Suicide and attempted suicide in Suriname: the case of Nickerie Epidemiology … · 2019. 5. 26. · Interestingly, self-directed violence may be relatively high in Suriname, interpersonal

Academic Journal of Suriname 2016, 7, 628-642 Social SciencesFull-length paper

Acad J Sur 2016 (7) 628-642

Suicide and attempted suicide in Suriname: the case of NickerieEpidemiology and intent

T. Graafsma*, K. Westra** and A. Kerkhof***Institute for Graduate Studies and Research (IGSR), *De Bascule, Academic center for Child and Youth PsychiatryAmsterdam, **Department of Clinical Psychology, Vrije Universiteit Amsterdam

AbstractBackground: In the past 15 years, the suicide rate for Suriname almost doubled. Themore agricultural districts show the higher rates. Research in the district Nickerieconcerning the years 2000-2004 revealed the highest rates of suicide and attemptedsuicide.Aims: To present a general overview of suicide prevalence data for Suriname, as well asto provide more detailed follow-up data on suicide rates and characteristics of suicidalbehaviour in Nickerie, covering the years 2000-2012.Method: Descriptive exploratory and epidemiological research on national data, specifiedfor Nickerie. As in 2000-2004, from 2004 to 2012 Nickerie police and hospital registrieswere studied (suicide: N=161, attempted suicide: N=646). In addition, a sample (N=348)of patients was interviewed about their motives for attempted suicide, using the SuicideIntent Scale (SIS).Results: The national suicide rate doubled since 2000, far beyond the world average andseems to flatten towards a rate of 27. The suicide rate in Nickerie was high (47/100 000).Unlike the increasing national rate, the Nickerie prevalence rate was fairly stable. Forsuicide, men were particularly at risk. The male - female ratio was 3:1. Most vulnerablewas the East-Asian community. Admissions to the two Emergency Wards in Surinameconfirm the overrepresentation of the East Asians in attempted suicide. Pesticideintoxication accounts for more than half of all suicidal behaviours. Data from Nickerieshow that most suicide attempts are impulsive actions. Suicidal intent is low to medium.Women attempting suicide score higher on suicidal intent than men.Conclusions: Compared to the results from previous research, both suicide andattempted suicide rates remain on a very high level. The implications of the study forpolicy and intervention are discussed.

Key words: suicide, suicide attempt, suicidal behaviour, pesticides, Suriname

IntroductionWorldwide, every year more than 800 000people die due to suicide. In May 2013, the 66thWorld Health Assembly adopted the first everMental Health Action Plan of the World HealthOrganization (WHO). Suicide prevention is anintegral part of the plan, with the goal ofreducing the suicide rate by 10% between 2015and 2020 (WHO, 2014).In most Western countries, the male-femalesuicide ratio is 3 to 1, in the low- and middle-

income countries the male-female ratio is lowerat around 1.5 to 1. For every suicide there aremany more people who attempt suicide withoutdeath as a result. It is generally assumed that forevery suicide at least 10 to 20 non-fatal suicideattempts take place Stigma attached to mentaldisorders and suicide, and the fact that in somecountries suicide is illegal may influenceregistration and result in underreporting (WHO,2014).

Correspondentie: Tobi Graafsma, Institute for Graduate Studies and Research at the Anton de Kom Universiteit ofSuriname, Leysweg 86, Paramaribo, Suriname, Tel: 490900, E-mail: [email protected]

Available on-line oktober 7, 2016

629 T. Graafsma et al

Acad J Sur 2015 (7), 628-642

Also in Suriname, a low-middle income country,suicide is a serious mental and public healthproblem As happened in many countries, over thepast 50 years the country faced increasing rates ofsuicides.Whereas currently the world average isestimated at 12/100 000 (Varnik, 2012), inSuriname, between 2000 and 2012 the suicide ratealmost doubled to more than 26/100 000 (Mohanand Punwasi, 2013), putting Suriname in the tencountries (reporting suicide data) with the highestsuicide rates (see also Table 1). The male-femaleratio is stable at 3 - 1.

Table 1Suicide year-prevalence in Suriname

Year Rate

1965 6.2

1976 11

1981 17.2

2000 14

2005 22.5

2012 26.7Note: rates per 100 000 inhabitants. Source: Mohan and

Punwasi, 2013

The suicide rate in Suriname approximates thesuicide rate of neighbour country Guyana, whichaccording to Värnik (2012) is 26, the highest onthe South American continent. Recent data fromthe Guyana National Suicide Prevention Plan2015 - 2020 show even higher rates: for the year2012 the suicide rate was 44.2 (Guyana Ministryof Public Health, 2014).For the Caribbean region, these figures are ratherexceptional because in the majority of countries inthe region suicide rates are low. For the year 2012for example Jamaica reports a rate of 1.2.Barbados reports a rate of 2.3 and Haiti reports arate of 2.8 (PAHO/WHO, 2014). Trinidad andTobago and Cuba come closer to the worldaverage with suicide rates of 13 and 11.4respectively (Matthies et al., 2008; WHO, 2014).Interestingly, self-directed violence may berelatively high in Suriname, interpersonalviolence in terms of the homicide rate is not. Therate is 5/100 000; the average in the regionhowever is very high: 30/100 000 (see alsoMatthies et al., 2008; Balraadjsing, 2012;Emmanuel and Campbell, 2012). Jamaica scoreshighest with a rate of 50 (UNDP, 2012).

Hickling (in Matthies et al., 2008) suggested thatthe low suicide rates in the Caribbean might bethe result of a general tendency among persons inthe region to express their anger outwardly (in theform of violence towards others) rather thaninwardly (resulting in suicide). Findings byHutchinson confirmed this for Trinidad but not forTobago, where both suicide and homicide rateswere low (Hutchinson, 2005)i. Another form ofinterpersonal violence is violence against anintimate partner - a very common phenomenon inthe Caribbean region - as is violence againstchildren (Krug et al., 2002; Pinheiro, 2006;Matthies et al., 2008; Van der Kooij et al., 2015;Mason and Satchell, 2016). Homicides followedby suicides almost always involve conflicts withintimate partners, often in the context of a womanending a relationship (Roma, 2012; Emmanueland Campbell, 2012). We think that the relationbetween homicide and suicide and homicidefollowed by suicide in the Caribbean region is notwell researched and deserves more attention.

For long and as everywhere in the world (see foran overview Pompili, 2010), due to a variety ofreasons Suriname did not address the problem ofsuicide. Some reasons are not specific forSuriname. Many consider suicide an enigma.Suicide attempts were and often still are felt asincomprehensible. Although (following Dutchlaw) attempting and dying by suicide is notconsidered a criminal act in Suriname, assisting orencouraging someone to take his or her own life isa criminal act. For most people in a moral andreligious sense suicide is prohibited: decidingover life and death is thought to rest in the handsof God. For those who are left behind, the suicideof a beloved person may mean they failed intaking care as a containing environment withintense guilt as a result. For many of those leftbehind, the burning question that may pre-occupytheir mind for years to come is: why? Suicidesand suicide attempts also bring about angryreactions. In particular when the attempt isinterpreted as a lack of courage as well asdesertion. Sometimes however suicide attemptsreceive respect and even sympathy, for examplewhen they are understood as acts of loyalty or asrescue operations aimed at avoiding traumatizingcircumstances like torture, rape or slavery.

More specifically, in Suriname, before the year2000 research in the area of suicide and suicideprevention was almost non-existent. Onlygradually some research could be developed intothe prevalence and background of suicidality.

Suicide and attempted suicide in Suriname: the case of Nickerie 630

In part this probably is due the general factorsdescribed above, but in part also to the fact that inSuriname most people who die by suicide have anEast-Asian, Hindustani background.Such happens in the majority of cases of suicide(East-Asians comprise of 27 % of the Surinamesepopulation). This contributed to a silence aboutthe subject, for the Surinamese governmenttraditionally is very careful in avoiding the risk ofstigmatizing groups of citizens, in particularethnic groups. The worsening of the problem overthe years however was such that denial could notlonger be maintained.Interestingly, one study reports that in thecommunity of East-Asians already upon arrivingin Suriname as indenture labourers (in the periodbetween 1873 and 1917)ii already then manyindividuals attempted suicide (Pronk, 1962).Within the East-Asian group, the male-femaleratio was very skewed: men were overrepresented(m-f ratio was 4:1). Interpreting the data Pronkreported, at that time the suicide rate within thecommunity probably was at least 32/100 000.Recent studies (see Hassankhan et al., 2016)describe in depth the adjustment problems andintense suffering brought about by migrating outof the motherland.

Facts on suicide and suicide attempts inSurinameSuicideSuriname is with some 541000 inhabitants(census 2012) the smallest independent countryon the continent of South America. The largestethnic groups in the country are the Creoles/Maroons with historical roots in Africa; the East-Asians with roots in (formerly British) India,mostly from the states of Uttr Pradesh, Bihariii

and surrounding regions; and the Javanese withroots in Java, Indonesia. The original populationis almost absent: only three per cent of thepopulation has an indigenous (Amerindian:Arowak, Trio and Cariben) origin. The census2012 showed the following (see table 2)iv :

Table 2Population Suriname according to ethnicity, inpercentages, 2012Creole/

Maroon

East-

Asians

Javanes

e

Mix Other

38 27 14 13 8

Source: Menke and Sno, 2016

In the period 2000 - 2013 the number of suicidesin Suriname increased steadily and doubled, bothfor men and women, see Figure 1. The male-female ratio roughly stayed at 3 - 1.

Figure 1.Suicides in Suriname, absolute numbers, 2000 –2013.

Source: Mortality data BOG, 2013; Jubithana, 2016

Concerning the division by ethnic groups: mostvulnerable is the East-Asian group with apercentage of 62%. A small decrease might betaking place, as well as an increase amongMaroons: suicide in the Creole/Maroon group isincreasing to almost 27% of the total number in2013. The male-female ratios (2012 and 2013)within the main two ethnic groups(Creoles/Maroons and East-Asians) show nosignificant differences from the general trend.

Table 3Suicides in Suriname, main ethnic groups,percentages, 2012 and 2013

Creole/

Maroon

East-Asian Javanese Mix

2012 23 65 3 7

2013 27 59 4 5

Mean 25 62 3,5 6


When looking at the 10 districts of Suriname:most vulnerable are the more agricultural districts:Nickerie (63% East-Asian), Saramacca (51%East-Asian) and Commewijne (34% East-Asian).Figure 2 shows the district-rates between 2005and 2009.

0

50

100

150

200

2000

2002

2004

2006

2008

2010

2012

TotalMenWomen


Acad J Sur 2015 (7), 628-642

Figure 2.Suicide in Suriname, district rates 2005-2009


In terms of methods: Punwasi (2012) and Jubitana(2016) report for the period 2005-2013 that themethods most used are ingestion of a pesticide orsome other chemical (70% of cases), followed byhanging (20% of cases). Pesticides are widelyavailable and accessed easily, in particular ofcourse in the agricultural areas where they areused frequently. Every year Suriname importstons of pesticides, in particular herbicides likeparaquat and glyphosate. Imports of theseherbicides are rising. The most lethal of the two,paraquat is used most as a method of ending one’sown life.In terms of age groups: the number of suicidesincreases in adolescence and young adulthood,peaks around 37, decreases after people enter theirfifties and increases again slowly in seniority(with a male-female ratio changing from 3 - 1 to 4- 1). Noteworthy here might be that in Surinameeuthanasia is prohibited. The situation inSuriname roughly corresponds to what is noticedworldwide: suicide is one of the leading causes ofdeaths among those in the economically mostproductive age groups. The low and middle-income countries bear the larger part of thesuicide burden. However, they are less wellequipped to prevent suicide due to inadequacies ininfrastructure and in economic and humanresources. Stigma related to suicidal behaviourand suicide remains a major obstacle to suicideprevention and intervention efforts (WHO, 2012).

Attempted suicideMany, and maybe even most suicide attempts donot come to our professional awareness. It isestimated that for every suicide, at least 10 to 20times - or even more - as much suicide attemptstake place, not resulting in death.

Estimations differ - for example because of thedefinition issue. Does reckless behaviour with aserious chance of dying need to be included?Should self-harm with a serious risk of dying beincluded?Or should we include only acts of killing oneselfintentionally? We might decide in favour of thelatter, but then other questions arise that may beof influence in deciding about in- or exclusion ofsome behaviour. For example: what is that“intent”? To be dead for example, or to stopthinking or stop mental pain (see in this regard f.e.Shneidman, 1985; Joiner, 2007; Kerkhof and VanSpijker, 2012)? These considerations must warnus that we interpret data on suicide and attemptedsuicide as well with care (see for other aspectsalso Shea, 1998).

Neighbour country Guyana reports an estimatedratio of 20 - 25 cases for every suicide death(MOH Guyana, 2014). Suicide attempts causingphysical damage and suffering often are presentedat an Emergency Department (ED) of a hospital.In general ED’s keep record of such cases. Ourdata on suicide attempts thus mainly come fromthe two Emergency Departments in the country.Attempts that do not result in admission to one ofthe ED’s stay outside formal registration. Poese(2014) reports for the ED of the ParamariboAcademic Hospital for the period 2008-2013 asteady admission of some 630 attempters yearlywith a male-female ratio of 1:1.5. About Nickerieand for the same period Graafsma (2014) reporteda mean yearly admission of 71 attempters, with amale-female ratio of 1:1.10. Calculating anattempted suicide rate out of these data for theParamaribo area is difficult because except for theNickerie district, the ED is the only in the countryand in principle services all but one districts. Formany emergency cases however, the ParamariboED cannot be reached within one hour. Poese(2014) reports that most attempters come from thedistricts Paramaribo and Wanica. Departing fromthe number of inhabitants in these two districts(according to the census 2012: 359 000) anattempted suicide rate can be calculated of 176.The actual rate will be higher of course. ForNickerie the attempted suicide rate for the period2008 - 2013 is 219. For both Nickerie andParamaribo, the male-female ratios are ratherremarkable. They do not conform to the ratio thatis generally reported for Western countries onattempted suicide, which is 1 - 3. But they doconform to the ratios for developing countries,which show more equality between both genders.

0 20 40 60

SipaliwiniMarowijne

BrokopondoParamaribo

ParaCoronieWanica

CommewijneSaramacca

Nickerie


The case of NickerieEast-Asians constitute the largest ethnic group inthe most western and agricultural district inSuriname, Nickerie. Previous epidemiologicalresearch (Graafsma et. al., 2006) revealed highsuicide rates in this district in the years 2000 -2004. The suicide rate for this five-year periodwas 49 per 100.000. Pesticide self-poisoning andhanging were the two methods most used. TheNickerie district is close to the most easternGuyanese district of East Berbice-Corentyne(region 6), known for its high suicide rate,estimated at 50.8 per 100.000, like Nickerie closeto twice the national rate (data MOPH Guyana,2015).

The use of pesticides in suicide and attemptedsuicide is a well-known phenomenon indeveloping agricultural and tropical countries(Gunnel & Eddleston, 2003; Gunnel, Eddleston,Phillips,& Konradsen, 2007; WHO, 2009). Easyaccess to and a wide availability of highly lethalpesticides like paraquat are understood to bemajor risk factors. The WHO estimates that370.000 people die of pesticide intoxicationyearly, more than one third of total worldwidesuicide deaths (Gunnel et al., 2007; WHO, 2009).Pesticides appear to be predominantly associatedwith impulsive acts of self-harm (WHO, 2009).Data from Graafsma et al. (2006) and later fromVan Spijker, Graafsma, Dullaart & Kerkhof(2009) confirmed this for the Nickerie district:most (some 80%) acts of attempted suicide in theNickerie district were characterized by attemptersthemselves as impulsive events. We will return tothe question of impulsivity in a moment.We wondered whether the increasing national ratewas reflected in the gradient of the Nickeriesuicide rate. This and the severity of the suicideproblem prompted us to continue the research,accompanied by some tailored forms ofintervention: 1) providing psychosocial help tosuicide attempters and their families and 2)influencing the attitudes (encouraging stricterlegislation included) towards selling, use, storageand disposal of pesticides - both strategiesconsidered to be forms of “good practice” insuicide prevention (see for example Beautrais etal., 2007). The epidemiological study thus aimedto provide follow up data on suicidal behaviour inthe district of Nickerie from 2004 to 2012, likebefore by studying police and hospital registries.In order to offer a long-term overview of suicidalbehaviour in Nickerie, some of the findings of theprevious study of Graafsma et al. (2006) havebeen integrated into this report.

Since 2004 additional data has been collectedthrough semi-structured interviews conductedwith individuals seen in the EmergencyDepartment of the Nickerie district hospitalbecause of attempted suicide. This data oncharacteristics, socio-demographic informationand motives in attempted suicide might help toidentify trends and risk factors. The interviewscontained a suicide intent scale to assess the intent(goal, seriousness) of the suicide attempt. Theunderlying factors of this scale were analysed togain more insight into the components of suicidalintent within the research sample.

MethodDesignThis study was an exploratory epidemiologicalstudy, using death registries, police registries andhospital registries to acquire data about thenumber of suicides, and hospital registriescombined with interviews of patients afterattempted suicide. All data from the registrieswere acquired from the Nickerie policedepartmentv and the Nickerie District Hospital.

Epidemiological data related to suicide andattempted suicide.In order to determine suicide rates, policeregistries and hospital records collected from2004 to 2012 were combined with municipaladministration registries. For this period 161 casesof suicide in the Nickerie district were registered.In this report, data from Graafsma et al. (2006)were added, concerning 68 suicides from the fourearlier years (2000 to 2003).In order to determine attempted suicide rates thehospital registry from 2004 to 2012 was used. Inthis period 646 patients entered the EmergencyDepartment (ED) because of attempted suicide.The data concerning the years 2002 and 2003have been adopted from Graafsma et al. (2006)vi .The total number of suicide attempts from 2002 to2012 was 796. The data gathered containedinformation on age, gender, ethnicity and method.

Psychological data retrieved from semi-structured interviewA subsample of 348 ED-patients agreed to beinterviewed after attempted suicide, which wasalmost 50% of all patients entering the EDbecause of a suicide attempt. This resulted in anextensive dataset collected about characteristics ofindividuals with non-fatal suicidal behaviourduring that timeframe. The patients notinterviewed either were sent home before contactwith the interviewers was established (often due


Acad J Sur 2015 (7), 628-642

to ED work-pressure, frequent changes in ED-staff, unavailability of beds) or refused to disclosetheir situation and motives, sometimes on advicefrom family members.Speaking about a suicide attempt still is verymuch taboo in the community, in particular sincefamily secrets and insurance - or religiousproblems may emerge. Some selection bias thuscannot not be ruled out. The semi-structuredinterview contained questions regarding suicidalintent, method, preparations, employment andincome, previous suicidal behaviour, family andliving conditions, health-care utilization andalcohol and drug usage.

These topics were adapted from the WHO/EUROMulticentre Study on Suicidal Behaviour EPSISinterview (Schmidtke, Bille-Brahe, De Leo &Kerkhof, 2004).

Suicide Intent Scale (SIS)In the interview, eleven items from the SuicideIntent Scale (Beck, Schuyler & Herman, 1974)were asked orally, since many patients wereilliterate so that the self-report version was

useless. These items were separately analysedusing factor analysis as to gain insight into thesuicidal intent of patients interviewed.The original scale contained 15 items. Only theinterview rated items were used (rated by studentswho conducted the interview within the hospitalsetting). The 11 items used in this study werescored with zero, one or two. Higher total scoreswere interpreted as reflecting a higher suicidalintent. Incomplete cases were left out (list wisedeleted). The total number of cases analysed was166.

ResultsIn the period studied, in Nickerie each year onaverage 17 individuals died from suicide and 72individuals consulted the ED because ofattempted suicide (see table 4).

Epidemiological study

Table 4Absolute numbers and rates suicides and attempted suicides in Nickerie 2000 - 2012

Different from the national increasing trend inSuriname (100% in 12 years), no rise or fall insuicidal behaviour in Nickerie was observed. Therates per 100 000 inhabitants are 47 for suicideand 199 for attempted suicide respectively (2002 -2012). The suicide rates for men are four timeshigher than for women (81 and 20 respectivelyduring the 2004-2012 period). Differences

between genders in attempted suicide rates aresmaller, with a rate of 192 for men and 207 forwomen. The male-female ratio here is ratherstable around 1:1. The sharp increase in suicidesin the year 2009 looks similar to developmentsdescribed in Europe and elsewhere (see Stuckler,Basu, Suhrcke, Coutts & McKee, 2011; Barr,Taylor-Robinson, Scott-Samuel, McKee &

Year Suicide Abs Rate/ 100.000 Att. Suicide Abs Rate/ 100.000 2000* 24 64 2001* 19 51 2002* 13 35 72 191** based on 37618 inhabitants 2003* 12 32 78 207** in the district

2004 20 56 84 2332005 24 67 65 1802006 19 53 76 211 Based on an average of2007 13 36 64 178 36020 inhabitants2008 13 36 66 183 in the district2009 24 67 60 1672010 18 50 78 2172011 17 47 83 2302012 13 36 70 194

Average 17 47 72 199* From Graafsma et al. (2006)**From Graafsma et al (2006), corrected


Stuckler, 2012). However, Suriname at large wasnot hit by the economic crisis in 2008 thataffected so many countries. The economic growthwas stable around 4%, mainly due to an increasedproduction of oil and gold. The rice sector(concentrated in Nickerie) showed an overall risein annual production, also about 4%, but could notcompete on the international market and in 2008got a “negative price” for its products. At thattime, Nickerian farmers did face an economiccrisis and needed governmental support forsurvival (Derlagen et al., 2013).In general, several conclusions can be drawn: a)The suicide rate in the Nickerie district is morethan twice the national rate and high; b) comparedto the national trend, the rates for suicide andsuicide attempts in Nickerie are stable: c)compared to European data (Schmidtke et al.(1996) the rates for suicide attempts in Surinameare not elevated.

SuicideIn Nickerie, in the period 2004 - 2012, 161individuals died because of suicide. On average,80% of all suicides involved males. In 22% of thesuicides the victim was between 16 and 25 yearsof age. A vast majority (91%) of the suicidesinvolved persons of East-Asian descent. Theprevalent methods were pesticide intoxication(51%) and hanging (44%). The mean age ofindividuals who died due to suicide in Nickeriewas 35. Hanging was the most deadly methodchosen with a case fatality rate of 1:1.2(completed suicides (CS): attempted suicide(AS)). The second most lethal method used waspesticide intoxication with 1:4.8 (CS:AS).

Attempted suicideIn the period 2004 - 2012 a total of 646 personswas registered as attempting suicide. On averagethis equates to 72 attempts each year. Slightlymore than half (54%) were females. Similar to thecases of suicide, people who attempted suicide inNickerie generally belonged to the East-Asiancommunity (85%). Most cases of attemptedsuicide fell into the 16-25 age category (39%). Anaverage of 8% of the suicide attempters were 15or younger and 72% were younger than 35 yearsof age. The method most used wasautointoxication by ingestion of a pesticide(mostly paraquat). This accounted for 50% ofattempted suicides (321 cases). In a total of 93%of suicide attempts a toxic substance of some sortwas used. On average, individuals attemptingsuicide but surviving were 6 years younger (29

years of age) than individuals whose attemptswere fatal (35 years of age).

Suicide: trendsWe already reported that for this period of timesuicide rates in Nickerie were high. In comparisonto the other nine districts in Suriname, they werethe highest in the country (Algoe and Punwasi,2013) and fluctuated around a mean of 47, almosttwice the current country rate. The suicide male-female ratio tended to be 4:1. No change could beseen in the suicide rate for women, but for men,after the sudden peak in 2009, a decline could benoticed. Whether this will result in a trulydownward trend remains to be seen. Nosignificant changes were detected in methodsused.

Suicide attempts: trendsRates for attempted suicide fluctuated around amean of 199, not very unusual and quite stable forboth males and females. The male-female ratioresembles the ratios often noted in developingcountries. Where for Western countries one wouldexpect a 1:3 ratio, we saw a stable 1:1.5. Noessential changes were visible in methods used.The use of pesticides as a method for attemptingsuicide increased over the past years, the use ofhanging decreased (Mohan and Punwasi, 2013).

InterviewsCharacteristics of attempters and their suicidalbehaviourMore women (63 %) than men (37 %) could beinterviewed. Almost half of them were notmarried at the time of the suicide attempt. Thewomen interviewed were significantly (t =2.6118; p<0.01) younger than the men with anaverage of respectively 25,7 and 29,2 years ofage. Both men and women were predominantlyfrom East-Asian descent (around 86 %). For bothgenders, the most common method in attemptedsuicide was the ingestion of a pesticide. Howeverthe prevalence of pesticide intoxication wassignificantly higher in men as compared towomen, χ2 (1, N= 343) = 25.05, p <.001.Different from the men (10,2 %), many women(38,4 %) used an overdose of medication in theirattempt, χ2 (1, N=343) = 31.53, p < .001.Female attempters remained in school longer(Mdn = 186.35) than male attempters (Mdn =149,13), and so they were significantly highereducated, U = 10832, p = .001. Of theinterviewees, 95 % did not receive any previoushelp from psychologists or psychiatrists.


Acad J Sur 2015 (7), 628-642

Almost half of the interviewed suicide attemptersthought their suicidal behaviour in some waycould have been prevented. That did not meanhowever they looked for psychosocial or medicalhelp: many respondents said they would behesitant to accept such help because of shame.That applied more to the men: only 37 % of themwould accept available mental health care such asprovided by a counsellor, a psychiatrist or apsychologist. Among the interviewed womenhowever, 50 % told us that they would haveaccepted mental help if available.Around 85 % of the suicide attempters stated thatthey did not plan their suicide attempt, and 82 %(both women and men) stated that they acted onimpulse. This is similar to what was earlierreported by Graafsma et al. (2006). Differences

could be seen in the attitude towards life anddeath. Almost 40% of women (Mdn = 182.40)reported they had a wish to be dead (expressing astronger intention of dying), whereas men (Mdn =151.79) more often did not want to be dead, U =11149, p =.002. Almost 40% of male attemptersingested some alcohol before attempting suicide;most (95%) women did not. About one quarter ofall interviewed suicide attempters (24 %) had oneor more suicide attempts in their history, but only5 % reported having had contact with a mentalhealth professional. More than half (56 %) ofpeople attempting suicide knew someone who hadattempted or died by suicide. For an overview ofinterview results see table 5.

Table 5 Overview of interview results 2004 to July 2013 in percentages of males and females


Suicidal IntentThe average score on the SIS items in this samplewas 7,2 (SD = 4.1). Women scored significantlyhigher than men (women 7,8; men 6.0; t = 2.8425;p < 0.01). There were no norms available for anincomplete sample of SIS items, but when scoreswere converted to match the original SIS(corrected for different scoring and number ofitems) they indicated a low level of suicidal intentfor men and a medium level of suicidal intent forwomen. Of course, these levels are only indicativebecause of methodological issues.Not only suicidal intent but also motives for thesuicidal behaviour were different for men andwomen. Unlike the women, most men (32 %)wanted to gain something with the suicidal act,suggesting that for a considerable number of menthe suicidal behaviour was a form of interpersonalcommunication and bargaining. Women primarilyindicated they wanted to die (39 %), suggestingthat - following Beck (1976, 1967) - their suicidalbehaviour first of all was motivated by a feelingof hopelessness.The group of girls (below the age of 16) withsuicidal behaviour deserves special attention.

These girls seemed quite serious in their suicideattempts. They scored equal to women (mean 7.7;SD = 4,2) on the items of the SIS and 28 % ofgirls even reported previous suicide attempts.They were not yet on the radar of health careprofessionals in Nickerie: only 1 out of 35 girlswho attempted suicide ever receivedpsychological assistance and none of thempreviously consulted a psychiatrist.

Factor analysis of the Suicide Intent ScaleThe structure underlying the 11 items of the SISwas analysed using exploratory factor analysis.The goal was to determine major componentsamong the 11 items.The total number of cases analysed was 166. Thereliability of the total scale proved to be sufficient(Cronbach’s α = 0.662; M = 7.2, SD = 4.08; ).Three (unrelated) components were identified: 1)Wish to die, 2) Chance of intervention/help and 3)Amount of preparation/planning. These 3 factorstogether explained 50,3% of the variance (seetable 6).

Table 6Factor loadings per item of the SIS (Extraction method: Maximum Likelihood. Rotation method: Varimax withKaiser Normalization)

Factor1 2 3

Feelings regarding life and death ,974 ,078 ,069

Intended purpose of attempted suicide ,694 ,153 -,050Perceived chance of dying ,517 ,109 ,330

Presence of person during attempted suicide ,134 ,669 ,084

Timing regarding possible intervention ,166 ,567 ,311

Contact with helper ,027 ,421 -,018

Measures regarding possible intervention ,074 ,192 ,470

Suicide note ,006 ,039 ,468Possible prior plans regarding attemptedsuicide

,008 ,203 ,433

Told plan to others ,036 -,058 ,251

Preparation Attempted suicide ,176 ,027 ,219


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When the scales underlying the 3 factors wereanalysed, it showed that the reliability for factor 1was good (Cronbach’s α= .753) and for factor 2and 3 the internal reliability was reasonable (α=.497 and α= .402 respectively). This implies thatconclusions using the items of factor 2 and 3should be drawn with some care. The scores werethe highest on factor 1 (Wish to die; M=3.47, SD=2.24,) and factor 2 (Chance of intervention/ help;M= 2.44, SD= 1.85,). Scores on factor 3 proved tobe remarkably low (Amount of preparation/

planning; M= 1.10, SD= 1.49,) which is congruentwith the impulsive nature of suicidal behaviourwe reported earlier.We wanted to know how these factors related toother items of the interview conducted in thisstudy. The SIS total score correlated withprevious suicide attempts (r = 0.316; sign. <0.01).For the separate SIS-factors, correlations withother aspects of the interview were found.However, these correlations in general were notstrong. See Table 7 for details.

Table 7Correlations of SIS-factors with interview variables

SUM factor 1Wish to die

SUM factor 2Chance of help

SUM factor 3Preparation

Needed healthcare after AS Pearson’s r ,008 ,173** ,016

Danger to life Pearson’s r ,156* ,027 -,130*

Gender Pearson’s r ,012 ,054 ,216**

Previous attempts Pearson’s r ,172** ,000 ,321**

Impulsive AS Pearson’s r -,088 -,025 -,369**

* = sign.<.05 (two-tailed); **= sign<.01 (two-tailed)

As can be seen in the table, factor 3 (preparation)produced the strongest correlations. It is nosurprise that the factor amount of planning/preparation correlated negatively with impulsivityof the attempt. More interesting is the positivecorrelation between amount ofpreparation/planning and previous attempts. Thissuggests more effort in planning in persons whohad repeated a suicide attempt. Danger to life isweakly correlated to feelings of life and death,opposite to the total SIS scale, which has no suchcorrelation. The reason for this probably can befound in table 7 as well; the amount of

preparation/planning has a striking negativecorrelation with danger to life found in theinterview sample.As noted earlier in this study, women scoredsignificantly higher on suicidal intent than men.This conclusion matches with the results of thefactor analysis. Table 8 shows the means forwomen and men. The table shows the moredeadly intent and greater amount of preparation ofwomen in the sample. The difference betweengenders on the factor chance of intervention/helpis smaller.

Table 8Mean scores of men and women on separate factors of the Suicide Intent Scale

Factor 1(Wish to die)

Factor 2 (chanceintervention/ help)

Factor 3 (planning/preparation)

MaleMean 3,10 2,31 ,68

SD 2,27 1,75 1,12

FemaleMean 3,67 2,51 1,35

SD 2,22 1,91 1,63


Trends retrieved from the interviewAll data available from the interview wassearched for changes during the years studied. Ingeneral, numbers turned out to be quite stablefrom 2004 -2012. The interview data shows thatthe mean age in the sample for both men andwoman is stable. However, the underlyingdistribution among the different age categories inwomen seems to change. The category under 16years old is increasing in recent years while thecategory of women aged 16-25 is decreasing(equal to findings from the hospital recordsabove).The willingness to talk to a mental health careprofessional or a counsellor (“if this service wouldbe available”) decreased from around 60% of thepatients who were willing to use mental care“when available” in 2004, to only 30% in 2012.This is remarkable, because the availability ofmental health care increased during this years,suggesting that the taboo on asking for mentalhealth care is still high. A stable 5% of theinterviewed patients received mental health careprevious to their current suicide attempt.

ConclusionsSuicidal behaviour is a major problem inSuriname. National data show that the suicide rateincreased steadily and momentarily suicide is oneof the leading causes of death. Far beyond theworld suicide rate, the national suicide rate inSuriname is 26.7 per 100 000 inhabitants (2012).More men than women die by suicide (ratio 3:1).East-Asians, living in the more agricultural areasof the country, are most vulnerable. Although27% of Suriname’s population is East-Asian, 62%of suicides happen in their communities. Creoleand Maroon inhabitants together amount to 38%of Suriname’s population, 25% of suicides takeplace among them. The main method used (70%)was ingestion of a pesticide, primarily paraquat.Slightly more women than men attempted suicide:the Emergency Department of the AcademicHospital Paramaribo reports a male-female ratio1:1,5. Recent impressions suggested that suicideattempts among the Maroons were increasing,among East-Asians decreasing. The main methodused was ingestion of a pesticide (38%), followedby ingestion of overdoses medicine (27%) andchemicals, other than pesticides ( 25%).

Data from the Nickerie district show that suicideis an urgent problem, affecting the community fordecades. The 10 years mean suicide rate was 47with a male-female ratio of 4:1. Again East-Asians were the most vulnerable.

The method most used was autointoxication witha pesticide (primarily the herbicide paraquat;almost 50% of cases). Hanging was the secondmost used method (44%), followed by ingestingsome other substance.In Nickerie also, more women than men attemptsuicide but the ratio is 1:1.10. Ingestion of apesticide was the method used most (51% ofcases), followed by ingesting of another chemical(37%).Data collected from interviewed suicideattempters should not be taken as representativefor those who actually died by suicide. It iswidely supposed that the biopsychosocialcharacteristics of people who die by suicide maybe different from those who attempt suicide andsurvive the attempt. Support for that hypothesiscomes from the SIS-results in this study: theseshowed a low (men) to medium (women) suicidalintent. So our conclusions may be consideredapplicable to people attempting suicide andsurviving that attempt.

To learn more about characteristics and causes ofsuicide, we need more research using autopsy-information (see Van Spijker et al., 2009).For attempters, characteristic was the impulsivityas said by most of them and as can be seen fromthe lack of preparation (see table 5). The questionthen is of course: was the attempt “irresistible” ordid one allow him- or herself to lose control?The question, although not easy to answer, isimportant for policy and treatment. In the firstcase one feels “overwhelmed” (like in a traumaticsituation), in the second case indulges in whatmight be a desire with a specific aim: for exampleto convince a leaving partner not to do so bythreatening to take one’s life. Almost 40% of mentook (“some”) alcohol before the attempt, mostwomen did not. In comparison with abstinence,alcohol intoxication increases suicide risk up to 90times, in particular in combination withimpulsivity (see Hufford, 2001). Whenintoxicated, people are more likely to attemptsuicide by using easy to access means that have avery low probability of survival. Suicideprevention among men thus may need a policydirected at restricting access to and use of alcohol.

The ease of access to very lethal pesticidesprovides every person in pain and despair wishingto end that situation with a powerful tool to do so.In a sense, pesticides are ultimate painkillers -unfortunately they may kill the person also.And as can be seen from the national and thedistrict-data: they are used widely.


Acad J Sur 2015 (7), 628-642

Together with its impulsive character andeventually reinforced by ingestion of somealcohol (as to overcome the disgusting smell forexample), we find a combination of some veryrisky conditions.In general, the characteristics uncovered by theinterviews do not differ from what we know fromother (developing or low-income) countries: manyattempters experience extreme poverty; they areinvolved in family conflicts, socially isolated andlow-level educated (sometimes hardly able to readand write), adolescent or young adults. Attemptspeak in adolescence and young adulthood,suicides peak some ten years later.As could be inferred from the interviews, stigmaon suicide and eventually on looking for help isstill very strong.Suicide is considered a solution (in particularattractive to people who like to be self-reliant);suicidal ideation is not yet considered a warningsign that one has to consult a professionalvii .

DiscussionLimitations of this studyData on suicide and suicide attempts came fromthe hospital and police registries. Almost half ofall persons coming to the Emergency Ward afterattempting suicide were interviewed. For a varietyof reasons, including that their physical conditiondid not necessitate it, not all persons attemptingsuicide came to the hospital. Of those who came,many were reluctant to be interviewed.Experience soon taught us that, when at homeagain, almost everyone refused to be interviewed.Repression of what happened set in very fast.Patients were therefore interviewed within thehospital setting. Many patients were not at easewith explaining their emotions and motives,although the interview could be conducted in theirlocal language. Distrust of hospital staff inhandling confidentiality certainly played a rolehere. Some selection bias thus cannot be ruledout. With regard to police suicide registration:every death must be registered by a physician andreported to the police. Also in all cases ofsuspected suicide, police has to be informed.Police registration thus is fairly reliable, although,for example because of stigma, it cannot be ruledout that some deaths by suicide actually arereported to have a different cause and thus are notincluded in the suicide statistics.

Strengths of this studyA strong aspect of this research is that it covers arather large period. That warrants the conclusionthat suicidal behaviour is a serious chronic health

problem, in particular in the district of Nickerie.The suicide rate of 47 deaths per 100 000individuals (NIckerie) is unacceptably high.Comparing the recent data with earlier data(Graafsma et. al., 2006), it can be concluded thatno indications can be seen of a clear decline insuicidal behaviour in the last decade. Thatsituation makes the implementation of a NationalStrategy for Suicide Prevention most urgent.The data from this study clearly indicate thatsomething also has to be done on regulation ofaccess and use of the most lethal pesticides. Theextent of the use of pesticides reported in thisstudy is even slightly higher than was foundearlier (Graafsma et al., 2006). Striking here is thefact that although suicidal intent is low tomedium, very lethal pesticides are ingested,maybe exactly because they are so easy to access(this also was suggested elsewhere, for exampleby Denning, 2000). As stated earlier, theextensive use of pesticides in attempting suicide isconsistent with findings in other studies (forexample Gunnell et al., 2007; Cha, 2016)investigating suicide in agricultural areas indeveloping countries and, as in Nickerie, inparticular among people from East-Asian,Hindustani descent.Many questions remain of course. There is thequestion “why did she or he do it?” both on anindividual level and at the level of the community.Are East-Asians, Hindustani more than otherethnic groups vulnerable for suicidality? Dobiological, genetic factors exert some influence?Besides, could culture exert influence, forexample through social learning and the massmedia? Do we need an ecological model indeed toaccount for the interplay between many riskfactors? And then there is the finding thatimpulsiveness in terms of a lack of plan andpreparations characterizes so many suicideattempts. Does this refer to problems in self-regulation as Baumeister (1999) suggested? Or isthis impulsiveness essentially related to rebellion,to liberation from the constraints of the family andall its intricacies and dependencies - like in thecase of Mahatma Gandhi as a young man?

Gandhi reports suicidal ideation together with afriend because the:“…lack of independence was intolerable. Evendeath was preferable. They decided to commitsuicide, made a suicide pact, sealed it by a visit tothe Kedarji Mandir, lighted a light to the deity tobless their enterprise, and proceeded to a lonelyspot with the seeds of the poisonous dhatura(belladonna) in their pocket. They swallowed a


few seeds each. But then their courage desertedthem”(Erikson, 1969, p. 134).

PreventionThe conclusions and the discussion of resultspoint in several directions that may help reduceand prevent suicide.Most urgent is the restriction on access topesticides. Graafsma et al. (2006) alreadyrecommended the control/limit of access topesticides. Yip, Caine, Yousuf, Chang, Chien-Chang Wu, and Chen (2012) showed this could beeffective. Even when means substitution occurs,the outcome is often less lethal and in some casessuicidal behaviour is even completely prevented.It is generally believed that suicidal impulses areoften short lived. So if time can pass by makingmeans of suicide less readily available aproportion of suicides could probably beprevented (Gunnell & Eddleston, 2003; Cha,2016). Vijayakumar & Sateesh Babu (2009)performed a small-scale experiment in fourvillages in India with promising results. Theyreported a significant decrease of suicide deathsfrom fourteen to three after the villagers stoppedusing chemical pesticides. Research elsewherealso shows that restriction of access to pesticidesmay reduce suicide substantially (see alsoHutchinson et. al, 1999; Gunnell & Eddleston,2003; Gunnell et al., 2007; Mishara, 2007;Cha et al, 2016). Cha et al. (2016) recommendthat restriction of access is accompanied bylegislation that can be controlled.To conclude: banning the most lethal pesticidesshould be considered first. We have to remainaware of course, that such “technical” measuredoes not address the psychological causes ofsuicidality and the motives involved, nor does thisalleviate the suffering of those who are leftbehind.As a second preventive measure access to primarymental health care is to be promoted. The findingin Nickerie that almost no suicide attempter isusing mental health care has to result in a publichealth campaign aimed at enhancing knowledgeabout mental health care and fighting stigma onmental health problems.A third preventive measure is to involve large-scale participation of people through a publichealth approach and offering them educationalprograms, for example in pesticide controlviii.Educating (primarily) young people in anothermatter: interpersonal conflict resolution,maintaining and safeguarding reciprocity andconnectedness, might be a good investment infuture family health.

Like in other developing and low-incomecountries many - if not most - suicide attempts inNickerie follow crises in interpersonalrelationships.A fourth preventive measure was proposed byGunnell et al. (2007) and also by Mishara (2007).They suggested that much can be gained in thearea of suicide prevention with improvedawareness in primary health care, for example bymeans of “gatekeeper” training activities forhealth care professionals like physicians, as thestrongest factor associated with suicide is ahistory of attempted suicide (Hawton and VanHeeringen, 2009).A fifth preventive measure could be directed toalcohol abuse and alcohol dependency.Restriction of access to alcohol might be apromising policy.Recently, the Surinamese government adopted aNational Suicide Prevention and Intervention Plan(June 2016). This is a major step forward, forexample because it provides for coordination andmonitoring of preventive actions. The Strategycontains valuable recommendations and usessuggestions from the WHO Preventing SuicidePlan (2014). Yet: many steps still have to bemade.

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i For more on the relation between violence and suicidalitysee for example Van Dulmen et al.( 2013).ii On July 1, 1863, the Dutch abolished slavery in Suriname.iii Where currently suicide rates are far lower than the Indianational average.iv For a detailed discussion on the categories “Creole” and“Maroon”: see Menke and Sno (2016, p. 105 - 126).v In Suriname, all deaths where suicide is suspected have tobe reported to police. This obligation applies also toattempted suicide, although in practice that does not happenanymore.vi No data on attempted suicide were available for the years2000 and 2001, since registration of attempts started in 2002.vii Notably, paraquat is loosely called a “medicine”.viii Currently, a public health program related toenvironmental and occupational health is conducted in acollaboration between the Tulane University School of PublicHealth and Tropical Medicine (New Orleans, US), theRegional Health Care center Nickerie (RGD), the AcademicHospital Paramaribo and the Anton de Kom University ofSuriname. A part of the program promotes awareness, safestorage and safe use of pesticides through a tailoredcommunity based participatory intervention.

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Suicide and attempted suicide in Suriname: the case of Nickerie Epidemiology … · 2019. 5. 26. · Interestingly, self-directed violence may be relatively high in Suriname, interpersonal