Integration of Suicide Prevention Strategy into the Mental Health Policy in Uganda: Policy Brief

Executive summary

Uganda has a high suicide rate of 19/100,000 and was ranked 17th for suicide as cause of death worldwide and 4th in Africa. We analysed surveillance data reported from all levels of health facilities into the Health Management Information System (HMIS) to identify the populations at risk and evaluate geographical distribution of suicide attempts and deaths following suicide attempts in Uganda between July 2016 and June 2017. Our results revealed that prevalence of suicide attempts was higher for males (7.1/100,000) compared to females (6.7/100,000) and the proportion of deaths among attempted suicide case persons was higher among males (38/1000) than females. This revealed that Suicide attempts and deaths due to attempted suicide attempts and deaths due to at tempted suicide are prevalent in Uganda with male individuals and Northern region most affected. Therefore, recognizing the burden of suicide and incorporating its prevention within mental health programs through a national suicide prevention strategy is key to scale up care for mental health disorders in Uganda.

Introduction

Suicide remains a significant social and public health problem with nearly one million deaths attributed to suicide around the world [1].Suicide rates have increased by 60% worldwide in the last 45 years and predictions show that by 2020 suicide deaths will increase to 1 in every 20 seconds [2]. Low and middle income countries bear the larger burden of the global suicide and are relatively less equipped to prevent it. Unable to keep pace with the rising demand for mental health care, they are especially hindered by inadequate infrastructure and scarce economic and human resources [6]. Suicidal behaviours are a complex process that range from ideation through verbal or non-verbal communication, to planning ,attempting and committing suicide. Suicidal behaviours are influenced by interacting biological, genetic, psychological, social, environmental and situational factors [4]. It has been reported that suicide attempts are up to 20 times more frequent than completed suicides [1] and a prior suicide attempt is the single most predictor of death by suicide. Factors that predispose one to attempt suicide which eventually culminates into a suicide death range from mental and physical illnesses, alcohol or drug abuse, chronic illness, acute emotional distress, violence, a sudden and major change in an individual’s life, such as loss of employment [1]. In 2008, suicide was recognized as a priority condition in the Mental Health Gap Action Program  mhGAP), the program to scale up care for mental, neurological and substance use disorders, particularly in low-and middle-income countries [5]. The World Health Organization (WHO) recommended an urgent need for countries to develop a comprehensive national suicide prevention strategy that contextualizes the problem and highlights specific actions that can be taken at multiple levels [1]. Furthermore, suicide is largely preventable therefore it is crucial that countries invest in human and financial resources for suicide prevention. Without a suicide prevention strategy, countries cannot put in place mechanisms to address this issue in a sustained manner [1].

Context and importance of the problem

Uganda ranks 17th in the WHO global suicide ranking of 2014. More than 19 per 100,000 deaths are attributed to Suicide [7]. The main activities in the prevention and control of suicide in Uganda are surveillance of suicide attempts, sensitization of the general public on suicide prevention and imprisonment of suicide attempt offenders.

However, Uganda has low budgetary allocations for mental health and as a result, there are few sustained efforts and activities that focus on suicide prevention. Also, considering suicidal attempts as a criminal of fence poses additional challenges for suicide prevention activities. This is because suicide attempt offenders could have underlying risk factors such as physical illness or emotional distress that will not be in prison. Therefore, there is an urgent need to recognize the burden of suicide and incorporate its prevention within mental health programs through a national suicide prevention strategy.

Approaches and Results

We conducted descriptive secondary data analysis to determine the burden and distribution of attempted suicide and suicide deaths among the population in Uganda using the District Health Information System (DHIS2). We defined a suspected attempted suicide case as an intended conscious act of self-destruction usually associated with feelings of hopelessness, helplessness and conflicts between survival and death. Monthly and annual district level aggregated data on attempted suicide prevalence was obtained from HMIS for 112 districts. The population estimates were based on the 2014 census data extrapolated using an annual growth rate of 3.03%. We calculated prevalence rates and distribution of case per sons by age and sex, and used Q-GIS software to map a tempted suicide by district. The prevalence of attempted suicide was higher among males(7.1/100,000) compared to females (6.7/100,000). The prevalence of deaths among attempted suicide cases was 28 per 100 deaths. The prevalence of deaths among attempted suicide cases was higher among males (38/1000) than females. The prevalence of attempted suicide between July 2015 and June 2017 was highest in the Northern region of Uganda (15/100,000).

Conclusion and implications

Uganda has a high burden of suicide attempts that potentially culminate into suicidal deaths. Male and the northern region are most affected. Investing in suicide prevention is important in saving lives, prevention of stigma following attempted suicide and saving financial resources. Therefore, there is need to incorporate a national suicide prevention strategy that fits within the overall mental health policy.

Critique of policy options

Uganda does not have a national suicide prevention strategy that is integrated within the overall mental health policy given the magnitude of the public health problem of suicidal attempts that eventually culminate into suicide. Without a suicide prevention strategy, Ugandan government cannot put in place mechanisms to promoting access to comprehensive services for those at risk , or affected by suicidal behaviours; to address this is sue in a sustained manner. There is no established integrated surveillance system, which serves to identify at-risk groups, individuals, and situations. The HMIS only encompasses suicide attempts without appropriate protocols for public reporting of suicidal attempts.

Policy recommendations

There is urgent need to develop a comprehensive National Suicide Prevention strategy that contextualizes the problem, outlines specific actions that can be taken at multiple levels and fits within the overall Mental Health Policy. Establish an integrated surveillance system within the HMIS, which serves to identify the types of suicidal be haviours, most at-risk groups, individuals, and situations. There is urgent need to develop standardized protocols that are cross-culturally acceptable for detection of all suicidal behaviors in health facilities.

References

1. Organization WH. Public health action for the prevention of suicide: a framework. 2012.

2. Bertolote JM, Fleischmann A. A global perspective on the magnitude of suicide mortality. Oxford textbook of suicidology and suicide prevention: A global perspective. 2009;:91–98.

3. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, et al. Global patterns of mortality in young people: a systematic analysis of population health data. The lancet. 2009;374:881–892.