RESULTS

Table 1: Demographic characteristics of completed suicide cases in Kermanshah province, Iran (March 2012 to March 2013)


Table 2: Suicide methods among completed suicide cases by gender and living area, Kermanshah province, Iran (March 2012 to March 2013)

Click here for Table 3: Chi-squared statistic and p-value for the test of independence between the variables with their corresponding Cramer's V measure of association

Click here for Table 4: Absolute frequency and percentage of completed suicide according to days of week, Kermanshah province, Iran (March 2012 to March 2013)

Click here for Figure 1: Age-distribution of completed suicide cases by suicide methods, Kermanshah province, Iran (March 2012 to March 2013)

Click here for Figure 2: Annual rates of completed suicides according to the counties, Kermanshah province, Iran, March 2012 to March 2013 (ranked by suicide mortality rate).

A total of 265 confirmed cases of death by suicide have been registered from March 2012 to March 2013 in the population residing in Kermanshah province, including 174 men (65.7%) and 91 women (34.3%) with a mean age of 31.3±14 years (Mean±SD). The sex ratio (male-to-female) of the deceased stands at 1.9:1 and more than 91% of women were housewives. In addition, 195 persons (73.6%) and 70 persons (26.4%) of the deceased resided in urban and rural regions, respectively. There is no significant difference (Chi2(1)=0.2, p-value=0.662) between married and single deceased (excluding 8 cases with unknown marital status). More detailed information about variables related to the completed suicide cases are presented in Table 1. For example, it can be observed that approximately 45% of the deceased who committed suicide were in the 20-29 year age group. Since the provincial statistical yearbook had no estimates for the population of the province in each age group during the study period, calculation of suicide rate in each age group was impossible. Nevertheless, Figure 1 shows the absolute frequency of suicide methods by age groups. It can be seen that intentional drug-poisoning is notably higher in the 20-29 age group.

The absolute frequency and percentage of suicide methods by gender and living area are presented in Table 2. Overall, the most common suicide methods in Kermanshah province were hanging (42%) followed by intentional drug-poisoning (20%), and self-immolation (18.5%). The most common suicide method was hanging (50%) for men and self-immolation (43%) for women. Based on contents of this table, 68.4% of males have committed suicide using violent methods (hanging, self-immolation, firearms) and 79.1% of females have committed suicide using the same three violent methods.

The overall annual suicide rate in Kermanshah province is estimated at 13.6 per 100,000 residents during the study period. Figure 2 shows the annual suicide rate of each county of the province. This figure shows that Qasr-e Shirin county with 27.2 and Harsin county with 7.0 per 100,000 residents respectively have the highest and lowest annual suicide rate in the province. Thus, there is an almost four times difference between incidences of suicide in these counties.

Results of Pearson's chi-square tests and Cramer's V values are reported in Table 3. According to the results, suicide method is significantly associated with gender, living area, occupation, age group, education and marital status. The corresponding Cramer's V values indicate that the association between suicide method and gender is stronger than the association between suicide method and any other factor. Similarly, we can see that gender is significantly associated with occupation, education, marital status and living area. More than 17% of the deceased had a history of previous suicide attempts but there was no statistically significant association between history of previous suicide attempts and other variables of the study.

Table 4 shows the frequency and percentage of committed suicide in weekdays. According to this table, although Monday has a slightly higher frequency based on the chi-square test for homogeneity, there is no statistically significant difference (Chi2(6)=12.44, p-value=0.053) between the frequencies of suicide in different weekdays.

DISCUSSION

As it is observed from results of this study, completed suicide has been focused on in the present study. The completed suicide statistics had appropriate reliability, because the records and reports of the death due to completed suicide had higher accuracy in comparison to attempted suicide statistics (15, 16). Based on the obtained results, the overall annual rate of completed suicide in this province stood at 13.6 persons per 100,000 people, and suicide rate was observed more in urban regions than rural regions. One of the most important causes for this event could be increased level and rate of urbanization in the province as a result of rapid migration of rural inhabitants to urban areas. Such change in the living environment has not been adequately coupled with concomitant cultural adaptation. In this regard, the completed suicide rate in this province is much higher than that of the national suicide rate (10, 17, 18). Some of the main reasons for the high rate of committing suicide in western provinces of Iran have been mentioned in previous research (2, 7, 10, 17). The ratio of males who died by suicide was higher than that of females, so this finding is consistent with the results of previous studies (16). The present study showed that the majority of the females who committed suicide were housewives. The reason for that is most middle- and old-aged females in Iran are housewives without income. Therefore, it seems rational that the majority of the females who committed suicide are housewives (16). The noticeable point is that Kermanshah province stood at the 3rd place in the country in 2004 in terms of death rate due to suicide, while four counties of Sarpol-e Zahab, Sahneh, Harsin and Qasr-e Shirin (all located in Kermanshah province) were among the highest death rate caused by suicide across the country (11). In the present study, three counties of Qasr-e Shirin, Sarpol-e Zahab and Sahneh are among the highest suicide rate yet (approximately 20 persons per 100,000 residents and higher).

High unemployment rate in this province, compared to the other provinces, has been cited as one of the main probable reasons for the high rate of suicide in Kermanshah province. Of course, relationship between economic problems and unemployment with suicide in Kurdish ethnicity has previously been mentioned (16, 17, 19, 20).

As mentioned, hanging and self-immolation are the main methods of committing suicide among males and females respectively; this finding is consistent with the pattern of suicide methods observed in previous years in this province (16) and also with the governing pattern on the whole country (21, 22) and in Middle Eastern countries (23). Based on this study, intentional drug-poisoning is the 2nd most common method that leads to deaths due to suicide. This method is frequently used in young female attempters and also is one of the main methods of suicide in males (24). Frequently use of violent methods in western provinces of the country such as Kermanshah province may be due to post-war problems between the Iran and Iraq. This is an important issue since, the outbreak of the Iran-Iraq war in most parts of western provinces of the country including Kermanshah province has been cited as the one of the main reasons for occurrence of violent behaviors including suicide (19, 25). The reasons for the high incidence of suicide by hanging have been studied, the results of which indicate that hanging is a more acceptable method, and death caused by hanging is less likely to be misclassified in the death group with ambiguous reasons or accidental death due to the transparency of death method (24, 26). If we study self-immolation as the main cause of death, it can be mentioned that this aggressive and violent suicide method is mostly common in developing countries such as Iran and other Middle Eastern countries (2, 24, 27). Among the main factors that influence the acceptability of suicide by self-immolation, we can refer to Kurdish ethnicity, female gender, young adult age (19), adjustment disorder (19, 28, 29), cultural differences in attitude towards self-immolation, storage and accessibility of inflammable liquids at home and also storage of kerosene at home for cooking usage (18). All of these factors play an important role in highlighting this violent suicide method in Kermanshah province and even "copycat" phenomenon can be influential with regard to the acceptability of this violent suicide method (17). It should be kept in mind that like other societies suicide is a phenomenon that conflicts with religious and socio-cultural values in Iran (2, 15, 20); so the true suicide incidence rate might have been underestimated (16). Undoubtedly, increasing mutual cooperation and collaboration among official organizations involved in registration of suicide statistics is one of the most effective measures to promote quality of death registration system's data in Iran (6).

Our results furthermore highlighted that most cases of suicide in this province occur in age group of 20-29 years. Also this finding is consistent with the results of previous studies (9, 16, 17, 25, 27, 30), and the average age of the study subjects at the time of death is similar to the age of the deceased from completed suicide in this province (11).

It should be noted that the previous history of attempting suicide is one of the recognized risk factors of subsequent suicide (18, 31). In this study, more than 17% of the deceased caused by suicide had a previous history of attempting suicide, so that activation of mental health services after attempting suicide for the doer and his/her family (15, 31) is similar to launching an online telephone line by psychiatrist or hospital admissions for high risk cases (31) which can play an important role in prevention of re-attempting suicide coupled with reduced rate of suicide as well.
In western countries, most suicide cases occur on Mondays and Tuesdays (32, 33). In our study, there is no significant difference among the frequencies of suicide in weekdays. It should be noticed that the pattern observed in western countries may be related to the early days of the business weeks but Monday in Iran is the middle of the weekdays. The pattern should be taken into reconsideration within the longer time frame using suicide data of other regions of the country.

Considering the above-mentioned issues, substantial efforts for preventing suicides are needed in western provinces of the country (10, 18). The policymakers of the health system of the country must seriously take into consideration the revision of suicide prevention programs and treatment of mental and reactive disorders, especially major depression, substance use disorders, bipolar disorders, mood and anxiety disorders (9). We further suggest that more information needs to be gathered specially within suicide prevention programs. These might at the very least include: "the causes for suicide", "any preceding psychological disorders among suicidal cases" and "the types of any medical treatment they received".

The following are considered as the main reasons influence on the increase in suicide cases in the Middle Eastern countries: Lack of success of regional countries in accurate and suitable transfer of Islamic values and principles to the young generation; superficial attention to the Islamic rules and not paying due attention to the depth of these rules (such as inattention to the fair distribution of wealth in society and its role in prevention of suicide); inferior position of women in some Middle Eastern countries dating back to the old culture and tradition of the countries, such as forced marriage (23). It can be understood easily that suicide is a very complex and multidimensional problem and tackling this problem requires joint efforts of all people, society and governments.
There are several practical strategies to reduce the completed suicide rate and to promote the mental health of society across the province. All of these effective strategies and community-based interventions should be taken into consideration by policy-makers of the health system to reduce the incidence of suicide in the west of Iran:

- Paying enough attention to enhancing social equity and alleviation of economic problems and unemployment rate;
- Dissemination of culture of simple living in society, especially among young couples;
- Increasing the number of family counseling centers and training at-risk individuals about coping skills;
- Making effort in line with promoting position of females in society with emphasis on increasing participation of women in the workforce;
- Making effort in line with adjusting conflicts as a result of incongruousness and clash of modern and traditional values.

The authors would like to thank Mr. Shahab Rezaeian (PhD student of Epidemiology, Shiraz University of Medical Sciences, Iran) and Mrs. Hadis Asadi (MSc of Nursing); as well as the chairman and personnel of Imam Khomeini hospital (Eslamabad-e Gharb, Kermanshah, Iran) for their collaboration throughout this work.

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