Evaluation of Suicidal Risk in Sickle Cell Patients Monitored at the Hubert Koutoukou Maga National University Hospital Center in Cotonou in 2022 ()
1. Introduction
According to Health Organization (WHO) estimates for 2019, the suicide rate in Africa was higher than the global average, with an increase of 37% compared with 2000. In Benin, in 2019 the age-standardized suicide rate was 12.7 per 100,000 inhabitants, higher than the global average of 09 per 100,000 [1] . A study conducted from 2013 to 2017 in northern Benin estimated the average suicide mortality rate at 14.9 per 100,000 inhabitants [2] .
Among the risk factors for suicidal behavior identified by various studies are pain and chronic illness [2] [3] . Suicidal behavior is reported to be 2 to 3 times higher in people with chronic illnesses than in the general population [4] , and all illnesses associated with pain, physical disability, neurodevelopmental disorders and distress increase the risk of suicide [5] [6] [7] .
In the WHO African Region, sickle cell disease is recorded in at least 40 countries, with prevalence rates of the βS gene ranging from 2% to 30% [8] . In Benin, one of the most prevalent chronic conditions associated with pain is sickle cell disease, due to the vaso-occlusive crises that constitute its most frequent acute complication. The prevalence of sickle cell trait S is estimated at 20%, and that of hemoglobin C at 10%. Similarly, the percentage of the population carrying SS homozygosity and SC double heterozygosity is estimated at 4.8% [9] . However, in the literature in Africa in general and Benin in particular, data are almost non- existent on suicidal risk among sickle cell patients, who nonetheless constitute a population at risk of suicide. The aim of this study, conducted with a view to filling this gap on the one hand, and contributing to suicide prevention on the other, was to assess the suicidal risk among people with sickle cell disease.
2. Materials and Methods
This was a descriptive and analytical cross-sectional study, conducted by survey of sickle cell patients followed up in the University Clinic for Blood Diseases (CUMAS) of Hubert Koutoukou Maga National University Hospital Center (CNHU-HKM) from August 15 to November 13, 2022.
As the prevalence of suicide in Benin is 12.7 per 100,000 inhabitants [1] , and the average number of new sickle cell patients admitted to CUMAS per year is 350 [9] , the prevalence of suicide in this specific population is estimated at 350 × 12.7/100,000, or 0.044. The sample size N representative of this specific population was calculated using the Schwartz formula, assuming a confidence interval of 95% and a margin of error of 5%.
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The sample was constituted by census of all sickle cell patients attending consultation or hospitalized, aged at least 16 years and having given their informed consent. Sickle cell patients whose clinical condition did not allow them to participate were not included, particularly patients experiencing a painful crisis.
The variables studied were socio-demographic data, marital status, professional status, reason for consultation, length of follow-up in the department, psychiatric history, universal risk factors associated with suicide and therapeutic recourse.
Data were collected using a questionnaire designed for this purpose and the Ducher Suicide Risk Self-Assessment Scale (aRSD), which was completed in the presence of the physician to overcome difficulties related to incomprehension or language barriers. The aRSD scale was chosen because it assesses the level of someone’s decision to act, and its reading is direct, based on the highest score. Its metrological qualities have been demonstrated in several publications, as has its predictive value. A score of 7 or more is considered a major risk for acting out, and one study found a sensitivity of 100% and a specificity of 87%. It appears to be a good tool for self-assessment of suicidal risk in everyday practice, as well as for research protocols [10] [11] . The questionnaire is appended to this article.
Data were entered, processed and analyzed using Epi Info software version 7.2.5.0. Standard statistical measures were used to describe the total population. The chi2 test was used to compare data. Links between values were considered statistically significant at the 0.05 probability level.
The various administrative authorizations were obtained before the start of the survey. Free and informed consent was also obtained from participants and the parents of minors. Anonymity and confidentiality were respected.
3. Results
A total of 65 patients with sickle cell disease were included.
3.1. General Characteristics
They consist of socio-demographic characteristic shown in Table 1. Women predominated at 58.46%, with a sex ratio (M/F) of 0.71. The average age was 27.04 ± 1.95 years, with extremes of 16 and 50 years, and a peak in the 20 - 30 age group represented at 47.69%. Christians peaked at 83.08%, as did singles at 64.62. The majority, 60.94%, came from monogamous families. Pupils and students were the most represented with 32.31%.
3.2. Reason for Consultation
The presence of 58.46% was not motivated by a complaint and was part of their follow-up. For the remainder (41.54%), their presence was motivated by somatic complaints, of which 21.54% were pain-related, i.e. half of the latter.
3.3. Previous Medical History
The majority of patients (36.92%) had been under CUMAS care for less than a
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Table 1. Distribution according to socio-demographic variables.
year. Only one of the 65 patients had previously been under psychiatric care. Of the universal risk factors associated with suicide, alcohol consumption was the most common, accounting for 36.92%, and 87.5% of patients reported occasional consumption.
3.4. Suicidal Risk
The scores obtained on the Ducher suicide risk assessment scale and their interpretations are presented in Table 2. According to this scale, 44.62% had a positive suicidal risk score, including 13.85% with a severe suicidal risk corresponding to an active desire to die, or even a defined short- or long-term suicide plan.
3.5. Factors Motivating Suicidal Ideation
Among patients with a positive suicide risk, 44.83% mentioned pain as a factor motivating their suicidal thoughts or desires. Figure 1 illustrates this.
3.6. Therapeutic Recourses
The different remedies used by patients are broken down in Figure 2. 46% of patients with a positive suicidal risk had shared their suicidal ideation or desire, confiding in either a family member (23%) or a close friend (14%), or both (9%). None of them had used a specialized health center on their own initiative, nor had they been referred to one by those to whom they had confided. They said they had received advice and encouragement.
3.7. Factors Associated with Suicidal Risk
In this study, as shown in Table 3, only the single-parent family appeared as a
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Table 2. Distribution according to suicidal risk and its severity.
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Figure 1. Distibution according to factors motivating suicidal ideation.
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Figure 2. Breakdown according to the request for help.
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Table 3. Factors associated with suicidal risk in sickle-cell patients.
factor significantly associated with suicidal risk in sickle-cell patients (OR = 8.03, CI95% [1.51 - 42.51]; p = 0.02). Gender (OR = 2.23, CI95% [0.79 - 6.17]; p = 0.12), ethnic group (OR = 1, p = 0.21) and monthly income (OR = 1, p = 0.40) were not significantly associated with suicidal risk.
4. Discussion
Our results showed a young population with a mean age of 27 years and extremes of 16 and 50 years, and a high proportion of 20 - 30 year-olds (47.69%). Women predominated (58.46%), with a sex ratio of 0.71. Singles were more represented (64.62%), as were Christians (83.08%), workers (58.46%) and those living in monogamous families (60.94%). Pain was the reason for attending the clinic for 21.54%, and 36.92% had been attending for less than a year. Suicidal risk was positive in 44.62% of patients, 13.85% of whom had a severe suicidal risk. For 44.83%, pain was the main reason for their intention to die. Of those with a positive suicidal risk, 46% had confided their intentions either to a family member or a close friend, but none had sought help in a health center, either on their own initiative or on advice. Only living in a single-parent family was significantly associated with suicidal risk among sickle-cell patients in this study.
4.1. Socio-Demographic Characteristics
The mean age in this study was 27.04 ± 1.95 years. This result is higher than those reported by some authors, who found 24.2 years, 24.75 years and 14 years respectively in their studies [9] [12] [13] . This observed difference could be explained by the age limit of 16 years in this study unlike theirs where no age limitation was made. The choice of this age limit is explained by the sensitivity of the subject studied and ethical considerations.
The most represented age group was between 20 and 30 (47.69%). Dodo et al. had also found the predominance of this age group in their study of sickle cell emergencies at the CNHU-HKM blood disease department [9] . This could be related to the relatively low life expectancy among sickle cell subjects in our context.
The female sex was predominantly represented (58.46%), thus agreeing with the results of Laghaf et al. in Mauritania and Dahmani et al. in Morocco, who also reported a female predominance [12] [13] . In contrast, Dodo et al. found a male predominance of 60.8% (2018) [9] . The female predominance could be explained by the female predominance (51.2%) of the Beninese population [14] and the fact that sickle cell disease is an autosomal recessive genetic disorder.
4.2. Reason for Consultation
Overall, the most frequent reason was systematic follow-up (29.23%), but in terms of functional sign, the most frequent reason was pain (21.54%). Dodo et al. also found pain to be the most frequent reason for consultation [9] . This observation could be justified by the fact that vaso-occlusive crisis is the main complication of sickle cell disease [12] [15] [16] .
4.3. Suicidal Risk
Based on aRSD scores, 44.62% of sickle cell patients in this study had a positive suicidal risk. Of these, 30.77% were at moderate risk, i.e. with thoughts of death or suicide, and 13.85% at severe risk, i.e. with an active wish to die, or even a defined short- or long-term suicide plan. We found no studies in the literature concerning suicidal risk in people with sickle cell disease. However, when comparing our results with similar studies on suicidal risk, they are similar to those of Trinanes et al. who reported 32.5% for suicidal ideation [17] . Tang et al. in their study of suicidal risk in chronic pain and Ducher et al. in their study of the descriptive epidemiology of suicidal risk in the French general medical system had respectively reported a suicidal risk of 20% and 24.3%, which are lower values than ours [4] [11] . This difference could be explained by the difference in the study population. In the study carried out by Ducher et al., the study population was represented by primary care consultants, regardless of their previous history, unlike ours, which concerned a specific population made up of people with sickle cell disease.
4.4. Factors Associated with Suicidal Risk
Our analysis showed that only single-parent family type was significantly associated with suicidal risk in sickle-cell subjects (p = 0.02; OR = 8.03; IC95% [1.51 - 42.51]). The World Health Organization, in its report published in 2014 on suicide prevention had also noted this factor as increasing suicidal risk [3] .
However, we note from our study that pain was an important factor. Indeed, 44.83% of the patients in our study with a positive suicidal risk had mentioned pain as the element justifying their suicidal ideas or desires. Tang et al. and Trinanes et al. also identified pain as a risk factor [4] [17] .
Age, gender and ethnic group were not significantly associated with suicidal risk in our study. This observation is also in line with the World Health Organization’s report on suicide prevention [3] . Ducher et al. also found no statistically significant association between age and suicidal risk. However, they did find a significant association between gender and suicidal risk; women were more at risk [11] .
Religion, marital status, occupational status, alcohol consumption and smoking were not significantly associated with suicidal risk in our study. In contrast, the World Health Organization and Ducher et al. found a significant association between marital status, occupational status, alcohol or tobacco consumption and suicidal risk. Indeed, divorce or separation, lack of employment, alcohol or tobacco consumption all increased suicidal risk according to their results [3] [11] . Van Praag, in his study on the role of religion in suicide prevention, concluded that religion was significantly associated with suicidal risk and was a protective factor against suicide [18] . This difference in results between our study and theirs could be explained by the difference in study population and also by the low statistical power associated with our sample size.
4.5. Therapeutic Recourses
46% of patients with a positive suicidal risk had shared their suicidal idea or desire, and had confided in either a family member (23%), a close friend (14%) or both (9%). None of them had used a specialized or non-specialized health center on their own initiative, nor had they been referred to one by the person or persons to whom they had confided. They said they had received advice and encouragement.
These results are in line with those of the World Health Organization, which stipulated that the demand for help in the event of a suicidal crisis remains low, especially as regards recourse to specialized healthcare; populations due to the stigma attached to suicide or the absence of psychological or psychiatric services do not seek help [3] .
This study has limitations worth mentioning. As the study took place in a national referral center, the results obtained may not reflect the general population, due to the high frequency of severe cases and the limited number of people attending national referral hospitals. However, given that recruitment was carried out in Cotonou, the country’s cosmopolitan main city, these results can be used. Although suicide is a public health issue, it remains a taboo subject in some parts of Africa. Some patients do not readily admit to having suicidal thoughts. This may result in under-reporting or concealment of embarrassing information, which could have an impact on their score on the suicide risk assessment scale. Socio-cultural and religious beliefs could also reinforce this. The small size of our sample did not allow us to achieve sufficient statistical power. Similarly, as our study was cross-sectional, it had limitations in identifying risk factors; cohort and case-control studies being the most reliable.
Despite these limitations, the results of this work are interesting for the understanding of suicidal risk in our context on several levels.
5. Conclusion
Suicide risk is high among sickle cell patients followed at the CNHU-HKM in Cotonou, and single parenthood is an associated factor. There is little help- seeking and a total absence of recourse to specialized medical services. The results of this study draw our attention to this subject, which is still stigmatized in our context. They show the need for special attention and psychosocial intervention for this specific population, with a view to proper suicide prevention.
Acknowledgements
The authors sincerely thank the Director of CNHU-HKM for his assistance with administrative formalities. They also thank the head of CUMAS and his medical staff for their support.
Appendix. Survey Questionnaire
Note: please complete this questionnaire by ticking or writing the answers that apply to you.