Faizan Qaisar1*, Mohsin Shafi1, Ayesha Majeed1, DileepKumar1, Awais Memon1and Umer Memon1 1Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, Sindh, Pakistan

1. ___________________________________________________________________________________________
*Corresponding author: Email: Faizanqaisar660@hotmail.com;
British Journal of Medicine & Medical Research
4(4): 1041-1048, 2014
SCIENCEDOMAIN international
www.sciencedomain.org
The Epidemiology of Deliberate Self-Poisoning
Presenting at a Tertiary Care Hospital in
Hyderabad Sindh, Pakistan
Faizan Qaisar1*
, Mohsin Shafi1
, Ayesha Majeed1
, Dileep Kumar1
,
Awais Memon1
and Umer Memon1
1
Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro,
Sindh, Pakistan.
Authors’ contributions
This work was carried out in collaboration between all authors. Author FQ designed the
study, wrote the protocol, and wrote the first draft of the manuscript. Author MS and DK
performed the statistical analysis, and ‘managed the analyses of the study. Authors AM, AM
and UM’ managed the literature searches and wrote the final draft. All authors read and
approved the final manuscript.
Received 15
th
August 2013
Accepted 9
th
October 2013
Published 4
th
November 2013
ABSTRACT
Objective: To observe the demographic characteristics of the patients, substance
abused, intention and precipitating factors for self-poisoning presenting to Accident&
Emergency department of Liaquat University Hospital Hyderabad, Sindh, Pakistan.
Patients and Methodology: A prospective observational study was carried out for a
period of 6 months from (March 2013 to August 2013).100 patients more than >12years
with a definite history of self-poisoning were included. Details regarding patients
demographic characteristics e.g. age, sex, maritalstatus, academic status,
socioeconomic standing etc. and substance abused for self-poisoning were recorded on
a specifically designed proforma.
Results: During the study period 100 patients of DSP were included. Of 100 patients
40% (n=40) were male age ranges from (15-50) and 60% (n=60) were female age
ranges from (17-50). Mean age of the patients was 23.63±8.370 (mean±SD). Out of
hundred patients 57% (F=31, M=26) were uneducated, 56% (F=34, M=22) were
unmarried, those who were unmarried had statistically significant relationship with the
Original Research Article

2. British Journal of Medicine & Medical Research, 4(4): 1041-1048, 2014
1042
use of organophosphorous compounds/Rat killer for self-poisoning (p= 0.0281). 85% of
the total patients belonged to lower socioeconomic class. Occupation wise mostly female
were household/house wife and male were farmer/labour. (49%) of the studied group
used organo-phosphorous containing compound insecticide/pesticides, 29% used Rat
killer. 11% of the patients consumed benzodiazepine for self-poisoning.60% of the total
patients had suicidal intention, use of organophosphorous compound/Rat killer is
significantly associated with the intention to suicide (p=0.0001), 33%of the patients
wanted to draw attention and 7% committed DSP to show anger, or to punish
themselves because of guilt Table 4. (46%) committed the act of DSP after having
conflict with parents other had interpersonal conflicts with husband/wife,
girlfriend/boyfriend and close relatives.
Conclusion: Use of organophosphorous containing compound/Rat killer are associated
with an intention to suicide (p=0.0001) and these are preferred substances used for self-
poisoning among unmarried population (p=0.0281).Demographic characteristics of
patients do not vary greatly with relation to their orientation to urban or rural areas as
well as choice of substance for self-poisoning were also independent to location
(p=1.0000).
Keywords: Self-poisoning; Liaquat university hospital Hyderabad; LUMHS Jamshoro;
Pakistan.
1. INTRODUCTION
Deliberate self-harm can be defined as an act in which a person harms himself/herself or
willfully ingest excessive or lethal dose of a drug which usually results in a non-fatal
outcome. European suicidology use the term of ‘Parasuicide’ for all such non-fatal suicidal
attempts [1].Deliberate self-poisoning (DSP) is an important health issue worldwide
especially in developing countries [2-3]. Exact prevalence of deliberate self-poisoning (DSP)
in Pakistan is not known as many of the cases of self-poisoning are not reported due to
religious, cultural, social reasons. However, available data on suicide suggests that in
Pakistan about 8 per 100,000 commit an act of deliberate self-poisoning per year [3].DSP is
not always associated with an intention to commit suicide as in some cultures, it is a
preferred and effective way to express anger, jealousy, and hostility or draw attention [4-
7].Nature and causes of deliberate self-poisoning are influenced by many factors such as
religion, socioeconomic status, ethnic background, and culture [8]. DSP increase morbidity
and mortality. Furthermore, the cost of managing DSP is also considerable especially in a
developing country like Pakistan[9-10].Para suicide is an important predictor of suicide in an
individual therefore several studies have been conducted on this issue all over the world as
well as in many cities of Pakistan. However, most of them are retrospective and were
performed in urban areas of Pakistan [11-12].We aimed to perform a prospective
observational study to report our experience of managing DSP patients at accident and
emergency unit of LUH Hyderabad, Sindh, Pakistan.
2. MATERIALS AND METHODS
Liquate University Hospital is a tertiary care teaching hospital. It is situated in Hyderabad,
the 2nd largest city of Sindh, Pakistan. Its accident &emergency unit works 24 hours a day
and deals with all sort of medical emergencies together with the cases of poisoning from
main Hyderabad city, villages close to Hyderabad and rural areas of interior Sindh. We

3. British Journal of Medicine & Medical Research, 4(4): 1041-1048, 2014
1043
performed cross-sectional, observational study from March 2013 to August 2013and
included all the patients more than 12 years old with a definite history of deliberate self-
poisoning .Cases of homicidal or accidental poisoning were excluded.DSP was defined as
ingestion of a poison or excessive dose of a medicine for self-harm. An Informed consent
was taken from each patient or from the accompanying attendant/close relative/guardian if
patient was unconscious. Participants who were less than <20 years an informed consent
was taken from their parents. Patient demographic details like age, gender, occupation,
address, socioeconomic status, marital standing, academic level, history of previous
attempts, poison used, and intention for self-harm were collected on a specifically designed
proforma. Areas that have the designation of, municipal committees, municipal corporations
or cantonment boards were considered urban areas and all the rest as rural. On the basis of
occupation, place of residence and monthly income socioeconomic status was determined
and classified as lower class, middle class and upper class. Educational status was
categorized into; uneducated, primary, Secondary, Intermediate or graduate and Masters.
2.1 Statistical Analysis
SPSS version 17 was used to analyze all the data collected and extracted in this study.
Categorical variable were expressed as percentage and continuous data were expressed as
mean +- SD. In addition the association and correlation between two categorical variables
were examined using the chi square test & fisher exact. A p-value of <0.05 was considered
statistically significant.
3. RESULTS
During the study period 100 patients of DSP were included. Of 100 patients 40% (n=40)
were male age ranges from (15-50) and 60%(n=60) were female age ranges from (17-50).
Mean age of the patients was 23.63±8.370 (mean±SD) Table 1.Out of hundred patients
57%(F=31, M=26) were uneducated, 56%(F=34, M=22) were unmarried. Use of
organophosphorous compounds/Rat killer for self-poisoning has a statistically significant
relationship with the unmarried population (p= 0.0281) Table 5. 85% of the total patients
belonged to lower socioeconomic class. Occupation wise mostly female were
household/house wife and male were farmer/labour. Complete detail of patient’s
demographic characteristics is summarized in Table 2. (49%) of the studied group used
organo-phosphorous containing compound insecticide/pesticides, 29% used Rat killer, 11%
of the patients consumed benzodiazepine for self-poisoning. Detail regarding other
substances used in our study for DSP is given in Table 3.60% of the total patients had
suicidal intention, use of organophosphorous compound/Rat killer is significantly associated
with the intention to suicide (p=0.0001) Table 5, 33%of the patients wanted to draw attention
and 7% committed DSP to show anger, or to punish themselves because of guilt Table 4.
(46%) committed the act of DSP after having conflict with parents other had interpersonal
conflicts with husband/wife, girlfriend/boyfriend and close relatives Table 5.Whereas 2% of
the patients committed DSP because of unemployment. Of 100 patients only 2% (n=2) had a
history of previous attempt of DSP.

4. British Journal of Medicine & Medical Research, 4(4): 1041-1048, 2014
1044
Table 1. Age distribution
Age Male Female
15-25
26-35
36-45
>45
Total
25
11
04
00
40
48
06
04
02
60
Table 2. Demographic details of patients
Education F
N=60
M
N=40
%
Primary 09 10 19 %
Secondary 3 4 7%
Matric 8 7 15%
Intermediate 2 0 2%
Uneducated 31 26 57%
Socioeconomic Status
Middle Class 08 07 15%
Lower Class 52 33 85%
Marital Status
Single 34 22 56%
Married 24 18 42%
Divorce 02 0 2%
Occupation
House Wife 18 0 18%
Household 34 0 34%
Students 08 7 15%
Labour 0 15 15%
Farmer 0 18 18%
Table 3. Substance/compound
Substance used Female
n=60
Male
n=40
%
Organophosphorous 26 19 45%
Rat Killer 15 14 29%
Sleeping Pills 06 5 11%
Vinegar 0 02 2%
Phenyl 6 00 6%
Ibert Folic 03 00 3%
Mosquito Killer 04 00 4%

5. British Journal of Medicine & Medical Research, 4(4): 1041-1048, 2014
1045
Table 4. Intention
Intention F
N=60
M
N=40
%
Suicide 38 22 60%
Draw Attention 16 16 32%
Self-Punishment 06 02 8%
Table 5. Precipitating factor
Precipitating factor Female
n= 60
Male
n= 40
%
Conflict With Parents 19 27 46%
Conflict With Relative 9 0 9%
Conflict With Children 04 02 6%
Conflict With Inlaws 09 0 9%
Conflict With Wife 0 02 2%
Conflict With Brother 4 02 6%
Conflict With Husband 11 11%
Conflict With Boyfriend/Girl Friend 4 05 9%
Unemployment 0 02 2%
Table 6. Chi-square with Yates correction
Association p-value =<0.05
Gender * choice of substance 0.5997
Socioeconomic status* choice of substance 0.7100
Location *choice of substance 1.0000
Marital status*choice of substance 0.0281
Education *choice of substance 0.9842
Intention*choice of substance 0.0001
Gender*intention 0.1572
Socioeconomic status*intention 0.9039
Location *intention 0.8583
Marital status*intention 0.8810
Education *intention 0.9039
4. DISCUSSION
LUH Hyderabad entertains all kind of emergencies including all cases of poisoning not only
from main city of Hyderabad but also from its surrounding villages and remote rural areas of
interior Sindh. In our study 56% patients belong to urban area of Hyderabad city and 44%
were from rural areas of interior Sindh Pakistan and villages close to Hyderabad.
Major findings of our study were a mixed population of the DSP Patients, 56% of them
belonged to main Hyderabad city and 44% of the patients were inhabitants of the villages
close to Hyderabad or remote areas of interior Sindh.Proportion of the female was greater
than male(60%).Mean age of the patients was 23.63±8.370 (mean±SD) Table 1. Out of
hundred patients 57% (F=31, M=26) were uneducated, 56% (F=34, M=22) were unmarried.
85% of the total patients belonged to lower socioeconomic class. (45%)(F=26, M=19) used

6. British Journal of Medicine & Medical Research, 4(4): 1041-1048, 2014
1046
organ phosphorous compound followed by Rat killer 29% (F=15, M 14). 80% (F=38, M=22)
patients had suicidal intention.
In terms of patients demographics our study agrees with the studies conducted in other cities
of Pakistan with slight variations. Study from a tertiary care hospital of Karachi reported that
they found female (59%) outnumbered the male (41%) with the age ranges from 12-
76.married women 32% were more than single women 25% while married men were 16%
and the number of divorces and widowed were negligible [13].Another study which was
carried out in JPMC Karachi reported that in their study 57% were female and 43% were
male with mean age 20 + 5years.47% were unmarried,48% were married while many of
them belong to Lower social economic class [14].Furthermore, a study that was carried out
in the accident and emergency department of Lahore reported that majority of patient were
female 60% self-poisoning found to be more in married women. Lower social class is
predominate [3].Study from a medical college in Quetta reported that in their study all of the
patients were female, most of them were young 16-25 years and belonged to lower social
class [15].
In our study, Organ phosphorous containing compound pesticide/insecticide (45%) and Rat
killer (11%) were found to be dominant agents used for self –poisoning (p=0.0281). Studies
that were conducted within the urban areas of Pakistan reported the use of other agents as
to be the most commonly used agents. A study in a tertiary care hospital in Karachi reported
that 47.3% used benzodiazepine for self- poisoning [16]. Another study from the same
hospital found use of benzodiazepine 60%, followed by organophosphate /insecticide
ingestion 20% to be most common agents for self-poisoning [13]. A study conducted in
Lahore reported use of benzodiazepine pills the predominantly consumed substance
28.57%followed by wheat pills (21.42%), copper sulphate (11.3%) and organophophate
compound (5.72%) [3]. Another study from the same hospital reported the ingestion of wheat
pills the most common mode of self -poisoning (33%) followed by bleach/bathroom cleaner
(25.7%), benzodiazepine (19%) [14].However in our study we found no significant
relationship among urban or rural population in relation to their choice of substance for self-
poisoning (p=1.0000).This may reflect the people included in our study, as several of them
were inhabitants of villages close to Hyderabad and rural areas of interior Sindh. Use of O.P
compounds and rat killer is common in villages and rural Sindh. Although 56% of patients in
our study belonged to urban area of Hyderabad, however, a good many number of people
living in Hyderabad have been migrated to Hyderabad from interior Sindh recently.
In our study we found conflict with parents (46%) and conflict with husband (11%) to be the
predominant precipitating factors for self- poisoning. Whereas a study conducted in
university hospital Karachi found interpersonal conflicts with the opposite sex to be the most
common precipitating factors. [10].Domestic problems and financial difficulties were reported
to be common factors for self-poisoning in the study conducted in Jinnah hospital Lahore [3].
In our study we found that 60% of patient had an intention to suicide .In a study conducted
by M.M Khan and H. Raza suicidal intention in 70%of patients were reported [16].we found
a statistical significant relationship between organophosphrous compounds/Rat killer and
intention to suicide (p=0.0001).
4.1 Limitation
Our study only addresses demographic character of the patients committing self-poisoning
and the substance used by them. It does not address the reason why patients belonging to

7. British Journal of Medicine & Medical Research, 4(4): 1041-1048, 2014
1047
lower socioeconomic group and uneducated are more vulnerable to self-poisoning. This
study also does not give details regarding the psychiatric morbidities, management plan of
these patients and resulting morbidity and mortality. These objectives were not within the
scope of our study. Although in the rural areas of Sindh use of organophosphorous
pesticides is common round the year but seasonal variability cannot be ignored this is why 6
months period may be insufficient for the exact evaluation of poison epidemiology.
5. CONCLUSION
The study shows thatuse of organophosphorous containing compound/Rat killer are
associated with an intention to suicide (p=0.0001) and these are preferred substances used
for self-poisoning among unmarried population.(p=0.0281).Although tendency to self-
poisoning in our study is more common among (socioeconomic class, uneducated people
and young age group with the preponderance of female but all these factors are independent
to each other, no statistically significant relationships were found Table 5. Demographic
characteristics of patients do not vary greatly with relation to their orientation to urban or
rural areas as well as choice of substance for self-poisoning were also independent to
location.
Easy availability of organ-phosphorous containing pesticides and rat killer as well as selling
of benzodiazepines compound in the form of sleeping pills and anxiolytics without
prescription have increased the risk of self-poisoning. Appropriate measures against the
selling of these compounds may decrease the incidence of self-poisoning.
CONSENT
All authors declare that ‘informed consent was obtained from the patient or accompanying
attendants.
ETHICAL APPROVAL
Not applicable.
COMPETING INTERESTS
Authors have declared that no competing interests exist.
REFERENCES
1. Mauri et al. Parasuicide and drug self-poisoning Clinical Practice and Epidemiology in
Mental Health. 2005;1:5.
2. Morgan HG, Burns-Cox C, Pocock H, Pottle S. Deliberate self-harm: clinical and
socio-economic characteristics of 368 patients. BrJPsychiat. 1975;127:564-74.
3. Haider SI, Haider I. Deliberate self-harm. Pak J Med Sci. 2001;17:151-5.
4. Maracek J. Psychological approaches to understanding suicide. In: De Silva P, ed.
Suicide in Sri Lanka. Kandy, Institute of Fundamental Studies. 1989;16–24.
5. De Silva P. The logic of attempted suicide and its linkage with human emotions. In: De
Silva P, ed. Suicide in Sri Lanka. Kandy, Institute of Fundamental Studies. 1989;25-
40.
6. Hawt on K. Deliberate self‐harm. Medicine. 1997;24:77–80.

8. British Journal of Medicine & Medical Research, 4(4): 1041-1048, 2014
1048
7. Williams H, Buchan T. A preliminary investigation into Para suicide in Salisbury,
Zimbabwe–1979/1980. Central Afr J Med. 1981;27:129–35.
8. Kreitman N. (ed) Para suicide, London: Wiley; 1977.
9. Hawton K, Fagg J. Suicide and other causes of death following attempted suicide. Br
JPsychiat. 1988;152:359-66.
10. Khan MM, Reza H. Gender differences in non -fatal suicidal behavior in Pakistan:
significance of sociocultural factors. Suicide Life Threat Behave. 1998;28:62-8.
11. Shahid M, Hyder AA. Deliberate-self harm and suicide: a review from Pakistan. Int J
InjContrSafPromot. 2008;15:233-4.
12. A.Memon, JM.Sheikh. Changing Trends in Deliberate Self Poisoning at Hyderabad.
JLUMHS. 2012;11(3).
13. Kermani F, Ather NA, Ara R. Deliberate self- harm: frequency and associated factor s.
J Sur g Pak. 2006;11:34- 6.
14. Shoaib S, Nadeem MA, Khan Z.Causes and outcome of suicidal cases presented to a
medical ward. Ann King Edward Med Col l. 2005;11:30- 2
15. Bertolote JM, Fleischmann A. A globalperspective on the epidemiology of suicide.
Suicidology. 2002;7:6–8.
16. Khan MM, RezaH.Deliberate Self Harm in Pakistan. Psychiatr Bull. 1996;20:367- 68.
© 2014 Qaisar et al.; This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Peer-review history:
The peer review history for this paper can be accessed here:
http://www.sciencedomain.org/review-history.php?iid=311&id=12&aid=2427