Suicidal Behaviours in Sickle Cell Patients at the Douala Sickle Cell Care Centre in Cameroon ()
1. Introduction
Sickle cell anaemia is a hereditary disease caused by an occasional mutation of a haemoglobin gene, resulting in the replacement of the normal haemoglobin A by the abnormal haemoglobin S. Recognized by the World Health Organisation (WHO) in 2006, sickle cell anaemia is the most widespread genetic disease in the world, mainly affecting people in sub-Saharan Africa [1] . It affects over 5 million people worldwide and accounts for most of the 300,000 new cases per year with a major haemoglobin abnormality [1] [2] [3] . It combines not only clinical manifestations (chronic haemolytic anaemia, vaso-occlusive phenomena, increased susceptibility to infections) but also psychological symptoms that are often disconcerting and can take various forms such as anxiety, stress, depression [4] [5] [6] [7] [8] . Such complications may themselves be a prelude to suicide. Suicide is the act of deliberately taking one’s own life [9] [10] . It is one of the world’s biggest public health problems, with 700,000 deaths recorded annually worldwide according to the WHO [11] . However, suicide is only the outcome of a process and is just one aspect of suicidal behaviour (SB): SB is a generic term encompassing different entities, including suicidal ideation (SI), suicide attempts (SA) and suicide [9] [12] . A suicide mortality rate of 7.6% (4 patients dead) was reported in a study on adults with sickle cell disease carried out in France and England in 2002 [13] . In 2009, a study of Black adult patients with sickle cell disease in the United States revealed that 29% of patients reported an episode of suicidal ideation and 8% reported a suicide attempt in their lifetime [14] . In 2017 in Jamaica, Kalina K. et al. reported 12.4% of suicide attempts among adolescents with sickle cell disease, compared to 6.6% in the national sample, adolescence and the female sex being the factors most associated with suicide attempts [15] . To the best of our knowledge, few studies in Africa, and particularly in Cameroon, have examined suicidal behaviour in this population, hence our interest in the study, which will enable us to collect data for setting up appropriate follow-up measures in our context. This study will therefore assess the prevalence and determine the factors associated with suicidal behaviour in adolescents and adults with sickle cell disease at the Laquintinie Hospital in Douala (HLD), Cameroon.
2. Methods
Design and site of the study: We conducted a cross-sectional, analytical study over a period of 6 months (from 1 January 2022 to 30 June 2022). It was carried out in the sickle cell disease care unit of the Laquintinie Hospital in Douala (HLD), which is the only care centre for this disease in the said town.
Study population: The study population included patients with the sickle cell disease, aged 12 years or older, who came for consultation at the Laquintinie Hospital’s Sickle Cell Department during the study period. All patients with the sickle cell disease who were consulted at the Laquintinie Hospital’s Sickle Cell Department and who gave their consent, or who had the consent of a parent if they were a minor, were considered to be part of the study. Those with another comorbidity and/or who could not read or write were excluded.
The sampling was done randomly.
Sampling: Sampling was consecutive and non-exhaustive.
Data collection: The questionnaire on suicidal behaviours was based on the “suicidal risk” section of the Mini International Neuropsychiatric Interview (MINI) of the Diagnostic Statistical Manual IV (DSM IV) of the American Psychiatric Association [16] . Based on a pre-established hetero-questionnaire, we were able to determine:
· Lifetime suicidal behaviours (SB) and yes/no response options were modified into never, rarely, often and always, apart from responses to the question “Have you ever attempted suicide?”.
· Socio-demographic data (age, sex, address, region of origin, profession, marital status, level of education, religion, monthly family income, family structure (presence of child(ren); sickle-cell and non-sickle-cell; parent(s) alive; parent(s) with sickle-cell; rank among siblings; siblings with sickle-cell.
· Clinical data (age at diagnosis of the disease, circumstances of discovery of the disease, most frequent reason for hospitalization, any complications, type of complications, number of hospitalizations in the last 12 months, number of vaso-occlusive crises in the last 12 months, number of blood transfusions in the last 12 months, hydroxyurea intake and duration of intake).
· Characteristics of suicidal behaviours (presence of a triggering event for suicidal behaviour, type of triggering event (emotional problems; issues at school or work; family problems; financial difficulties; death of a close relative; sickle-cell anaemia-related event; others), suicidal methods (drugs; chemicals; firearms; knives; others), whether or not suicidal behaviours were communicated to family and friends, type of suicidal behaviours: premeditated or impulsive), and the extent to which suicidal behaviours had been reported, and factors associated with suicidal behaviours (personal and family factors (alcohol or drug abuse, family history of suicide (attempted suicide or suicide) within close family circle, socio-professional factors, protective factors (religious beliefs, family support, social support, personal convictions), poor integration into living environment, interpersonal conflict/disagreements, inappropriate media coverage with access to suicidal means, and traumatic life events were recorded.
Data analysis: The data collected was entered and analysed using version 26 of the SPSS® (statistical package for social science) software. This enabled us to determine the different numbers and percentages for the qualitative variables, and the mean and standard deviations for the quantitative variables. The variables were considered statistically significant for values p ≤ 0.05. A univariate analysis was carried out to determine the risk factors associated with suicidal behaviours in patients with sickle cell disease, then a multivariate analysis using logistic regression was carried out on all the related factors found to be statically significant (p ≤ 0.05) and slightly non-significant (p ≤ 0.05) to eliminate bias and identify the independent factors associated with suicidal behaviours.
Ethical considerations: The data collected were kept confidential in accordance with the Helsinki Declaration, and a request for ethical clearance was made. The study was submitted to the Institutional Research Ethics Committee of the University of Douala for ethical clearance, and to the hospital authorities for research authorization. The study was conducted in strict compliance with the fundamental principles of medical research, which include: the principle of the interest and benefit of the research, the harmlessness of the research, confidentiality, justice.
3. Results
In all, 171 patients were involved in the study out of the 191 sickle cell disease patients that were initially approached.
3.1. Socio-Demographic and Clinical Features of the Study Population
Females accounted for 60.20% (n = 103) of the sample population size as compared to 39.80% (n = 68) for males.
The mean age was 23.36 ± 8.42 years, with extremes ranging from 12 to 50 years, and the median was 22 years. The most represented age group was [20 - 30[, i.e. 45.60% (n = 78). We found out that 46.20% (n = 79) of the sickle cell patients were single compared to 43.30% (n = 74) who did not have a partner and 5.90% (n = 10) who were married. The secondary education level was the most represented, with 48% (n = 82) of the population, and the “student” variable had a higher frequency of 39.20% (n = 67).
In the study, 36.97% (n = 61) of the sickle cell patients had not been hospitalized over the previous 12 months, compared to 60.03% (n = 104) who had been hospitalized at least once.
The average number of hospital admissions over the previous 12 months was 1.96 ± 2.57. Vascular occlusive crises (VOC) were by far the most frequent reason for hospitalization in 70.27% (n = 104) of the population, followed by anaemia in 33.78% (n = 50) and infections in 16.89% (n = 25). During the last 12 months, at least one vaso-occlusive crisis (VOC) had been recorded in 82% (n = 123) of sickle cell patients. The average VOC was 3.97 ± 4.38 over the previous 12 months. We also found out that 83.63% (n = 138) of the population did not take hydroxyurea, which is part of the treatment for sickle cell patients (Table 1).
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Table 1. Socio-demographic and clinical characteristics of adolescents and adults with sickle cell disease at the Laquintinie hospital in Douala, Cameroon.
3.2. Prevalence of Suicidal Behaviours
In the sample, 95 out of 171 had had SIs, giving a SI prevalence of 56% (Figure 1). Of these sickle cell patients, 22 out of 171 had attempted suicide, giving a prevalence of 13% for suicide attempts (Figure 2). We found out that all of the 22 sickle cell patients who attempted suicide had had suicidal thoughts. Among the 22 patients who attempted suicide, 14 (64%) relapsed after their first suicidal trial (Figure 3).
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Figure 1. Prevalence of suicidal ideations.
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Figure 2. Prevalence of suicidal attempts.
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Figure 3. Percentage of suicidal relapse.
3.3. Characteristics of Suicidal Behaviours
Sickle cell disease-related complications were the main triggers for suicide attempts, accounting for 36.25% (n = 29), followed by school or work issues and family problems. The use of knives and drug overdose were the most frequently used means of suicide, each accounting for 38.10% (n = 8), followed by other means such as hanging and chemical substance consumption.
3.4. Factors Associated with Suicidal Behaviours
After a multivariate logistic regression analysis, the factors found to be independently associated with suicidal ideation (Table 2) were the lack of family support (OR = 0.34 (0.15 - 0.77); p = 0.01), feeling of worthlessness (OR = 0.40 (0.08 - 1.96); p = 0.02), not often being considered by people around them (OR = 2.97 (1.26 - 6.99); p = 0.01) and having just the primary level of education (OR = 0.08 (0.09 - 0.79); p = 0.03).
After a multivariate logistic regression analysis, the following (Table 3) were found to be independently associated with suicide attempts: the fact of being rarely exposed to suicide-related content in the media (OR = 4.17 (1.40 - 71.80); p = 0.03) and a constant feeling of sadness when returning home (OR = 18.02 (1.59 - 20.55); p = 0.01).
3.5. Events Which Triggered Suicidal Attempts (Table 4)
The triggering event of the suicide attempt was linked to complications linked to sickle cell disease (29 people, or 36.25%); secondly came school problems (17.5%).
3.6. Means Used for Attempted Suicide (Table 5)
For committing a suicidal act, the means most used in our sample was stabbing (38.5%) or taking medication at a lethal dose (38.5%).
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Table 2. Factors associated with suicidal ideation among adolescents and adults with sickle cell disease at Laquintinie Hospital in Douala, Cameroon.
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Table 3. Factors associated with suicide attempts among adolescents and adults with sickle cell disease at Laquintinie Hospital in Douala, Cameroon.
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Table 4. Triggering event of suicidal behavior.
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Table 5. Means used for suicide attempt.
4. Discussion
The general objective of this study was to determine the prevalence and factors associated with suicidal behaviours in adolescents and adults with sickle cell disease at the Laquintinie Hospital, Douala. The study revealed a lifetime prevalence of SIs in 56% of the sickle cell disease patients. In a study by Eyoum et al. in 2023 on the general population of Douala, the lifetime prevalence of SI was 36.4% [17] . Meanwhile the prevalence in our results is about 1.5 times higher than theirs. This higher prevalence in our population over the general population is due to the fact that Sickle cell patients are subject to physical as well as psychological pain combined with suffering, and frequently faced the reality of death from an early age; leading to fear, sadness, with suicidal ideation emerging during the rumination phase [18] .
A 13% lifetime prevalence of SA was found in the study population. This prevalence is almost similar to that of Komal et al. in Jamaica, who found a SA prevalence of 12.4% in adolescents with sickle cell disease [15] . This prevalence is approximately twice that found by Eyoum et al. in the general population of Douala, who reported a 7.8% lifetime prevalence of SA [17] . The fact that the rate was higher in our population confirms that sickle cell disease is a risk factor for suicide attempts. All the sickle cell patients who had attempted suicide had had SI. The presence of SI therefore favours the occurrence of suicide attempts, and SIs are a potential suicidal act.
The primary factors identified as having triggered suicidal behaviours were complications related to the sickle cell disease, followed by issues at school or work and family problems. This result differs from that of Eyoum et al. carried out in the general population, who reported family problems as the first triggering event, followed by school problems. This may reflect the greater psychological impact of the disease itself compared to external factors. Knives and drug overdose were the most frequently used methods of suicide in the study population. These methods were found by Eyoum et al. in 2023 in the general population [17] . This can be explained by the easy access to these means in our context. The primary level of education was found to be a factor associated with suicidal ideation. This could be explained by the fact that in our context, during adolescence, most children are in secondary school; being in primary school would therefore correspond to a delay in schooling, which could be linked to difficulties in having a regular school course over one or more years due to hospitalisations and frequent consultations imposed by the disease; a cause of failure at school. The study established a link between the fact of not being considered by those around them and the absence of family support as a favouring factor to the occurrence of suicidal ideations. This could be explained by the fact that these elements are associated with a feeling of isolation, which often goes in hand with depression and a feeling of loneliness and despair. The feeling of not being worthy of life has also been associated with suicidal ideation, since this feeling results from a low self-esteem and therefore a feeling of despair. Being rarely exposed to suicide-related content in the media and frequently experiencing sadness upon returning home were equally associated with suicide attempts. This low level of exposure could be associated with a lack of awareness of the harmful consequences of suicide on the individual, his/her family and society, which would justify its being a risk factor for suicide attempts. The use of a cross-sectional design limits the ability to draw causal relationships in this study.
5. Conclusion
The prevalence of suicidal behaviours among sickle cell patients is very high, suicidal ideation being present in 1/2 of the patients and suicide attempts in 1/6. It is reported to be more common among women and young adults, and the most common age group identified with suicidal behaviour is between 20 and 29. The factors most closely associated with suicidal ideation are the fact of having just a primary level of education, a feeling of worthlessness, no consideration from people around, and a lack of family support. Being rarely exposed to suicide-related content in the media and frequently experiencing sadness upon returning home were independently associated with suicide attempts. As a result, preventive measures need to be put in place at individual, family and societal level. Sickle cell patients must be aware of their illness and develop individual means of coping with the heavy psychological impact, including seeking help from psychologists. Families should be there for their sickle cell family member(s) and support them in all aspects of life as much as possible. The general public must be aware of the disease in order to integrate sickle cell patients in the society, and hospital staff must provide comprehensive care especially medical and psychological care for sickle cell patients and their families. They must systematically screen adolescents and adults with sickle cell disease to identify suicide tendencies and refer them to a psychiatrist or psychologist for appropriate treatment.
Authors’ Contributions
All authors contributed to this study and have read and validated the final version of this manuscript.
Limitations of the Study
Our study would benefit from being able to be carried out in a multi centered manner in order to guarantee better validity to our results.
Survey Sheet for the Study on the Prevalence and Factors Associated with Suicidal Behavior among Adolescents and Adults with Sickle Cell Disease at Laquintinie Hospital in Douala
The following questionnaire concerns suicidal behavior. Please answer all the questions in the section reserved for answers based on the different proposals.