Trend and epidemiology of suicide attempts by self-poisoning among Egyptians.

Suicide attempts by self-poisoning have become a critical health problem. This study aimed to investigate the trend, incidence, and the associated risk factors of suicide attempts by self-poisoning. A total of 7398 Egyptian patients were analyzed. The trend of suicide attempts by self-poisoning was analyzed using 6745 patients over four registry years from January 1, 2016, to January 1, 2020. Then, the associated risk factors behind attempted suicide by self-poisoning from January 1, 2019, to January 1, 2020, were assessed using 2523 suicide attempters by self-poisoning, 201 fatalities by self-poisoning, and another 653 survivors of accidental poisoning. Results showed a rising trend of suicide attempts by self-poisoning over the studied years. The incidence of suicide attempts through deliberate self-poisoning represented 26.63/1,000 (CI95%: 25.63-27.86) to the admitted patients and 26.10/100,000 (CI95%: 25.10-27.14) to the regional population. The death rate due to suicide attempts by self-poisoning was 2.08/100,000 (1.90-2.49). The case fatality rate and the proportionate mortality rate for suicide by self-poisoning were 7.38% (CI95%: 6.45-8.42) and 14.11% (CI95%: 12.4-16.0) respectively. Multivariate analysis revealed that attempted suicide by self-poisoning was predicted among patients aged <25 or 25-40 years old (OR = 27.49, CI95%: 15.28-49.64 and OR = 59.42, CI95%: 32.76-107.77 respectively), those of low or moderate socioeconomic status (OR = 35.03, CI95%: 21.32-57.56 and OR = 14.11, CI95%: 10.86-18.43 respectively), students (OR = 2.91, CI95%: 1.57-5.43) and those living in rural residency (OR = 4.12, CI95%: 3.27-5.19). Suicide attempts by self-poisoning exhibited an incremental rise across time which raises a serious concern. Efforts should be directed to overcome the mentioned risk factors triggering suicide attempts by self-poisoning.

Introduction

Suicide, either attempted or completed, is a significant problem that affects young people and adolescents. WHO states that suicide is the worldwide 2nd leading cause of death among people aged 15–29 year [1]. Although WHO states an overall decline in the global age-standardized suicide rates in the suicide worldwide 2019 report (except in some regions, for example, the Americas), these rates vary between countries from less than two deaths by suicide /100,000 to more than 80/100,000 [2]. Most deaths by suicide occurred in developing countries with low incomes [3].

Regrettably, the suicide rate in the Middle East region doubled from 1990 to 2015 [4]. Although the rate in Upper Egypt ranged from 0.6 to 0.8 per 100,000 [8], these figures include only the successful suicides. Para-suicide, which refers to failed attempts of non-fatal self-harm, is 30 times more common than completed suicide [5, 6].

Suicide methods vary worldwide based on socio-cultural backgrounds and differences in legislation between countries which not only affect the suicide rate but also suicide methods [5, 6]. Self-poisoning, firearms, and hanging are the most commonly used [7]. In the United Kingdom, suicidal self-poisoning represents approximately 25% of total suicides, while the United States considers it the most commonly used way of attempting suicide among youths [8, 9].The situation worsens in the developing world with a steady increase in deaths from suicide by self-poisoning [10]. In Egypt, there is a significant 38.4% increase in suicide attempts by self-poisoning among youths [11].

Attempted self-poisoning has replaced the traditional methods due to easier access to drugs and chemicals. Pesticides alone account for one-quarter of global suicide rates [12]. In developed countries, drugs used in suicidal attempts by self-poisoning include psychotropic drugs, analgesics, antihistamines, antidepressants, psychoactive drugs, and sedative-hypnotics [9, 13]. The situation is somewhat different in developing countries because pesticides are the most widely used method of suicide. However, central nervous system affecting drugs, and analgesics are commonly used agents [9, 13]. On the other side, pesticides were considered the chief materials used for attempting suicide by self-poisoning in Egypt. The residence and age of patients attempting suicide influence the type of material they use to attempt suicide. Though youth victims prefer xenobiotics, pesticides are commonly used by older subjects living in rural areas [14]. Previous studies investigating attempted suicide by self-poisoning in our region are primarily insufficient and are based on previous numbers that may be misleading or inexact [15]. This work aimed to assess the trend, incidence, and risk factors associated with suicide attempts by self-poisoning among Egyptians by examining cases admitted to approved poison control centers.

Materials and methods

Study design and setting

An analytical study was conducted on patients presented Tanta and Menoufia Universities Poison Control Centers that serve two large Egyptian governorates with a population of at least 10,000,000 people living in an area of more than 4485.03 square kilometers. Medical records of patients presented over four registry years from January 1st, 2016, to January 1st, 2020, were reviewed. Those diagnosed with suicidal attempts by self-poisoning were analyzed to assess the trend of suicide. Then, a comprehensive analysis of attempted suicide from January 1, 2019, to January 1, 2020, compared to survivors of accidental poisoning during the same year was conducted to assess the associated risk factors.

Subjects and sampling

A total of 7,398 Egyptian patients were recruited. Among them, 6745 participated in trend analysis. To assess the risk factors associated with attempted suicide by self-poisoning, 3377 patients were analyzed including 2523 suicide attempters by self-poisoning, 201 fatalities by self-poisoning and a further 653 accidental poisoning survivors (representing the last year admitted patients January 1, 2019-January 1, 2020). Demographic data of suicide attempters by self-poisoning were compared with demographics of fatalities by self-poisoning and accidental poisoning survivors. Moreover, the attempted suicide by self-poisoning was compared with fatalities by self-poisoning in terms of the causative agent exposure and the reported reasons. Furthermore, we calculated the death rates, case fatality rates, and Proportionate mortality rate and mortality rates. describes the distribution of the studied patients according to the manner of exposure and data analysis.

Inclusion criteria

All patients admitted to poison control centers with complete medical records were c eligible. Drug poisoning was established as per the International Classification of Diseases. Egyptian poison control centers are the only governmental authorities delegated to receive admissions of acutely intoxicated patients and patients receiving toxins or chemicals regardless of exposure circumstances, provided that they were presented alive. Deaths before referral are neither admitted nor counted in the database. All confirmed cases are documented in the database, while undiagnosed query cases were reported under the query category. The exposure pattern was estimated based on the history provided by adult patients or their caregivers in the case of minors or mentally disabled patients. In addition, the manner of self-poisoning could be concluded easily as some patients were reported in the database for previous suicide attempts. Other rare cases bear the signs of previous suicide attempts in other ways, e.g., cut the wrists etc.

Exclusion criteria

It included patients with suspected addiction, iatrogenic intoxication, and intoxication due to chronic drug use, as well as patients who had been discharged from the hospital against medical advice or who had spent < 24 hours with an uncertain fate.

Data collection tools

Medical records of patients admitted from January 1, 2016, to January 1, 2020, were extensively reviewed. From these records, we extracted the number of cases of attempted suicide per year which was used in trend analysis. Then, for January 2019-January 2020, we recruited cases of suicidal attempt by self-poisoning, fatalities by self-poisoning and cases of accidental poisoning. A predesigned case report form was distributed for both mentioned centers. Once upon admitting the patients, clinical and toxicological assessment was conducted. The manner of poisoning was determined (suicide attempt, or accidental). Furthermore, the type of chemical was determined from the history reported by the patients themselves or companions or in a few cases some patients brought the medicine package used. If necessary, clinical and/or laboratory examination were used to confirm the diagnosis [16].

A team consisting of a toxicologist, a psychiatrist, and a nurse was assigned to each suicide attempt. Demographic data included age, gender, residence, occupation, and socioeconomic standard. Patients were asked to answer questions about the triggers for the suicide attempt (financial issues, family conflicts, emotional issues, or bullying). Patients who could not choose among these factors were considered unknown risk factors.

The socioeconomic standard was categorized into high, medium, or low [17]. Subsequently, patients underwent a psychiatric evaluation according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria [18].

Compliance with ethical standards

The current study began after obtaining approvals from both centers research ethics committees (ID: 2/2021COM and No.: 34244/11/20). Patient confidentiality was maintained after the Helsinki Declaration. The medical records were completely anonymous. The above-mentioned research ethical committees have waived the requirement for informed consent.

Statistical analysis

Data were analyzed using SPSS 28. Qualitative data were presented as numbers and percentages. Graphing of the trend over four registry years was conducted using Microsoft Excel 2010. A Chi-square test (X2) was used to compare qualitative variables. Binary logistic regression analysis was implemented to determine the associated risk factors for attempting suicide by self-poisoning. All significant variables in the univariate logistic regression were subjected to multivariate logistic regression to detect the riskiest factors for attempted suicide [19]. A p value < 0.05 was considered significant. The incidence rate was estimated per 1,000 patients admitted and 100,000 population per governorate and calculated by dividing the number of events by the number of patients admitted or the number of regional populations derived from official population data [20]. Case fatality rate was calculated as the number of self-poisoning-specific deaths among the incident cases divided by total number of incident cases. Proportionate mortality rate was calculated as the number of deaths due to self-poisoning divided by deaths from all causes.

Results

Trend of suicide attempts by self-poisoning during four years of registration data

The number and incidence of suicide attempts by self-poisoning for the years 2016–2017, 2017–2018, 2018–2019, and 2019–2020 are shown in (Figs The number of suicide attempts by self-poisoning increased from 932 in 2016 to 2523 by January 2020. The current study showed an apparent increase in cases of suicidal self-poisoning and attempted suicide by self-poisoning during the four years studied.

Trend of attempted suicide by self-poisoning (incidence /100000 population during 4-year registry data).

The total number of suicides by self-poisoning reflects the sum of attempted and successful suicide by self-poisoning.

Trend of attempted suicide by self-poisoning (incidence /1000 admitted patients during 4-year registry data).

The total number of suicides by self-poisoning reflects the sum of attempted and successful suicide by self-poisoning.

The incidence of suicide attempts by self-poisoning and deaths during the year 2019–2020

From January 1, 2019, to January 1, 2020, the total number of patients with suicidal self-poisoning was 2724 (n = 2523 attempts + 201 completed). The total number of accidental poisoning cases was 659 (n = 653 survivors + 6 deaths)). Suicide attempters by self-poisoning were 79.4% compared to 20.6% for accidental poisoning patients with an incidence rate of 26.63/1,000 admissions (CI95%: 25.63–27.86) and 26.10/100,000 population (CI95%: 25.10–27.14). The suicide rate by self-poisoning is 2.1/100,000 (1.9–2.5). The case-fatality rate and proportionate mortality rate from suicide by self-poisoning were 7.4% (CI95%: 6.5–8.4) and 14.1% (CI95%: 12.4–16.0), respectively (

Out of the 2724 cases of attempted and successful suicide by self-poisoning during the year 2019–2020, females, students, individuals aged less than 25 years old, those living in urban areas (62.7%), those suffering from family disputes (58.2%), or psychological disorders (37.3%) had increased odds of death and were significantly at risk of death from suicide by self-poisoning more than others. Furthermore, Aluminum phosphide was the leading cause of suicidal death by self-poisoning (94.5%). The most widely used way for attempting suicide by self-poisoning was pesticides (38.7%), then aluminum phosphide (29.3%). Drugs constituted about (18.5%) and included central nervous system (CNS) depressants (40.7%), cardiovascular and xanthine derivatives (27.4%), antipsychotics (21.8%), and antidepressants (20.9%). Family conflicts (30.8%), financial problems (23.6%) and psychological problems (21.4%) constituted the main conveyed reasons for attempting suicide by self-poisoning (

Univariate analysis of risk factors associated with suicide attempts by self-poisoning

Univariate analysis for risk factors associated with attempted suicide by self-poisoning were age ≤25 years and 25–40 years old [OR = 6.97, CI95%: 5.29–9.20 and OR = 1.36, CI95%: 1.10–1.68 respectively], being a female [OR = 2.03, CI95%: 1.71–2.42], a student [OR = 5.49, CI95%: 4.26–7.08], not working individual (OR = 1.59, CI95%: 1.31–1.93), being a rural resident [OR = 2.56, CI95%: 2.15–3.06] and those with low and moderate socioeconomic status [OR = 13.43, CI95%: 8.82–20.47 and OR = 2.81, CI95%: 1.86–4.25 respectively] (

Multivariate analysis of risk factors associated with attempting suicide by self-poisoning

Multivariate analysis revealed that attempted suicide by self-poisoning was predicted among patients aged <25 or 25–40 years old (OR = 27.49, CI95%: 15.28–49.64 and OR = 59.42, CI95%: 32.76–107.77 respectively), those of low or moderate socioeconomic status ((OR = 35.03, CI95%: 21.32–57.56 and OR = 14.11, CI95%: 10.86–18.43 respectively), students (OR = 2.91,CI95%: 1.57–5.43) and those living in rural residency (OR = 4.12, CI95%: 3.27–5.19). The logistic regression model designed to assess predictors of suicide attempts was statistically significant (p < 0.001 justifying 43.7% (NagelkerkeR2) of the variance in suicide and appropriately classified 86.3% of patients (

Discussion

This study showed that (79.4%) of the patients included in the study attempted suicide by self-poisoning. The rate of suicide attempts by self-poisoning in the general population was 26.10/100,000. Moreover, it was elaborated in the current study that 1196 out of 2523 suicidal attempters during the year 2019–2020, were less than 25 years, representing about (47.4%) of total suicide attempts by self-poisoning. Similarly, a dramatic increase in suicide attempts by self-poisoning was reported, especially in children aged less than 19 over the last 10 years [21]. These numbers are much higher than those reported earlier in 2004, which reported that about 2.9% of teens who attempted suicide needed emergency admission. Though this rise reflects the catastrophic surge of this serious problem, part of the gap in numbers is attributable to the sampling difference between the different studies. Our study targets only those admitted to poison centers while the mentioned study, in 2004, calculated this rate considering the general population [22].

Nevertheless, Suicides by self-poisoning/1,000 admissions were significantly increased over a four-year period. Suicides by self-poisoning reached 28.76/1000 populations including attempted and successful suicides in 2019–2020, reflecting the severity and evolution of this problem. It has been reported that the suicide rate has increased by 16% over the past decade in the United States [23]. Studies in Australia, the United Kingdom, Italy and Brazil have reported an increasing trend, raising global concerns [24-27].

The current study reported that the death rate due to suicide by self-poisoning was 2.08/100,000 during 2019. The rate ranged between 0.47 and 2.41 during the past two decades [28-30] The rate changes from study to study and may vary in different countries over time, and even within the same country. This difference can be illustrated by the difference in the culture of the population studied, the size of the carefully studied environmental area, the health care system facilities, and the diversity in socio-demographic conditions. Also, preliminary screening may occur, which may reduce the proper number of suicide attempts from one area to another [31-34].

The most common method used to attempt suicide by self-poisoning in the current study was pesticides. The main drugs used were central nervous system depressants while aluminum phosphide was the leading cause of suicidal deaths due to self-poisoning. Similarly, In Sri Lanka, nearly half of self-poisoning cases are attributed to pesticides [35]. These findings are consistent with other studies in different contexts [12, 29, 36]. An earlier study in Egypt warranted the increased deaths due to self-poisoning using the aluminum phosphide [14]. These products’ easy availability and low cost (pesticides) may explain their widespread use. On the contrary, in developed countries, drugs that act in the central nervous system are the most common means of attempting suicide by self-poisoning [37]. Differences between countries can be attributed to differences in socioeconomic conditions and access to medicines [38].

The current study investigated some motives for attempting suicide by self-poisoning, such as family disputes and psychological disorders. These findings coincide with previous studies suggesting that attempted suicide by self-poisoning may be related to recent family arguments or psychiatric disorders, in which emotional release or coping strategies can occur [30, 39, 40]. The association between mental disorders and the suicide attempt is consistent with additional studies in different contexts [6, 41]. Exacerbation of depression in the population, which may be exacerbated by societal problems such as unemployment, may lead to attempted suicide by self-poisoning. Conflicts, relationship failures, and examination failures are found in developing countries [42].

Furthermore, the stigma associated with suicide attempts can lower incident reporting. In our study, the causes of attempted suicide are unknown in about 5% of patients. This may be attributed to the tendency of patients’ relatives to deny or refuse to acknowledge the attempted suicide. Some patients do not have families, and clinicians also face obstacles in evaluating and managing such cases [43, 44].

The present work reported that subjects under 25 were more likely to attempt suicide by self-poisoning than other elderly people. This may be related to the emotional distress and unemployment that young people face and the unfortunately and predictable overdose medications commonly consumed by this age group, and the responsibility of older adults to their families may hinder such suicidal thoughts [29, 36, 45].

Easy access to the internet, social media, and smart device usage among this age group can negatively impact mental health and ability to deal with various stressors. Egypt ranks high in internet use in the Middle East and shows high smartphone use among youth (90%) [46].

The current study described that female are at greater risk of attempting suicide by self-poisoning than males. Globally, self-harm is ranked second among females and third among males [40, 47]. A recent study in Egypt reported that two-thirds of suicide self-poisoning cases occurred among females [48]. In Australia, the number of females attempting suicide by self-poisoning was greater than that of males (3:1) [24]. Females tend to consume items already available in the home, while males tend to ingest or purchase an item kept outside [48].

Availability of the substance, especially pesticides, as well as hormonal disturbances and the habitual tendency of females to conflict with their guardians, are among the main reasons for attempting suicide by self-poisoning [49-51]. The burden of spinsterhood on females, along with low socioeconomic levels and low wages, paves the way for the spread of suicide attempts by female self-poisoning [48].

Qin et al. elaborated on the gender differences among patients of attempted suicide. Mental disorders, living in urban areas, without children, and having a family history of suicide increases the risk of suicide in females compared to males [41]. Toth et al., studied gender differences in suicide attempts as there was a gender factor in the presentation of depression among patients with interpersonal struggles. Females with interpersonal conflicts who attempted suicide by self-poisoning showed higher levels of depression than males [52].

Students and patients who did not work showed a significantly suicide attempts by self-poisoning. This finding has been reinforced elsewhere [53, 54]. Another study described even low-paid work as having a direct primary link to higher suicide rates. Moreover, this study suggested that an increase in salaries would lead to a rapid decrease in the suicide rate [55].

Our study showed that patients with low socioeconomic status and those living in rural areas were at significantly increased risk of attempting suicide. This result was agreed upon by Liu et al. It can be justified by the resulting anxiety, and the consequent illicit drug use associated with low income [56, 57]. However, this is in contrasts to Finkelstein et al., who reported conflicting results and stated that hospitalization due to suicidal overdose is more common among patients with high socioeconomic conditions [23]. Sun et al. found the rural-urban discrepancy 2.5:1, indicating that the difference can be justified by differences in age, literacy, occupation and residency [57]. On the contrary, another study conducted in rural Sri Lanka reported a significant reduction in the suicide attempts by self-poisoning. The authors attribute this to the heavy dependence on agriculture and grazing for subsistence without the need for additional resources [58].

Preventing suicide by self-poisoning and all types of suicide is a public health responsibility to overcome the increasing trend in suicide rates, which affect individuals and families, communities, and society. Therefore, putting in place policies to reduce such a risk is urgent. Nurses, toxicologists, and public health professionals remain focused within the health care professional community on identifying risk factors for suicide and implementing these policies in practice. It is necessary to know the groups at high risk [59].

Nurses working in psychiatric liaison, CAMHS or primary care must have in-depth knowledge and skills to conduct comprehensive assessments. It is necessary to adopt approaches that address the individual and societal factors that motivate suicide. In societies where basic needs such as the emotional, financial and religious needs of its inhabitants are available, suicide and its consequences rarely occur.

Strengths and limitations

Although the study was conducted in two Egyptian governorates only, it provided a recent report on the seriousness of the current suicide attempts through self-poisoning. Examining several issues such as follow-up of survivors to check whether cases were referred for psychological counseling, and whether there were any other hidden factors to avoid a recurrence of the suicide incident was out of our hands. This might be due to the sensitivity of this topic and the stigma associated with it within the victims’ families.

Conclusion

Suicide by self-poisoning is increasing in Egypt, which raises concern. Family disputes, financial and psychological issues were the main reasons for attempting suicide by self-poisoning. Students, those under the age of 40, those who live in rural areas and those of low and moderate socioeconomic standards are more likely to attempt suicide by self-poisoning. Attempted suicide by self-poisoning is a multifactorial problem that requires a deep understanding and cooperation among all interested parties including physicians, nurses, family, community, clergy and state leaders to provide support, health education and legislation.

1 Feb 2021

PONE-D-20-34054

Incidence, Distribution, and Associated Factors of Suicide in Two Egyptian Provinces

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Reviewer #1: The topic of the paper is clinically relevant and could help to explain and understand the specif-ic circumstances of suicidality in Middle Eastern countries compared to other parts of the world.

The title is not sufficiently focussed more a short version of the abstract. The abstract is too long for an original paper and needs to be more structured based on the established format of the journal.

For an international readership it would be especially interesting to compare international trends to the situation in Egypt and the middle eastern region. I would suggest to take out gen-eral statements on suicide and refer to the literature and focus on describing the specific cir-cumstances and risk factors for suicidal behaviour and suicide in the region. That should follow a clear structure in the introduction, so that the reader always knows what the authors are re-ferring to. Critical factors like cultural aspects, religion, family structures and gender related expectations and risk factors are not described in a way, that allows the reader to be prepared for the results section. Also the fact, that suicidal behaviour and thoughts are highly stigma-tized and the suicide rate might be under reported would be important for the conclusion and discussion later on. Also suicide rates in specific populations like street entrenched youth or rural populations are not reflected or presented. So the reader learns very little about specific vulnerable populations and risk factors.

Also to study something is not a sufficient objective. I’m sure the authors had interests and ideas beyond that.

The method section again needs a clear structure like describing the study sample e.g how many patients in phase 1 and 2 etc., the evaluation methods, the timeframe and the expertise used and available to carry out the research and the detailed statistical procedures used. The governorates were not mentioned so the reader can not apply context knowledge. The termi-nology between self-poisoning and suicide is used in a confusing way. It should be clearly em-phasized what the authors are talking about.

The lack of information and structure makes it complicated to understand the results. What constitutes the assessment of poisoning, Who is doing that and based on what criteria it is classified as suicide. In case of the use of psychotropic substances often several substances are used at once but there is no mention of polysubstance use. That way the results section is ex-tremely complicated to follow and unclear in its conclusions. A straight forward presentation of results should be well structured and allowing the reader to understand every step of the as-sessment!

The discussion of the paper is including a lot of interesting and important considerations, which should already been mentioned in the introduction. Again it needs restructuring in order to be able to draw conclusions. The discussion is also not answering the question related to the in-crease in suicidal actions. Also there is a lack of comparison to the international development and the international literature. Is Egypt in a specific situation? Are there specific provinces which are worse off and why? Some comments are inconsistent:

they mentioned suicide but their focus on self-poisoning

They mentioned that the study was along 4 years and, in the discussion, said 2019-2020 only.

They stated in the results the total number of self-poisons was 3383 and in discussion only the suicidal number (2724). Needs clarification.

They did not name the governorates or give any background about them.

They showed that the rates of their centers are much higher than the Egyptian national number without any rationalization.

The explanation of the third paragraph as a difference in the culture only needs to be more explained.

The explanation of the gender differences in the fourth paragraph as by hormonal caus-es only are not logic.

Same for the fifth paragraph, hormonal reason is reported as an explanation for suicide in students!

In the eighth paragraph, I think these are risk factors for suicidal self-poisoning not causes of suicide.

Risk factors have weak explanations.

Based on that the conclusions are not really conclusions because there are no recommenda-tions or suggested consequences based on the results presented.

I recommend the authors to collaborate with native speakers use more visuals in order to increase readability.

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Reviewer #1: No

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19 Feb 2021

Dear editor and reviewers, thanks so much for your great and endless effort. We hope to find the response satisfactory and admired

Submitted filename: Response-to-reviewers-comments.docx

Click here for additional data file.

24 Jan 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Saeed Ahmed, MD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: No

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: (No Response)

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: No

Reviewer #3: (No Response)

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: 1. Lines 24 and 25 mention, “the first part was conducted retrospectively to show the trend of suicide attempts over 2016, 2017, and 2018” - So, the 4419 patients mentioned here – are those who attempted suicide or those who died of suicide? I recommend that the data regarding patients diagnosed with suicide by self-poisoning and suicide attempt by self-poisoning is delineated and changed across the article (see point 8 below) accordingly.

2. Line 60 – “Reports published in the US considered suicide by self-poisoning the most common method of suicide attempts among adolescents (66.5%)”. I recommend removing suicide by self-poisoning and replacing it with self-poisoning as the article refers to suicide attempts and not suicide.

3. Line 77 – The sentence does not clearly communicate the author’s thoughts to the reader. Can you clarify “drugs?” I recommend rewriting the sentence for clarity.

4. Line 83-87 – The sentence is too long and loses clarity. I recommend breaking it into two sentences.

5. Line 97 – Same question as point 1. Does 969, 1,192, and 2,258 refer to patients who died of suicide or are these the number of patients who attempted suicide. Based on this the diagnosis should reflect suicide by self-poisoning versus suicide attempt by self-poisoning

6. Line 101- Why was accidental poisoning included in the study? Is there a relevance to suicide which is the primary objective of the study?

7. The lines 129-146 under data collection tools are confusing to the reader. Do these lines refer to patients who attempted suicide by overdose? Clarifying point 1 above and rewriting this section is recommended.

8. Lines 169-171, 173, 175, 186 and table 1, 222, 247, 274, 288, 298, 307, 316 and 343 – does this data pertain to suicide attempts or to suicide? If it refers to suicide attempts, then the sentences need to be changed to reflect that.

9. Line 224 – the article refers to suicide attempts and not suicide as mentioned in this line. Recommend changing it for accuracy.

10. Line starting 337 ending in 339 is incomplete and I recommend rewriting it to convey accurate meaning.

Reviewer #3: The manuscript by Kasemy, et al studies the important topic of suicide.

Strengths of the paper:

- The title is appropriate for the content of the text.

- The abstract describe findings of the study as well as suggestions on what can be done to prevent this global public health issue.

- The introduction to the article is well laid out that includes prevalence, specific methods of suicide, and risk factors, both nationally and globally.

- Methods and results are clearly described. Tables included in the manuscript help quickly review the study outcomes.

- Discussion and conclusion further elaborate risk factors and differences in methods of choice to commit suicide in Egypt and in comparison to other countries (vis-a-vis developed and developing countries) and the possible reason for those differences.

Some weaknesses are:

- Not always easily readability of the text and makes it difficult to follow at times.

- In line 47, it is not clear if the authors are implying suicide being the leading cause of death in children and adolescents or suicide deaths by numbers in this age group.

- In line 48, the authors report a steady increase in suicide rates globally (WHO 2001 data). However, new data in the Suicide worldwide 2019 report by WHO (published in 2021) states overall the global age-standardized suicide rate is somewhat in decline (except some regions, for example, the Americas). Ref: https://www.who.int/publications/i/item/9789240026643

- Authors rightly report stigma surrounding the suicide. In line 303, the authors suggest gender differences in suicide rates to hormonal or interpersonal conflict. The full comprehension of the gender paradox in suicidal behavior requires further research. Suggestion for authors to review studies on gender differences in suicide and other possible risk factors including but not limited to psychiatric disorders.

Ref: Qin, P., Agerbo, E., Westergård-Nielsen, N., Eriksson, T., & Mortensen, P. (2000). Gender differences in risk factors for suicide in Denmark. British Journal of Psychiatry, 177(6), 546-550. doi:10.1192/bjp.177.6.546. Tóth MD, Ádám S, Birkás E, Székely A, Stauder A, Purebl G. Gender differences in deliberate self-poisoning in Hungary: analyzing the effect of precipitating factors and their relation to depression. Crisis. 2014;35(3):145-53. doi: 10.1027/0227-5910/a000245. PMID: 24491825.

- In line 293, the authors report risk factors in less than 25 years old population. It is unclear if authors are implying social media as the monster or a specific online site named the monster.

- Lines 296, 300, 303 have missing references.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

5 Feb 2022

Based on your valuable comments, we have changed the article starting from the title till its end. The authors extend their appreciation for the reviewers for their great efforts in improving the quality of the manuscript. We found all proposed comments valuable and enriching the article. We hope we could fix the modifications meeting your expectations. Based on your valuable and comments, we changed the title and delineated the attempted from those died by suicide self-poisoning hoping to find satisfactory and clearly presented. All changes are found in documents of response to reviewer's comments and manuscript either with tack changes or without. I hope you find it well written and to the point. We did our best.

Submitted filename: Response to Reviewers comments.docx

Click here for additional data file.

11 Apr 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Saeed Ahmed, MD

Academic Editor

PLOS ONE

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #4: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: (No Response)

Reviewer #4: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: (No Response)

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: No

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The authors have adequately addressed comments raised in a previous round of review and feel that this manuscript is now acceptable for publication except for multiple grammatical errors. I encourage authors to fix these before publication.

Suggestion for authors: can use online freely available software like Grammarly, etc.

Reviewer #4: The authors present results from a study of trends in suicide and attempted suicide rates in Egypt over a 4 year period as well as risk factors for attempted suicide in 2019. Authors find that rates are increasing over time, that family, psychological issues, and financial issues are common reasons for attempted suicide, and that age, residential location, working status, and SES are risk factors for attempted suicide. The manuscript will be strengthened if the authors consider the following points:

1. Abstract: authors present results from the univariate logistic regression models. However, the multivariate model is more appropriate for final results, since this accounts for other variables included in the model.

2. In the subjects and sampling section of the Methods, authors state that fatalities were excluded from the analyses of risk factors. Authors should provide additional justification for this decision. Some of the information collected on the attempts are likely known about the fatalities. At a minimum, authors should provide some information about how the characteristics (age, gender, other variables known) of those who died by suicide in 2019 compared to those who attempted suicide that year, but were unsuccessful.

3. In the inclusion criteria section, authors state that all patients admitted to poison control centers with complete medical records were eligible for the study. Authors should provide information about poison control centers in Egypt so that readers understand who the population under study is. For example, are all cases of suspected poisoning referred to poison control centers (including deaths)?

4. In the Statistical Analysis section, authors should describe their approach for model building - how did they go from the univariate model to the multivariate model? Was overlap/collinearity between variables considered?

5. Univariate analysis section of results: Authors do not mention the finding for medium SES.

6. Multivariate analysis section of results: why do the authors combine categories for variables in the multivariate models? This needs to be justified and explained.

7. Authors spend several paragraphs in the Discussion about females attempting suicide, yet females are not significantly more likely than males to attempt suicide in the multivariable model.

Minor points:

1. Abstract: "The death rate due suicide" should be "The death rate due to suicide" and "which raise a serious concern" should be "which raises a serious concern". Also, to be consistent with later presented results in the manuscript, "CI95%" should be "95% CI"

2. Introduction: "among 15-29 year" should be "among people aged 15-29 years" and "2nd cause of death" should be "2nd leading cause of death"

3. Inclusion criteria: "For example, cut the wrists" is an incomplete sentence.

4. Data collection tools: "which was use in trend analysis" should be "which was used in trend analysis", "Confirmed by clinical evaluation..." is an incomplete sentence, and "age, gender, etc." should list all variables collected, not just saying "etc."

5. Statistical Analysis: "Qualitative data was" should be "Qualitative data were" and "Calculated by dividing..." is an incomplete sentence.

6. Figures 3 and 4: in the legends "slef-poisoning" should be "self-poisoning" and "self-posioning" should be "self-poisoning". Also, authors should clarify what is meant by total cases - is this attempted + successful?

7. Results, 1st paragraph: "attempted suicide by suicide" should be "attempted suicide by self-poisoning"

8. Table 1: the denominator written in the table for proportionate mortality rate does not seem correct, as this is the same as what is written for the self-poisoning suicide death rate.

9. Table 2 (and related text in Results): The percentages in the text of the paragraph at the bottom of page 7 (for aluminum phosphide and drugs used in attempted suicide) do not match what is presented in Table 2. Authors should also clarify in the text and the table that the percentages for the drugs are calculated out of the 467 individuals who used drugs.

10. bottom paragraph of page 7: "was pesticides (38.7%) then aluminum..." should be "was pesticides (38.7%), then aluminum..."

11. Univariate analysis results: the OR written for age<25 years does not match Table 3. Based on the numbers presented, it seems as though the number in the text is probably correct, while there is a typo in Table 3. Authors should carefully check the numbers and make the correction wherever it is needed. "female student" should just be "student" and the OR and CI for not working should be corrected (since the authors have re-written the OR and CI for student). "patients Those" should be "individuals" or "patients" and "confidence interval" should be "95% CI" to be consistent with other presented results in this section.

12. Discussion, 1st paragraph: "The rate of suicide attempts in the general..." should be "The rate of suicide attempts by self-poisoning in the general..." In this same paragraph, authors compare the result to a study of teens and make a point that the rate is much higher in 2019 than 2004. It is unclear why this comparison is relevant if the 2004 study is just about teens, while the current study is about all attempts.

13. Discussion, 2nd paragraph: "Suicides by self-poisoning reached 28.76" should be clarified. First, authors should state whether this is out of admissions or population (/1000 or /100000). Second, authors need to clarify if this is attempts, deaths, or attempts+deaths.

14. Last sentence on page 12 ("Examining several issues...") is an incomplete sentence.

15. Conclusion: authors do not mention financial reasons, which was more common than psychological reasons for the attempted suicide. Also, the summary sentence on the results from the logistic model needs to be rewritten, since the authors have combined variables together (students under the age of 25, for example), while the model looks at each variable while holding the other variables constant (so authors can say, "students, those under the age of 25 and those who live in a rural area..."

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

Reviewer #4: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

18 Apr 2022

Response to reviewers’ comments

Thanks so much for your valuable comments that enriched the article. We responded to all comments and we hope you find it satisfactory and admired.

Reviewer #3:

The authors have adequately addressed comments raised in a previous round of review and feel that this manuscript is now acceptable for publication except for multiple grammatical errors. I encourage authors to fix these before publication.

Suggestion for authors: can use online freely available software like Grammarly, etc.

We have sent the manuscript to a proofreader who had checked for any errors or mistake. However, we didn’t highlight the language changes as they were many, to avoid confusing the other responses to reviewer comments.

Reviewer #4:

1. Abstract: authors present results from the univariate logistic regression models. However, the multivariate model is more appropriate for final results, since this accounts for other variables included in the model.

Corrected as per request.

2. In the subjects and sampling section of the Methods, authors state that fatalities were excluded from the analyses of risk factors. Authors should provide additional justification for this decision.

Totally agree with this point. Unfortunately, exclusion of fatalities from analysis was based on the reviewer requirement in the last round of revision. However, we had deleted the statement” fatalities were excluded from the analyses of risk factors”, and we included the fatalities in the analysis as revealed at Table (2). Besides, we elaborated in this part in the abstract, results, discussion, especially the point referring for significantly higher fatalities due to self-poisoning by Aluminum phosphide.

3. Some of the information collected on the attempts are likely known about the fatalities. At a minimum, authors should provide some information about how the characteristics (age, gender, other variables known) of those who died by suicide in 2019 compared to those who attempted suicide that year but were unsuccessful.

The authors, as per the request, conducted the test of significance to compare characteristics (age, gender, other variables known) of those who died by suicide in 2019 compared to those who attempted suicide that year. A table was added (Table 2).

4. In the inclusion criteria section, authors state that all patients admitted to poison control centers with complete medical records were eligible for the study. Authors should provide information about poison control centers in Egypt so that readers understand who the population under study is. For example, are all cases of suspected poisoning referred to poison control centers (including deaths)?

Agree. This part was rephrased completely in the section of the methodology under the subheading Inclusion criteria. The route of admission to poison control centers and triaging the patients were mentioned in more comprehensive way. We hope it meets your expectations.

5. In the Statistical Analysis section, authors should describe their approach for model building - how did they go from the univariate model to the multivariate model? Was overlap/collinearity between variables considered?

This part was fixed and rephased with a reference. Based on Bursac et al., 2008, the best way to select the included varaibles is to subject all significant variables in the univariate logistic regression to multivariate logistic regression to detect the riskiest factors to attempted suicide by self-poisoning.

6. Univariate analysis section of results: Authors do not mention the finding for medium SES.

Detailed results of univariate logistic regression, including the medium SES was reported in the results section as per request.

7. Multivariate analysis section of results: why do the authors combine categories for variables in the multivariate models? This needs to be justified and explained.

Based on that comment, and to allow simple and easy interpretation, we do uncombined all variables and re-performed logistic regression as revealed at Table (4) and the corresponding part in the results section.

8. Authors spend several paragraphs in the Discussion about females attempting suicide, yet females are not significantly more likely than males to attempt suicide in the multivariable model.

Right. The multivariate model didn’t outline being a female as one of the significant suicide attempt risk factors, as this model highlight the most significant predictor considering the other variables which showed the riskiest factors like SES, age, residency and occupation. However, we could not overlook the significance of gender seen in the univariate analysis and when comparing studied patients according to the successfulness and manner of exposure (attempted versus successful, and accidental versus suicide self-poisoning). 62% of the Self-poisoning attempters, and 79.6 were females (which constituted more than half of studied Patients. Moreover, the added paragraphs were response to the reviewer comments in the first and second rounds of revisions.

the

Minor points:

1. Abstract: "The death rate due suicide" should be "The death rate due to suicide" and "which raise a serious concern" should be "which raises a serious concern". Also, to be consistent with later presented results in the manuscript, "CI95%" should be "95% CI"

The Confidence interval 95%

was fixed at the different sections of the text aligned with the results, as per request.

2. Introduction: "among 15-29 year" should be "among people aged 15-29 years" and "2nd cause of death" should be "2nd leading cause of death"

Fixed

3. Inclusion criteria: "For example, cut the wrists" is an incomplete sentence.

Fixed

4. Data collection tools: "which was use in trend analysis" should be "which was used in trend analysis", "Confirmed by clinical evaluation..." is an incomplete sentence, and "age, gender, etc." should list all variables collected, not just saying "etc."

Fixed

5. Statistical Analysis: "Qualitative data was" should be "Qualitative data were" and "Calculated by dividing..." is an incomplete sentence.

Fixed

6. Figures 3 and 4: in the legends "slef-poisoning" should be "self-poisoning" and "self-poisoning" should be "self-poisoning". Also, authors should clarify what is meant by total cases - is this attempted + successful?

Fixed. The total number of suicides by self-poisoning reflects the sum of attempted and successful suicide by self-poisoning. This clarification was added to the mentioned figures’ ligands.

7. Results, 1st paragraph: "attempted suicide by suicide" should be "attempted suicide by self-poisoning"

Fixed

8. Table 1: the denominator written in the table for proportionate mortality rate does not seem correct, as this is the same as what is written for the self-poisoning suicide death rate.

Fixed, it was typing error.

9. Table 2 (and related text in Results): The percentages in the text of the paragraph at the bottom of page 7 (for aluminum phosphide and drugs used in attempted suicide) do not match what is presented in Table 2. Authors should also clarify in the text and the table that the percentages for the drugs are calculated out of the 467 individuals who used drugs.

Sorry for this mistake due to reanalysis of data based on reviewers’ comments, there was unintended mismatching between table and text which was figured out after submission. However, the numbers and percentages of Causative Agent used as mentioned at Table (2), is calculated out of 2724 as highlighted in the title of the table, and not out of 467. We used the word causative agent to include the different categories of used substance in terms of chemicals, drugs, pesticides,….etc. However, a brief hint was added to the text clarifying the overall number of cases included in the calculation.

10. bottom paragraph of page 7: "was pesticides (38.7%) then aluminum..." should be "was pesticides (38.7%), then aluminum..."

Fixed

11. Univariate analysis results: the OR written for age<25 years does not match Table 3. Based on the numbers presented, it seems as though the number in the text is probably correct, while there is a typo in Table 3. Authors should carefully check the numbers and make the correction wherever it is needed. "female student" should just be "student" and the OR and CI for not working should be corrected (since the authors have re-written the OR and CI for student). "patients Those" should be "individuals" or "patients" and "confidence interval" should be "95% CI" to be consistent with other presented results in this section.

The entire section was revised and corrected as per your suggestion.

12. Discussion, 1st paragraph: "The rate of suicide attempts in the general..." should be "The rate of suicide attempts by self-poisoning in the general..." In this same paragraph, authors compare the result to a study of teens and make a point that the rate is much higher in 2019 than 2004. It is unclear why this comparison is relevant if the 2004 study is just about teens, while the current study is about all attempts.

This paragraph was rephrased and fixed to alleviate the confusion. We fixed the mentioned words. Regrading specifying the teens, this was requested by the reviewer in the second round of revision, considering the significance of suicide by self-poisoning among the patients aged less than 25 in the current study. Moreover, we had added a reference supporting the findings of suicide by self-poisoning among teens. Then, in the next paragraph, we discussed the problem of suicides by self-poisoning among admissions without reflecting on specific age group. We hope that meets your expectations.

13. Discussion, 2nd paragraph: "Suicides by self-poisoning reached 28.76" should be clarified. First, authors should state whether this is out of admissions or population (/1000 or /100000). Second, authors need to clarify if this is attempts, deaths, or attempts+deaths. Fixed

14. Last sentence on page 12 ("Examining several issues...") is an incomplete sentence. Fixed

15. Conclusion: authors do not mention financial reasons, which was more common than psychological reasons for the attempted suicide. Also, the summary sentence on the results from the logistic model needs to be rewritten, since the authors have combined variables together (students under the age of 25, for example), while the model looks at each variable while holding the other variables constant (so authors can say, "students, those under the age of 25 and those who live in a rural area..."

Fixed

Submitted filename: Response to Revierwers comments.docx

Click here for additional data file.

9 May 2022

10 May 2022

Response to reviewers’ comments

Reviewer #3 and Reviewer #4:

Thanks so much for your support and great efforts to make our article presented in the best way.

Reviewer 4#: The authors have addressed the majority of my earlier concerns. There just remain a few very minor points that should be corrected:

1. on page 8, 1st full paragraph beginning with "Out of the 2724 cases...": authors refer to female students less than 25 years old are at higher risk of death from suicide when referring to results in Table 2. The results would suggest that females have increased odds of death relative to males, students have higher odds of death than those working, and those <=25 have higher odds of death than those >25. So interpreting the results as the combination of those variables (female students less than 25) is not exactly consistent with the analysis. Authors should rephrase this to indicate that sex, occupation, and age are separate variables.

Response: Thanks so much and we apologize for this misinterpretation. We corrected it as per your request on individual basis. Fortunately, this part was interpreted on individual basis on the discussion section as previously recommended.

2. Also on page 8 in the Univariate analysis section, authors said in their response that they corrected the repeated OR and CI, but that is not reflected in the submitted clean or corrected version with changes highlighted. The OR for not working is written exactly the same as the OR for student, but Table 3 shows these are in fact different ORs and CIs. Authors should put the correct OR and CI for "not working" in the text.

Response: Thanks so much and we apologize for this mistake (typo), and we corrected it. OR and CI were written separately for both students and not working

3. In the 1st paragraph of the Discussion, authors added a percentage (37.4%) for the 1196 attempts made by individuals less than 25 - authors should recheck that percentage, since 1196/2523=47.4 and 1196/ (2523+201) =43.9, so it is not clear where the 37.4% is coming from.

Response: Thanks so much and we apologize for this typing error, and we corrected it from 37.4 to 47.4%

4. Table 1: authors should include a note about where the 1424 (corrected denominator for the proportionate mortality rate) comes from or what it refers to

Response: This part was fixed in the results section, and as a foot note under Table (1).

The equation of proportionate mortality rate = number of deaths (suicide) due to self-poisoning divided by deaths from all causes. The total number of deaths during this year from all causes in the referred hospitals where the poising centers present equaled 1424.

Proportionate mortality rate: Deaths caused by a particular cause/Deaths from all causes

Submitted filename: Response to Revierwers comments.docx

Click here for additional data file.

3 Jun 2022

Trend and Epidemiology of Suicide attempts by Self-poisoning among Egyptians

PONE-D-20-34054R4

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7 Jun 2022

PONE-D-20-34054R4

Trend and Epidemiology of Suicide attempts by Self-poisoning among Egyptians

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Table 1

Incidence and associated deaths rates of attempted suicide by self-poisoning during the year Jan 2019– Jan 2020.

	No	(CI95%)
Poisoning type    • Suicide by self-poisoning (attempted +completed)    • Accidental Poisoning (survivors +dead)	2724659	80.5% (80.4–80.6)19.5% (19.4–19.5)
Living    • Suicide by self-poisoning attempters    • Accidental Poisoning survivors	2523653	79.4% (77.9–80.8)20.6% (19.1–22.0)
Death    • Completed suicide by Self-poisoning    • Dead by Accidental poisoning	2016	97.1% (93.8–98.9)2.9% (1.1–6.2)
	Incidence rate	CI95%
Incidence rate of poisoning in relation to all admitted patients    • Suicide attempt by Self-poisoning (n = 2523)    • Accidental Poisoning (n = 653)	26.63/100006.89/100	25.63–27.866.38–7.44
Incidence rate of suicide in relation to all regional population    • Suicide attempt by Self-poisoning(n = 2523)    • Accidental Poisoning(n = 653)	26.10/1000006.76/100000	25.10–27.146.26–7.29
Self-Poisoning suicide death rate (n = 201/2724)	2.08/100000	1.90–2.49
Case fatality ratea    • Suicide by Self-poisoning (n = 201/2724)    • Accidental Poisoning (n = 6/659)    • Total (Suicide by Self-poisoning + accidental poisoning)	7.38%0.91%6.12%	6.45–8.420.41–2.015.36–6.98
Proportionate mortality rateb (n = 201/1424)	14.11%	12.43–16.0

a. Case fatality rate was calculated as the number of self-poisoning-specific deaths among the incident cases divided by total number of incident cases.

b. Proportionate mortality rate was calculated as the number of deaths due to self-poisoning divided by deaths from all causes.

Table 2

Distribution of attempted and successful suicide by self-poisoning (n = 2724) regarding the demographic data, causative agent exposure and reported reasons during the year 2019–2020.

	Groups				p- value	OR [CI95%]
	Suicide by self-poisoning (n = 201)		Self-poisoning attempters (n = 2523)
	no	%	no	%
Age (years)					<0.001*
≤25	185	92.0	1196	47.4		12.83[7.65–21.51]
>25	16	8.0	1327	52.6		1.0
Gender					<0.001*
Male	41	20.4	858	34.0		1.0 [1.41–2.86]
Female	160	79.6	1665	66		2.01
Residence					<0.001*
Rural	75	37.3	1533	60.8		1.0
Urban	126	62.7	990	39.2		2.60[1.93–3.50]
Occupation
Working	2	1.0	674	26.7	<0.001*	1.0
Not working	42	20.9	903	35.8	<0.001*	55.93[13.82–226.40]
A student	157	78.1	946	37.5		15.67[3.78–64.98]
SES
Low	71	35.3	1750	69.4	0.092	0.42[0.14–1.19]
Medium	126	62.7	732	29.0	0.280	1.76[0.62–5.01]
High	4	2.0	41	1.6		1.0
Reported causes					<0.001*	-
Family disputes	117	58.2	776	30.8
Psychological disorders	75	37.3	541	21.4
Financial issues	2	1.0	596	23.6
Emotional issues	7	3.5	340	13.5
Bullying	0	0.0	156	6.2
Unknown	0	0.0	114	4.5
Causative Agent
Pesticide	4	2.0	976	38.7	<0.001*	-
Aluminum phosphide	190	94.5	740	29.3
Zinc phosphide	7	3.5	257	10.2
Hydrocarbons	0	0.0	83	3.3
Drugs	0	0.0	467	18.5

*: significant SES: socioeconomic standard

Table 3

Univariate analysis of risk factors associated with attempted suicide by self-poisoning versus accidental poisoning during the year 2019–2020.

	Poisoning						p- value	OR [CI95%]
	Self-poisoning attempters (n = 2523)		Accidental poisoning survivors (n = 653)		Total (n = 3176)
	no	%	no	%	no	%
Age (years)
≤25y	1196	47.4	90	13.8	1286	40.5	<0.001*	6.97 [5.29–9.20]
>25-40y	965	38.2	373	57.1	1338	42.1	0.001*	1.36 [1.10–1.68]
>40y	362	14.3	190	29.1	552	17.4	-	1.0
Gender
Male	858	34.0	334	51.1	1192	37.5	<0.001*	1.0
Female	1665	66.0	319	48.9	1984	62.5		2.03[1.71–2.42]
Residence							<0.001*
Rural	1533	60.8	246	37.7	1779	52.6		2.56 [2.15–3.06]
Urban	990	39.2	407	62.3	1397	47.4		1.0
Occupation
Working	674	26.7	303	46.0	977	30.8	-	1.0
Not working	903	35.8	266	40.4	1363	36.6	<0.001*	1.59 [1.31–1.93]
A student	946	37.5	90	13.7	1036	32.6	<0.001*	5.49 [4.26–7.08]
SES
Low	1750	69.4	197	30.2	1947	61.3	<0.001*	13.43 [8.82–20.47]
Medium	732	29.0	394	60.3	1126	35.5	<0.001*	2.81 [1.86–4.25]
High	41	1.6	62	9.5	103	3.2	-	1.0

*: significant SES: socioeconomic standard

Table 4

Multivariate analysis of risk factors associated with attempted suicide by self-poisoning using Binary logistic regression.

	P value	OR	CI95%
			Lower	Upper
Age	<0.001*
Age: 25–40	<0.001*	59.42	32.76	107.77
Age (<25)	<0.001*	27.49	15.28	49.46
Sex (Female)	0.064	1.26	0.99	1.60
Residence (Rural)	<0.001*	4.12	3.27	5.19
Socioeconomic standard	<0.001*
Moderate	<0.001*	14.11	10.86	18.34
Low	<0.001*	35.03	21.32	57.56
Occupation	0.002*
Not working	0.719	1.05	0.80	1.38
Students	<0.001*	2.91	1.57	5.43

*: significant