Prevalence and correlates of suicidal behavior in primary care settings in Mozambique | BMC Psychiatry

Suicide is a serious global public health problem and is among the top twenty causes of death worldwide, with more deaths from suicide than malaria, breast cancer or war and homicide [1,2,3]. Reducing suicide mortality is an important priority of the World Health Organization (WHO) and is included as an indicator in the United Nations Sustainable Development Goals (SDGs). [4] and in the WHO Mental Health Action Plan 2013-2030 [5]. About 800,000 people commit suicide each year. [6,7,8]which represents an overall mortality rate of 16 people per 100,000 population or one death every 40 s [6]. Due to the COVID-19 pandemic and associated mental health issues, there are global concerns that suicidal behaviors may increase during and after the pandemic. [9]. Worldwide, suicide is the second leading cause of premature death among people aged 15-29 after traffic accidents and the third leading cause among people aged 15-44. [8, 10].

Due to the stigma surrounding suicidal behavior, estimates of suicidal behavior may be grossly underestimated in some countries, especially in countries where suicide is illegal. [11]. The WHO estimates that for every suicide, there are more than 20 suicide attempts. Suicide happens globally, although 79% of all suicides worldwide occur in low- and middle-income countries (LMICs) [12]. Rates of suicidal ideation, suicide planning, and suicide attempts in the past year show significant variability between LMICs among patients attending primary care. A study conducted in five MIC-LICs (India, Nepal, Ethiopia, Uganda, South Africa) revealed that on average 10.3% of those who sought primary health care reported having had suicidal ideation during of the last 12 months [13]. This study found great variability, however, with suicidal ideation ranging from 14.8% of primary care participants in South Africa to 5.0% in Uganda. Over the past 12 months, in Nepal and South Africa, young people had an increased prevalence of suicidal ideation and in Ethiopia and Nepal, women had double the prevalence of suicidal ideation in health care settings. outpatient primary health care [13]. Another study on suicidal ideation in Morocco reports a rate of 5.3% per year [14]. One factor that complicates the assessment and comparison of these statistics between countries is the lack of uniformity in the assessment and reporting of suicidal thoughts and behaviors. For example, a study conducted at a general practice outpatient facility in Kenya assessed the frequency of suicidal ideation and suicide attempts in the previous month instead of the previous 12. It revealed that the rate of suicidal ideation was 20%, suicide planning was 10%, and 4% of participants reported a suicide attempt. [15]. This creates some challenges compared to a study in Morocco which found that 1.2% of respondents had attempted suicide in the previous 12 months. [14].

In Mozambique, more than 90% of the population receives health care through the centralized public system of the Ministry of Health which has more than 1,300 public clinics. [16]. The centralized nature of the Mozambican health system presents an opportunity to integrate screening for suicidal behavior into routine activities as a suicide prevention strategy. In 2014, the WHO estimated that Mozambique had an age-standardized suicide rate of 27.4/100,000, which puts Mozambique’s suicide rate at a rate significantly higher than the world average and makes it the highest rate in Africa. [8]. However, in 2019, the WHO revised this estimate to 8.4/100,000, citing concerns about the “data quality” of suicide estimates for Mozambique and noted that these figures may not be reliable. It would not be surprising if the prevalence of suicidal behavior in Mozambique is very high given that its population has endured decades of trauma from anti-colonial struggles (1964-1975) and another protracted war (1976-1992), which have leads to prolonged political instability and the destruction of health systems. These historic traumas have been compounded by severe natural disasters such as Cyclones Idai and Kenneth in 2019 which left hundreds of thousands of people homeless and contributed to widespread destruction of the healthcare system. [17].

Mozambique has generated limited research on suicidal behavior; a literature search revealed only three peer-reviewed publications focusing on suicide in the country. The first forensic study of deaths by suicide in Sofala province showed that 10% of more than 1,000 violent deaths were due to suicide, with an average age of 31 years. The most common methods were hanging (43%) followed by the use of an unspecified substance (28%) and the use of rat poison (26%). [18]. In the same study, data on suicide attempts showed that 18% of psychiatric emergency department visits were for suicide attempts, women made up the majority (68%), and the average age was 27. The most common method for attempts was rat poison (66% of attempts) [18]. Another population-based household survey conducted in central Mozambique (3,060 people in Manica and Sofala provinces) reported a 30-day prevalence of suicidal ideation of 5.9%. [19]. The third study involved patients who attempted suicide and were treated at Nampula Central Hospital from 2014 to 2016, in which more than half of the patients were between 15 and 24 years old and suggested that impulsivity was the primary route to suicidal behavior. [20].

To date, there are no previous studies on suicidal behavior among primary care populations in Mozambique. In this context, primary health care provides a range of care, including co-located but specialized mental health services. Suicidal behaviors and other mental health issues are not routinely tracked among primary care recipients, but those deemed to be in need of mental health services are referred to mental health specialists collocated. The lack of integration of mental health into primary health care – including systematic screening for suicidal behavior – constitutes a major missed opportunity for suicide prevention and treatment in Mozambique. Primary care settings are often considered an optimal setting to screen patients at risk for suicidal ideation and refer patients for suicide prevention interventions. Identifying these high-risk individuals and providing them with follow-up and supportive care should be a key component of all comprehensive suicide prevention strategies. The purpose of this study is to provide information on the prevalence of suicidal behavior and associated factors for adults attending primary care clinics in Mozambique. Information from this study can aid in the development and implementation of suicide screening, identification and prevention interventions.