals. According to the results of that study, having a family and children, along with receiving support and dependence on them, is considered a protective factor against suicide attempts [12].
The highest rate of suicide attempts was among individuals with middle and high school education, and a significant number of those who attempted suicide were students. In some studies, illiterate individuals and those with primary education have shown a higher prevalence of suicide [5]. It appears that an increase in education level and intellectual maturity leads to improved coping methods and the use of problem-solving strategies, allowing these individuals to make more appropriate decisions during crises [32]. The results also indicated a higher prevalence of suicide among unemployed and jobless individuals. Given that high school adolescents and most young people aged 20-25 in Yasuj are not in a favorable situation regarding employment status and financial independence, the findings are justifiable. Other studies also identify unemployment, poverty, lack of financial independence, and low income as factors contributing to suicide attempts in Asian and European countries [1].
Suicide attempts were more common among urban residents than among rural residents, which is consistent with the findings of other studies. However, in the study by Rahmani et al., suicide attempts are more prevalent among rural residents [5]. The reasons for this difference are likely related to the type of study and geographical location. Although a previous history of suicide attempts can influence the likelihood of recurrence, in the present study, most of the individuals who attempted suicide had no prior history of such attempts. In other similar studies, most of the suicide attempters also had no previous history [31, 33]. Nevertheless, a history of unsuccessful suicide attempts does impact the likelihood of recurrence [30]. Various studies have found that counseling and support measures are effective in reducing the risk of recurrence of suicide attempts [34, 35].
The use of medication was reported as the most common method of suicide, followed by substance abuse and poison ingestion. Additionally, shooting with a gun was the least commonly used method of suicide. Consistent with these findings, other studies have also reported the use of pills as the most common method of suicide [31, 36]. In the studies conducted by Armitage et al. and Ahmed & Heun, poison ingestion had been also noted as a common method of suicide [13, 37]. It seems that easy access to medication, particularly over-the-counter drugs from pharmacies, encourages individuals to use this method. Furthermore, due to the specific geographical area of Yasuj and the high usage of agricultural pesticides, people have easier access to these substances. Although the history of substance abuse among suicide attempters was low, substance abuse ranked as the second most common method for committing suicide. Possible factors influencing this situation include the use of substances by adolescents and young people, especially excessive use and exceeding the recommended dosages, which can create a foundation for suicide in these individuals. Although self-immolation has been one of the most common and severe methods of suicide among women in Dishmok [5], the prevalence of self-immolation was low in the present study. Possible reasons for this difference can be attributed to the specific geographical area and the type of study conducted in Dishmok. Another potential factor is the denial of suicide attempts by most burn patients, who consider their burns to be unintentional and accidental. In the study by Shakibkhah et al., hanging has been identified as the most common cause of suicide in Kohgiluyeh and Boyer-Ahmad Province, Iran, during the period from 2016 to 2021, while in the present study, hanging has been noted as a cause but with less prevalence [38]. The highest prevalence of suicide occurred in winter, followed by autumn, while the lowest number of suicide attempts was recorded in summer. Similar studies have also indicated an increase in suicide rates during winter and autumn [12, 36], although in some studies, suicide attempts have been most frequent in spring [39, 40]. These differences appear to be due to the geographical characteristics of the studied areas and the diversity of climate. However, considering the effect of mood disorders on the incidence of suicide attempts [41], the nature of winter and autumn, climate changes during these seasons, and the subsequent suicidal thoughts and possible actions should also be taken into account.
Also, 92.34% of the patients who attempted suicide recovered and were discharged from the hospital. Given that a previous history of suicide is a significant risk factor for repeated suicide, the risk of recurrence can be reduced by referring these individuals to psychological centers and providing them with the necessary counseling and support [35, 36]. In this regard, all those who recovered from suicide in the present study were counseled in coordination with mental health experts and received the necessary psychological services. However, for these counseling programs to be successful, the continuation of these sessions and measures to facilitate the patient’s participation in the aforementioned sessions should be considered.
The present study had some limitations. Because the information was recorded years ago, it may not be completely reliable or may not contain all the necessary information. Additionally, due to the lack of gender separation in suicide attempts, it was not possible to compare women and men. Furthermore, individuals who did not seek medical attention after attempting suicide or who denied their suicide attempt, considering it an unintentional and accidental incident, are other limitations that likely contributed to the low number of reported suicide attempts. Moreover, due to incorrect addresses and the hospitalization of suicide attempt patients from surrounding cities in Yasuj hospitals, as well as the existence of another hospital not affiliated with Yasuj University, it was not possible to accurately calculate the prevalence of suicide attempts; thus, the rate of suicide attempts may not be reliable.
A longitudinal study over the next five years, with comprehensive data collection, is recommended to examine trends and the prevalence of suicide along with all related factors. Furthermore, a case-control study would be beneficial for identifying risk factors associated with suicide attempts.
Conclusion
The frequency of suicide attempts in Yasuj between 2019 and 2023 is high and shows an increasing trend, with taking drugs being the most common method of suicide attempts.
Acknowledgments: This article is the result of a research project approved by the Vice Chancellor for Research of Yasuj University of Medical Sciences. The researchers feel it is necessary to express their gratitude and appreciation to the respected Vice Chancellor for Research of the university, the Yasuj City Health Center, the Mental Health Unit of the Health Deputy, and the esteemed experts of this unit who cooperated in collecting and completing the data.
Ethical Permissions: The present study was approved by the Research Ethics Committee of the Vice-Chancellor’s Office of Research at Yasuj University of Medical Sciences (IR.YUMS.REC.1403.111). All ethical principles necessary for conducting the study, especially the confidentiality of the information examined, were observed throughout the study.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors' Contribution: Zahmatkeshan N (First Author), Methodologist/Main Researcher/Discussion Writer (60%); Rastgouyan F (Second Author), Introduction Writer/Methodologist/Assistant Researcher (15%); Azmooni M (Third Author), Methodologist/Statistical Analyst (15%); Zarei Z (Fourth Author), Assistant Researcher (10%)
Funding/Support: This research was funded by the Yasuj University of Medical Sciences Research Center.
Suicide is the intentional act of taking one’s own life, a phenomenon that dates back to the dawn of humanity, and its prevalence is increasing with the industrialization of countries [1, 2]. By definition, attempted suicide is an act, in which a person intentionally engages in abnormal behavior, such as self-harm or taking a substance in greater quantities than prescribed for treatment, with the intention of achieving desired changes [3]. Suicide is one of the most complex and dangerous human behaviors, affecting millions of people worldwide, and it represents a significant tragedy at social, familial, and personal levels [4]. This issue ranks among the ten leading causes of death globally, with 10.6 out of every 100,000 people committing suicide each year [5]. The frequency of suicide varies based on geographical context, with 79% of the world’s suicides occurring in low- and middle-income countries [2, 6]. Although the suicide rate in Iran is lower than that in most Western countries and, according to the World Health Organization’s ranking, it falls within the 15-19 age group among the 90 countries with the lowest suicide rates worldwide, it is higher than in other Middle Eastern countries [7, 8]. According to the Iranian Forensic Medicine Organization, the number of suicide victims increased by more than 4 percent in the first eight months of 2020 compared to the same period in the previous year. Based on this statistic, at least 15 people in Iran lose their lives to suicide every day [9]. Official suicide statistics focus solely on successful suicides, and there are no accurate statistics on unsuccessful suicide attempts. However, to obtain more reliable statistics, it is estimated that for each successful suicide, there are 6 to 8 suicide attempts [5].
Studies have identified various factors that contribute to suicide attempts, including incurable physical illnesses, mental disorders, drug and alcohol abuse, family problems, economic factors (such as poverty and unemployment), social isolation, mourning the loss of loved ones, and demographic factors such as marital status, gender, and religion [1, 4, 10]. Research has also indicated different methods of suicide, with individuals resorting to a wide range of actions to end their lives. For example, in the northeast of Iran, self-harm, hanging, and jumping from heights have been common methods of suicide [11]. In the south of Iran, hanging and self-immolation are more prevalent. Additionally, hanging, self-harm, self-immolation, and jumping from heights are common methods in the west of Iran [12]. In the southwest of Iran, self-immolation and self-harm with sharp instruments have been reported [13]. Although self-immolation is a rare phenomenon in developed countries, it has been reported as one of the three most common methods in countries such as Pakistan, Sri Lanka, Iran, and India [14].
Suicide imposes enormous costs on healthcare systems [11], with estimates in Ireland and Scotland showing that each instance of suicidal behavior costs an average of €1.5 million. These figures are expected to increase if preventive measures and support policies are not implemented [15, 16]. Studies indicate that the number of suicide attempts in Iran is higher than in other Middle Eastern countries [9], and in Kohgiluyeh and Boyer-Ahmad provinces, field surveys reveal a high number of suicide attempts among young women and men relative to the population of this province [17, 18]. Therefore, accurate knowledge of the pattern of suicide occurrences at the national level can significantly contribute to the prevention of this phenomenon. With careful planning to control the influencing factors, the health level of the community and vulnerable groups can be improved [19].
Veisani et al. indicate that during a six-year period from 2011 to 2016, the rate of suicide attempts in men ranged from 177.9 to 172.2 per 100,000 populations per year, while in women, it ranged from 221.1 to 144.9 per 100,000 populations [20]. Additionally, in the study by Mojahedi et al. conducted in the South Khorasan province in Iran, 4,613 cases of suicide attempts and 86 cases of successful suicides are recorded during the years 2014-2019, resulting in an incidence rate of suicide attempts of 111 per 100,000 [21]. In a study conducted in Shahrood City in northeastern Iran, the rate of suicide attempts is 155.84 per 100,000 over two years (from April 2016 to March 2017) [22]. A study conducted in Kohgiluyeh City reports a suicide attempt prevalence of 92.5 per 100,000 people over six months in 2012, with higher rates among women in the adolescent and young adult age groups [17]. Furthermore, the most common causes of suicide included problems in family relationships and physical violence by a spouse [17, 18]. Moreover, in a study in Gachsaran City in Kohgiluyeh and Boyer-Ahmad province, the incidence of suicide attempts is 2.8 per 1,000 people in 2015, with a significant relationship found between male gender, unemployment, and love problems with suicide [17, 18]. The study by Jahani Dolatabad et al. indicates an upward trend in the suicide rate in Iran from 2011 to 2021, with Kohgiluyeh and Boyer-Ahmad province ranking second in this upward trend and third in overall suicide rates in Iran, with an average suicide rate of 0.088 [23]. Suicide has been increasing in Boyer-Ahmad province, and according to the aforementioned study, this province hold the third rank in suicide attempts in Iran, also demonstrating an upward trend. It appears that suicide attempts have become an epidemic, spreading harm to those around the victims, affecting public opinion, and impacting peers of the same age as the victims of this social phenomenon, which causes public distress and depression. This situation significantly involves the active force of society, as indicated by the provided statistics. Moreover, most studies conducted in this province or other cities have been limited to short time frames or previous years, highlighting the need for more recent statistics. Additionally, studies in Kohgiluyeh and Boyer-Ahmad province and other cities in Iran have shown conflicting results regarding the factors associated with suicide, the methods used, and trends in suicide. Therefore, the present study was conducted to determine the frequency of suicide attempts and related factors from 2019 to 2023 in Yasuj, Iran.
Instrument and Methods
The present descriptive cross-sectional study was conducted in Yasuj, Iran. Yasuj City is located in the southwest of Iran, and its population, including the surrounding villages, is approximately 300,000 people. A census sampling method was used. All individuals who attempted suicide between the first of April 2019 and the end of March 2023 and who were referred to medical centers affiliated with Yasuj University of Medical Sciences with a diagnosis of attempted suicide were included in the study.
The inclusion criteria for the study required confirmation of the diagnosis of a suicide attempt by an emergency medicine specialist, along with the recording of the patient’s information in the suicide file. The exclusion criteria included incomplete client information. The sample size consisted of all suicide attempts within a five-year period, which were included in the study using a census method.
After the proposal was approved and the code of ethics in research (IR.YUMS.REC.1403.111) was obtained from the university’s research vice-chancellor, the researchers were introduced to the city health care center. Demographic data, as well as the time, reasons, and methods of suicide, were collected using a form designed based on similar studies. This form included questions about the patient’s demographic information (age, sex, marital status, employment, etc.), as well as factors and methods related to suicide, which were extracted by a researcher from the patient files in a computer information system and maintained in the statistics unit at Yasuj City health center (the Mental Health Unit of the Health Deputy).
The data were analyzed using descriptive statistics, including frequency, percentage, mean, and standard deviation, using SPSS software version 26.
Findings
During the five-year study period (2019-2023), 4,481 suicide attempts were referred to hospitals affiliated with Yasuj University of Medical Sciences, of which 343 (7.65%) resulted in death and 4,138 (92.35%) resulted in recovery. The highest number of suicide attempts occurred in 2021; however, the rate of successful suicides was lower than in other years (19.40%). The lowest number of attempted suicides was recorded in 2022. Nevertheless, there was an increasing trend in suicide attempts in 2023 (Figure 1).
Figure 1. Frequency of suicide attempts among patients referred to the hospitals in Yasuj City by year
Based on the number of patients referred, the estimated incidence rate in 2021, which had the highest number of suicide attempts, was 384.29 cases per 100,000 people. In contrast, in 2022, which had the lowest number of patients, the incidence rate was 226.23 cases per 100,000 people (Table 1).
Table 1. Frequency of suicide rate and consequences during a 5-year period (2019-2023)
According to the results, 2,327 individuals (51.9%) were men, while 2,154 individuals (48.06%) were women. In terms of age group, during the five-year study, the highest percentage of suicide attempts (33.18%) occurred in the 16-20 age group. Most suicide attempts (3,005 individuals, 67%) were among single individuals, while 2,003 individuals (44.69%) were unemployed. Furthermore, 2,723 individuals (60.76%) had completed middle or high school education, and 2,519 individuals (56.21%) lived in urban areas. Regarding the previous history of suicide attempts, only 135 individuals (3.01%) reported a history of previous attempts, and 325 individuals (25.7%) reported a history of substance abuse. The results also indicated that the highest number of suicide attempts occurred in the winter (1,671 cases, or 37.26%), while the spring season had the lowest number of cases, with 621 (13.85%) (Table 2).
Table 2. Frequency of suicide attempts according to demographic factors
Regarding the methods of suicide, the highest number of cases reported was due to drug poisoning in both sexes (3,267 cases (74.66%)). The next categories included suicide attempts by substance abuse (414 cases, or 9.43%), poisoning (372 cases, or 8.54%), shooting with a firearm (295 cases, or 6.72%), self-immolation (18 cases, or 0.41%), and hanging (10 cases, or 0.23%; Figure 2).
Figure 2. Frequency of suicide attempt methods among patients referred to teaching hospitals in Yasuj City by year
Discussion
The present study was conducted to determine the frequency of suicide attempts and related factors from 2019 to 2023 in Yasuj, Iran. The prevalence of suicide among patients referred to hospitals affiliated with Yasuj University of Medical Sciences ranged from 258 to 402 per 100,000 people. Of these cases, 7.65% resulted in death, while 92.34% recovered. In this regard, the incidence of suicide in the cities of Gerash and Khorasan Razavi was reported to be 59.93 and 97.2 per 100,000 people, respectively [7, 24]. Additionally, in the systematic review conducted by Daliri et al., which covered the entire country during the years 2001-2014, the overall estimated incidence of suicide attempts has been 8 per 100,000 people, with this rate reported as 37 per 100,000 people in Kohgiluyeh and Boyer-Ahmad province [25]. The results of this study indicate that this province is one of the regions with the highest prevalence of suicide in the country, which is an important and concerning issue. Furthermore, the incidence of suicide leading to death has been reported to be 2.2% in a study conducted in Mashhad [7], whereas in the present study, this rate was 7.65%. The differences between the results of the present study and those of the aforementioned research may be attributed to climatic and cultural conditions, the demographic distribution of the studied population, and the specific social and economic conditions of this underprivileged province. In this study, the results indicated that the prevalence of suicide attempts in 2021 was higher than in other years. Possible causes for this increase may be linked to the spread of the COVID-19 pandemic, as the consequences of the pandemic have led to greater tensions and an increase in suicide attempts, as noted in another study [26]. Other potential factors may relate to more accurate documentation in hospitals due to the heightened sensitivity during the pandemic, which has contributed to more precise reporting of suicide attempts.
In the present study, men had the highest number of suicide attempts. Generally, the suicide rate among men is higher than that among women worldwide, although it varies significantly across different countries [27]. Consistent with the present study, other research has also found that the prevalence of suicide in men is greater than in women [28, 29]. The results of these studies indicate that men are at a higher risk of suicide due to factors such as greater emotional suppression, the inability to meet desired standards, challenges in fulfilling their own and their families’ demands, and feelings of worthlessness following these failures [27]. However, some studies have reported results that contradict the findings of this study. For example, Rahmani et al. and Piraee et al. conducted in Dehdasht in Kohgiluyeh and Boyer-Ahmad provinces have shown that the prevalence of suicide in women is higher than that in men [5, 17]. Similarly, in the study by Ahmed & Heun in Iraqi Kurdistan and that by Yaseh et al. in Kermanshah, the prevalence of suicide in women has been reported to be higher than in men [13]. The results of these studies identified factors, such as deprivation in the studied areas, identity disorders in women, early and sometimes forced marriages, and restrictions imposed by husbands as significant contributors to the incidence of suicide among women. In addition to these factors, the type of study and the methodology employed may also be considered other reasons for this discrepancy. The findings of the present study indicated that most suicide attempts occurred in the age group of 16-20, followed by individuals over 30 years old. In general, people are more prone to suicide during their late adolescence and early adulthood [29]. The suicide rate is the highest in the world among individuals aged 15-24 years. Psychological crises during adolescence and young adulthood, along with social and cultural issues, poor economic status, and early marriage, are among the influential factors in this regard [30]. Consistent with the results of this study, other studies in Iran and abroad have also reported the highest number of suicide attempts in the age group of 15-34 years [10, 13]. The findings also indicated that a percentage of individuals who attempted suicide were in the age group of 10-15 years, which is lower than the global average and suggests the occurrence of child suicide. Similar results were reported in the study by Piraee et al. in Kohgiluyeh [17]. This decrease in the average age of suicide attempts, particularly in Kohgiluyeh and Boyer-Ahmad province, is a significant and concerning issue that highlights the need to focus on children’s mental health. In general, childhood traumas, especially in girls, can create a foundation for suicide attempts. Issues, such as lack of emotional and social support, poverty, academic failures, parental separation, inappropriate guardianship, and sexual abuse can contribute to this risk [14]. The need for appropriate support for vulnerable children and monitoring their conditions are crucial issues that should be addressed by relevant organizations and policymakers. The results showed that the suicide rate is higher among single individuals of both sexes. Consistent with these findings, other studies have also reported a higher prevalence of suicide among single individuals [12, 31], although some results contradict the present findings. For instance, the study by Rezaeian reported a higher suicide rate among single and divorced individuals. According to the results of that study, having a family and children, along with receiving support and dependence on them, is considered a protective factor against suicide attempts [12].
The highest rate of suicide attempts was among individuals with middle and high school education, and a significant number of those who attempted suicide were students. In some studies, illiterate individuals and those with primary education have shown a higher prevalence of suicide [5]. It appears that an increase in education level and intellectual maturity leads to improved coping methods and the use of problem-solving strategies, allowing these individuals to make more appropriate decisions during crises [32]. The results also indicated a higher prevalence of suicide among unemployed and jobless individuals. Given that high school adolescents and most young people aged 20-25 in Yasuj are not in a favorable situation regarding employment status and financial independence, the findings are justifiable. Other studies also identify unemployment, poverty, lack of financial independence, and low income as factors contributing to suicide attempts in Asian and European countries [1].
Suicide attempts were more common among urban residents than among rural residents, which is consistent with the findings of other studies. However, in the study by Rahmani et al., suicide attempts are more prevalent among rural residents [5]. The reasons for this difference are likely related to the type of study and geographical location. Although a previous history of suicide attempts can influence the likelihood of recurrence, in the present study, most of the individuals who attempted suicide had no prior history of such attempts. In other similar studies, most of the suicide attempters also had no previous history [31, 33]. Nevertheless, a history of unsuccessful suicide attempts does impact the likelihood of recurrence [30]. Various studies have found that counseling and support measures are effective in reducing the risk of recurrence of suicide attempts [34, 35].
The use of medication was reported as the most common method of suicide, followed by substance abuse and poison ingestion. Additionally, shooting with a gun was the least commonly used method of suicide. Consistent with these findings, other studies have also reported the use of pills as the most common method of suicide [31, 36]. In the studies conducted by Armitage et al. and Ahmed & Heun, poison ingestion had been also noted as a common method of suicide [13, 37]. It seems that easy access to medication, particularly over-the-counter drugs from pharmacies, encourages individuals to use this method. Furthermore, due to the specific geographical area of Yasuj and the high usage of agricultural pesticides, people have easier access to these substances. Although the history of substance abuse among suicide attempters was low, substance abuse ranked as the second most common method for committing suicide. Possible factors influencing this situation include the use of substances by adolescents and young people, especially excessive use and exceeding the recommended dosages, which can create a foundation for suicide in these individuals. Although self-immolation has been one of the most common and severe methods of suicide among women in Dishmok [5], the prevalence of self-immolation was low in the present study. Possible reasons for this difference can be attributed to the specific geographical area and the type of study conducted in Dishmok. Another potential factor is the denial of suicide attempts by most burn patients, who consider their burns to be unintentional and accidental. In the study by Shakibkhah et al., hanging has been identified as the most common cause of suicide in Kohgiluyeh and Boyer-Ahmad Province, Iran, during the period from 2016 to 2021, while in the present study, hanging has been noted as a cause but with less prevalence [38]. The highest prevalence of suicide occurred in winter, followed by autumn, while the lowest number of suicide attempts was recorded in summer. Similar studies have also indicated an increase in suicide rates during winter and autumn [12, 36], although in some studies, suicide attempts have been most frequent in spring [39, 40]. These differences appear to be due to the geographical characteristics of the studied areas and the diversity of climate. However, considering the effect of mood disorders on the incidence of suicide attempts [41], the nature of winter and autumn, climate changes during these seasons, and the subsequent suicidal thoughts and possible actions should also be taken into account.
Also, 92.34% of the patients who attempted suicide recovered and were discharged from the hospital. Given that a previous history of suicide is a significant risk factor for repeated suicide, the risk of recurrence can be reduced by referring these individuals to psychological centers and providing them with the necessary counseling and support [35, 36]. In this regard, all those who recovered from suicide in the present study were counseled in coordination with mental health experts and received the necessary psychological services. However, for these counseling programs to be successful, the continuation of these sessions and measures to facilitate the patient’s participation in the aforementioned sessions should be considered.
The present study had some limitations. Because the information was recorded years ago, it may not be completely reliable or may not contain all the necessary information. Additionally, due to the lack of gender separation in suicide attempts, it was not possible to compare women and men. Furthermore, individuals who did not seek medical attention after attempting suicide or who denied their suicide attempt, considering it an unintentional and accidental incident, are other limitations that likely contributed to the low number of reported suicide attempts. Moreover, due to incorrect addresses and the hospitalization of suicide attempt patients from surrounding cities in Yasuj hospitals, as well as the existence of another hospital not affiliated with Yasuj University, it was not possible to accurately calculate the prevalence of suicide attempts; thus, the rate of suicide attempts may not be reliable.
A longitudinal study over the next five years, with comprehensive data collection, is recommended to examine trends and the prevalence of suicide along with all related factors. Furthermore, a case-control study would be beneficial for identifying risk factors associated with suicide attempts.
Conclusion
The frequency of suicide attempts in Yasuj between 2019 and 2023 is high and shows an increasing trend, with taking drugs being the most common method of suicide attempts.
Acknowledgments: This article is the result of a research project approved by the Vice Chancellor for Research of Yasuj University of Medical Sciences. The researchers feel it is necessary to express their gratitude and appreciation to the respected Vice Chancellor for Research of the university, the Yasuj City Health Center, the Mental Health Unit of the Health Deputy, and the esteemed experts of this unit who cooperated in collecting and completing the data.
Ethical Permissions: The present study was approved by the Research Ethics Committee of the Vice-Chancellor’s Office of Research at Yasuj University of Medical Sciences (IR.YUMS.REC.1403.111). All ethical principles necessary for conducting the study, especially the confidentiality of the information examined, were observed throughout the study.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors' Contribution: Zahmatkeshan N (First Author), Methodologist/Main Researcher/Discussion Writer (60%); Rastgouyan F (Second Author), Introduction Writer/Methodologist/Assistant Researcher (15%); Azmooni M (Third Author), Methodologist/Statistical Analyst (15%); Zarei Z (Fourth Author), Assistant Researcher (10%)
Funding/Support: This research was funded by the Yasuj University of Medical Sciences Research Center.
Keywords:
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