Introduction

During 2012, suicide represented 50% of violent deaths in males and 71% in females worldwide [1]. Suicide has been the most frequent external cause of death in Spain since 2008, according to the National Statistics Institute [2]. The risk of suicide is considered higher for individuals who have made a previous attempt than for those who have not, regardless of age and sex [3, 4]. The WHO has reported that the prevalence of self-reported suicide attempts is around 4/1,000 adults [1].

Suicide attempts have major personal, family, social, and economic repercussions [1, 5]. Suicide rates are recorded in most developed countries, but there is little information on suicide attempts [1, 6, 7]. The identification of a suicide attempt is complex, hampering data gathering [8], because of difficulties in establishing its true intent [9]. The WHO proposed the term “non-deadly suicide behavior” for suicidal actions that do not end in death [8]. The International Statistical Classification of Diseases, tenth revision (ICD-10) labels voluntary poisoning and self-harm behaviors with the codes X60-X84.

The dimension and characteristics of suicide attempts have been assessed by general population surveys in Europe [10, 11]and Spain[12, 13] and by the analysis of data obtained from hospital emergency department records [14, 15]. However, there are known to be more suicide attempts than those leading to hospital emergency department admission [16, 17], and around half of individuals visiting the emergency department after self-harm are not hospitalized and are not taken into account in hospital-based surveys of suicide attempts [18]. It is therefore possible to obtain further and more complete information may be obtained by studying the records of prehospital emergency services. In Spain, the prehospital medical emergence system forms part of the national public health service but is managed and organized by each Autonomous Community in the country, and there is no single national database. In Andalusia, the Spanish Autonomous Community with the largest population (more than 8 million inhabitants during the study period), prehospital emergency medical services are provided by the public emergency healthcare service (Empresa Pública de Emergencias Sanitarias [EPES])[19]. EPES coordination centers (one in each province of Andalusia), receive and manage emergency telephone calls and order the most appropriate mobile resource, assigning a priority level to each call [20, 21]. Consequently, all data on calls and on the activity of responding emergency teams in Andalusia are kept in a single database.

The objective of this study was to analyze the number and characteristics of suicide attempts between 2007 and 2013 by reviewing records of the public emergency healthcare service information system.

Methods

An observational, cross-sectional, and retrospective study was conducted of suicide attempts recorded in the EPES of Andalusia between January 1 2007 and December 31 2013.

Sources of information and selection of records

The same number (061 or 112) is used by the coordinating center in each of the eight provinces of Andalusia and is attended 24 h/day, being available to all members of the public, other emergency services, and law enforcement organizations [22]. Calls can be received from an informant or from the person making the suicide attempt. Calls are managed by the medical phone operator and coordinator, and the responses to callers range from health advice to the immediate activation of mobile resources according to the priority assigned to the call. Prioritization criteria are based on the severity of the medical situation and appropriate response time. Data were obtained from the EPES Information System (SIEPES) on calls labeled by the phone operators and/or the emergency healthcare teams as suicide attempts, defined according to a common protocol (see below).

Suicide attempt definition.

The SIEPES protocol establishes the following criteria:

• Calls in which the word “suicide” (or analogous term) is mentioned during responses to the standard questions asked by the phone operator are automatically labeled code X84 [16, 22], considered to represent labels from X60 to X84 of the ICD-10.
• After attending the emergency, the extra-hospital healthcare team labels the case as a suicide attempt or assigns an ICD-9 code for the attempt mechanism. i.e., 305.4, 305.8, E950 -E959, or E980 -E989 (Table 1).

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Table 1. ICD 9 and ICD 10 codes that define a case as “suicide attempt”.

https://doi.org/10.1371/journal.pone.0195370.t001

In the present study, data were also gathered on codes 969, 300.9, and V62.84, but only when these were associated with X84 or the aforementioned ICD9 codes in the database (Table 1). These codes were included because they do not rule out a suicide attempt, given that healthcare professionals may label the clinical event but not identify and document a suicide attempt when the intentionality is unclear [7,14, 16].

Results

In the region of Andalusia, out of 6,608,031 calls received by the EPES between January 12007 and December 312013, 20,942(0.31%) were identified as suicide attempts in this study, a rate of 36 attempts per 100,000 inhabitants. Code X84 was assigned to 76.31% of cases and code 305to 16.57% (Table 2).

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Table 2. Frequency of ICD 9 and ICD 10 codes that define a case as “suicide attempt”.

https://doi.org/10.1371/journal.pone.0195370.t002

Characteristics of recorded suicide attempts

The mean (SD) age of the individuals attempting suicide was 42.72 (±15.94) yrs. The rate increased with higher age up to 45 yrs and then decreased, being lowest among over 80-yr-olds. Among younger age groups, a peak rate of 6.60% was observed in those aged 20–24 years in comparison to 0.04% in those aged 15–19 years. Just over half of suicide attempt-related calls in the region were for females (50.98%), with a rate of 36.3 per 100,000 inhabitants versus 33.1 per 100,000 inhabitants for males, a ratio of 1.10: 1. Among provinces, the female: male ratio was highest in Malaga (1.23:1), which also had highest age-adjusted suicide attempt rate (68.07 per 100,000 inhabitants), much higher than the province with the lowest rate (Huelva: 17.60 per 100,000 inhabitants) (Table 3 and S2 Table).

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Table 3. Description of calls related to suicide attempts in Andalusia between 2007 and 2013.

https://doi.org/10.1371/journal.pone.0195370.t003

The lowest call rate for suicide attempts was in 2007 (32.4 per 100,000 inhabitants) and the highest in 2013 (40.4 per 100,000 inhabitants), although there was no linear increase over the study period. As shown in Table 3, suicide attempt calls were more frequent during the summer months (9.24% in July and 9.48% in August), at weekends (15.06% on Saturday and 15.36% on Sunday), and between 16:00–23:00 (46.66%). The call rate was highest at 14:00 (6.35%) (Fig 1) and remained elevated until midnight, more markedly between 16:00 and 23:00, followed by a marked reduction until 8:00 h.

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Fig 1. Number of suicide attempts by time of day.

https://doi.org/10.1371/journal.pone.0195370.g001

Out of the 20,942 cases of attempted suicide recorded, 84.07% were classified as non-delayable. The patient was evacuated or taken to hospital in 72.52% of cases, while the patient died (before or after treatment by the mobile team) in 2.47% of cases (Table 3).

Analysis of hospital admissions

Table 4 summarizes data on evacuation to a hospital emergency department as a function of selected factors; a full list is exhibited in S3 Table.

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Table 4. Logistic regression of suicide attempts with respect to evacuation (summarized).

https://doi.org/10.1371/journal.pone.0195370.t004

There was a two-fold lower likelihood of evacuation in over-65-yr-olds than in younger patients. Evacuation to hospital was most frequently ordered at 3:00 and 8:00 in the morning, followed by a decrease until midnight. The most influential factor was the code assigned by the attending healthcare team; the likelihood of hospital evacuation was at least 2.5 fold higher when any of the following codes were assigned (in descending order of influence): 950, 969, 300.9, V62.84, 980, or 305. No differences were found in evacuation to hospital as a function of sex, day of the week, month or year.

Discussion

In this seven-year study of prehospital emergency services in Andalusia, the highest estimated suicide attempt rate among adults in our region was in the most recent year studied (2013), indicating that there are four suicide attempts for every actual suicide. In contrast, the WHO reported in 2014 that there are at least 20 suicide attempts for every actual suicide [1]. Suicide attempts represent a small percentage of emergency calls but affect a young population and there are few specific protocols for the emergency response to this situation [1, 24].

The present study focused exclusively on pre-hospital emergency services using information retrieved from the EPES database. Most published studies on suicide attempts in the healthcare setting are based on data from hospital emergency departments, and we could trace no published research that used information from pre-hospital emergency services in other countries, hampering comparison of our results with findings elsewhere.

In general, the suicide attempt rate (per 100,000 inhabitants) was lower in the present population (mean of 36.0, range, 32.4–40.4 in different years) than in other parts of Spain [14, 25–27], other European countries [28, 29] and the USA (163.1–173.8 per year)[30].

Virtually no gender difference was observed in the present study, with the likelihood of a suicide attempt being only 1.05-fold higher for females. However, a higher frequency of suicide attempts among females than males has been observed in other Spanish regions and European countries [14, 22, 25–29] and in the USA, where the American Association of Suicidology [31] reported three female attempts for each male attempt between 2008 and 2015. These discrepancies might be attributable to cultural differences, although this proposition is not supported by the variability in the reported gender balance of attempts among different populations within Spain [14, 25–27]. It should first be explored whether variations are attributable to differences in methodology and/or the type and quality of data sources/data.

The mean age of adults attempting suicide was higher in Andalusia than has been reported in other Spanish regions (Madrid, Galicia, and Murcia) [14, 25–27]and in some other European countries [29]and the USA [30]. Results in other Spanish and European populations are closer to those obtained in the USA in comparison to the present findings, but the variability among studies is very high. In Andalusia, a peak in recorded suicide attempts was observed between 20–24 years of age, older than the ages at which a peak has been observed in other regions or countries. Thus, Canner et al [30] reported that visits to the emergency department for suicide attempt or self-harm peaked between the ages of 15 and 19 years in the USA. Various factors may help to explain this discrepancy, including our utilization of pre-hospital medical service versus emergency department records, and it has also been proposed that the classification of acts as intentional may vary among healthcare professionals, especially in relation to younger individuals [32, 33]. However, further research is required to elucidate the reasons for this difference in age profile.

The number of calls for suicide attempts was higher in Malaga than in the other provinces, and further investigation is warranted in this province to examine possible explanations for this finding.

The most influential factor for evacuation to hospital was the code assigned by the attending emergency team according to the severity of the suicide attempt. The likelihood of evacuation was lesser among over 65-year-olds, suggesting that protocols for evacuation to hospital may require revision, given evidence of a higher post-attempt mortality rate in older individuals [26].

In the present study, suicide attempts were more frequent during the very hot summer months, and a review by Deisenhammer [34] proposed that attempts were more frequent on days with higher temperatures and more hours of sun; however, the findings were not conclusive, and some of the reported data were contradictory. In our Southern Spanish population, attempts were more frequent on public holidays and at weekends, as also observed in a region of Northern Spain [35]. Studies in different parts of Spain have reported that suicide attempts treated by hospital emergency departments are more frequent at weekends and are often associated with the consumption of recreational drugs and/or alcohol [26, 35, 36]. An association between alcohol use and suicide attempts is well documented [37–39], and alcohol consumption is especially high at weekends in Spain, including increasingly popular binge-drinking gatherings of adolescents and young adults [40,41]. However, the present data do not allow conclusions to be drawn on a possible causal relationship between the increased consumption of alcohol and the higher frequency of suicide attempts observed at weekends.

Finally, the procedure followed to meet our study objective revealed problems in identifying suicide attempts from prehospital emergency service records, which do not appear to pay special attention to this issue. This may result in an underestimation of suicide attempt rates, as also acknowledged by Clements et al [17]. Steps were taken to reduce the loss of cases in the present study by including those labeled as a suicide attempt by the call operator/coordinator as well as by the emergency healthcare team in situ, which may be less likely to identify a case not originally assigned the X84 code given their focus on the severity and treatment of injury rather than its cause or intentionality.

There are few published data on prehospital emergency calls for a suicide attempt. In their analysis of psychiatric prehospital emergencies, Panjonk et al [42] found that 26% were for suicide attempt or suicidal ideation.

Although the evidence on suicidal behavior appears generally inadequate, it suggests the need to develop specific healthcare strategies, assigning particular importance to the extra-hospital emergency response.

Conclusion

Information obtained from extra-hospital emergency services provides valuable data on the characteristics and timing of suicide attempts and on the priority assigned to cases and their outcome. These data complement information gathered on suicide attempts in studies of hospital emergency departments or in population surveys.

There is a need for research to establish a consensus on the definition and recording of suicide attempts in order to advance knowledge on the scale and characteristics of this phenomenon.

Supporting information

Acknowledgments

The authors are grateful to the Public Enterprise of Healthcare Emergencies of Andalusia (Empresa Pública de Emergencias Sanitarias de Andalucía) for providing the data used in this study.