Journal of Forensic and Legal Medicine 61 (2019) 1–4

Contents lists available at ScienceDirect

Journal of Forensic and Legal Medicine

journal homepage: www.elsevier.com/locate/yjflm

Research Paper

Pattern of suicide by self-poisoning in Northern Tunisia: An eleven-year T

study (2005–2015)
Meriem Gharbaouia,b, Mehdi Ben Khelila,b,∗, Hana Harzallahb, Anis Benzartia,b, Mongi Zhiouaa,b,
Moncef Hamdouna,b
a
Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
b
Department of Legal Medicine, Charles Nicolle Hospital, Tunis, Tunisia

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: The aim of our study was to discuss the epidemiological features of self-poisoning suicide in Northern
Suicide Tunisia.
Intentional-poisoning Methods: We conducted a retrospective, descriptive and cross-sectional study, including all the cases of fatal self-
Drugs and non-drugs poisoning suicide occurring between January 2005 and December 2015.
Epidemiology
Results: In the study period, 204 cases of self-poisoning suicide occurred in northern Tunisia, with a prevalence
of 0.44 cases/100 000 inhabitants/year. Among these cases, 59% were females (the sex ratio was 0.69). The
mean age was 34 ± 15.3 years-old. The most common age group of the victims (28.4%) was between 20 and 29
years old. Victims were unemployed in 45% of cases and single at the time of suicide in 52%. None of the victims
left a suicide note. Self-poisonings were due to the ingestion of drugs (52.5%), pesticides (42.6%), caustic
products (5.5%) and Butane gas (1 case).
Conclusions: Fatal casualties of self-poisoning in Tunisia are frequently young, single, unemployed women. This
pattern would allow planning of targeted preventive measures.

1. Introduction an increasing trend in Asian countries,7,8 while voluntary drug in-

Suicide remains a global major health problem.1 The exact estima-
tion of its incidence is even more difficult in the countries where suicide
and mental health are still facing stigmatization.
In Tunisia, suicides were traditionally committed more frequently
by young and vulnerable persons who would commit suicide by
hanging.2 Self-poisoning used to represent the second suicide method in
Tunisia but was surpassed by self-immolation after the Revolution of
January 14th, 2011.2,3
Suicide is the second leading cause of death in European young
people.4 Suicide attempts and suicide are often a reaction to universal
and multifactorial issues such as family problems, problems with
partners, psychiatric illness, economic problems, and alcohol or drug
abuse.5
A self-poisoning suicide may be defined as the self-exposure of an
individual (by ingestion or another route of administration) to an
amount of substance associated with the significant potential to cause
death. In low and middle income countries, the ingestion of pesticides
was reported to be the most common method and accounts for an es-
timated one-third of all suicide attempts and suicides worldwide5,6 with
toxication remains the most used way of suicide in the other parts of the
world.9 Self-poisoning was reported to be the most observed mode of
suicidal attempts before a completed suicide.10
Few data have been reported from the Arab Region or North-African
countries, related to self-poisoning. However, such reports could add
missing figures that would help in drawing a global picture of this
phenomenon.
The aim of this study was to analyze the pattern of self-poisoning
suicide in Northern Tunisia between 2005 and 2015.
2. Methods
2.1. Study design and data collection
We conducted a retrospective, descriptive and cross-sectional study,
over a period of eleven years (January 2005–December 2015). Our
study was realized in the Legal Medicine Department of Charles Nicolle
Hospital situated in Tunis the capital of Tunisia. Our Department,
which covered the medico-legal activity of almost all the northern part
of Tunisia (10 out of the 11 governorates of Northern Tunisia the 24

∗
Corresponding author. 20 Rue Ahmed Khairedine, Le Bardo, 2000, Tunisia.
E-mail address: mehdi.benkhelil@fmt.utm.tn (M. Ben Khelil).

https://doi.org/10.1016/j.jflm.2018.10.004
Received 9 March 2018; Received in revised form 10 September 2018; Accepted 19 October 2018
Available online 24 October 2018
1752-928X/ © 2018 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
M. Gharbaoui et al. Journal of Forensic and Legal Medicine 61 (2019) 1–4

governorates of Tunisia). The population of the North of Tunisia ac- Table 2

counted for about 42% of the total population of Tunisia (4.6 mil- Distribution of fatal self-poisoning suicide according to gender.
lion).11 Self-poisoning prevalence was calculated by dividing the Females (n=121) Males (n=83) p Total (%)
number of cases by the absolute mean number of inhabitants in these
districts (national censuses conducted in 2004 and 2014).11 n % n %
We included all the cases of self-poisoning suicides examined during
Year 0.06
the study period. We excluded cases where the self-inflicted character 2005 10 8.3 7 8.4 – 8.4
was not established formally. Data were collected from medical and 2006 6 5 6 7.2 – 5.9
hospital records, the deceased's relatives commemoratives, police 2007 8 6.6 4 4.8 – 5.9
minutes and autopsy reports. Information concerning the occupational 2008 5 4.1 6 7.2 – 5
2009 11 9.1 13 15.7 – 11.9
status and the mental health history of victims was missing in 10–20%
2010 18 14.9 6 7.2 – 11.4
of cases. 2011 14 11.6 6 7.2 – 9.9
2012 12 9.9 19 22.9 – 15.3
2.2. Statistical analysis 2013 17 14 5 6.0 – 10.9
2014 8 6.6 5 6.0 – 6.4
2015 12 9.9 6 7.2 – 8.9
Data were analysed with the software IBM SPSS V.20. Pearson's chi- Age group 0.004
squared test and Student's t-test were used respectively for both cate- < 18 20 16.5 4 4.8 – 11.8
gorical variables and means comparisons. For cases of non-applicability 18–19 12 9.9 2 2.4 – 6.9
20–29 39 32.2 19 22.9 – 28.4
of the Pearson's chi-squared test, we used the Mann-Whitney U test.
30–39 20 16.5 18 21.7 – 18.6
Significance was defined as p value < 0.05. 40–49 12 9.9 19 22.9 – 15.2
50–59 12 9.9 14 16.9 – 12.7
3. Results 60–65 3 2.5 4 4.8 – 3.4
> 65 3 2.5 3 3.6 – 2.9
Motive 0.05
During the study period, we identified 204 victims who died after a Unprecised 57 47.1 42 51.2 – 48.8
self-poisoning suicide in Northern Tunisia between 2005 and 2015, Financial 9 7.4 5 6.1 – 6.9
representing 16.5% of total suicides and a prevalence among the gen- problems
Familial 28 23.1 16 19.5 – 21.7
eral population of 4.6 cases per 100 000 inhabitants.
conflicts
The mean age was 34.2 ± 15.3 years old (13–86 years-old). The Psychiatric 20 16.5 18 22 – 18.7
sex ratio was 0.69 with 121 females (59.3%) and 83 males (40.7%). disorder
Most victims were aged between 20 and 39 years (47%) (Table 1). We Professionnal/ 7 5.8 1 1.2 – 3.9
found an increase in the number of victims in 2012 (n = 29) compared school
conflict
to the other years with an exceptional majority of men rather than
Marital status 0.05
women (n = 19) (Table 2). Single 73 60.3 34 41.0 – 52.5
Most of the victims were single (52.5%) at the moment of suicide. Married 30 24.8 31 37.3 – 29.9
Most suicides happened in the summer and spring (33.3% and 25.5% Widowed 1 0.8 0 0 – 0.5
respectively) (Table 1). Suicides took place in the victims’ private Divorced 2 1.7 4 4.8 – 2.9
Unprecised 15 12.4 14 16.9 – 14.2
houses in 96% of the cases. In 49.5% of cases, victims were unemployed Season 0.3
and 9.3% were unskilled workers. We noted an important number of Atumn 17 14.0 20 24.1 – 18.1
female students committing self-poisoning suicide with a significant Winter 30 24.8 17 20.5 – 23
variation according to men (n = 30; p < 0.001). Mental disease his- Spring 31 25.6 21 25.3 – 25.5
Summer 43 35.5 25 30.1 – 33.3
tory was reported in 39.2% of our cases with a non-significant pre-
Profession < 0.001
dominance of female victims (55%, p = 0.19). Schizophrenia and de- Unemplyed 57 47.1 44 53 – 49.5
pression were the most reported mental illnesses (40% and 27% Worker 9 7.4 10 12 – 9.3
respectively). Functionnary 2 1.7 2 2.4 – 2
A history of suicidal attempt was reported in 20.6% in which 10% of Manager 1 0.8 3 3.6 – 2
Retired 0 0 2 2.4 – 1
cases committed more than one suicide attempt and a history of suicidal Student 30 24.8 2 2.4 – 15.7
Unprecised 22 18.2 20 24.1 – 20.6
Table 1 History of 0.19
Distribution of fatal self-poisoning according to gender. age and season. psychiatric
disorder
n % Yes 44 36.4 36 43.4 – 39.2
No 77 63.6 47 56.6 – 60.8
Gender distibution History of 0.06
Male 83 40.7 suicide
Female 121 59.3 attempt
Age group Yes 20 16.5 22 26.5 – 20.6
< 18 24 11.8 No 101 83.5 61 73.5 – 79.4
18-19 14 6.9 History of 0.07
20-29 58 28.4 suicide
30-39 38 18.6 threat
40-49 31 15.2 Yes 22 18.2 23 27.7 – 22.1
501-59 26 12.7 No 99 81.8 60 72.3 – 77.9
60-65 7 3.4 Type of 0.02
> 65 6 2.9 toxicant
Season Drugs 71 58.7 36 43.4 – 52.5
Autumn 37 18.1 Psychotrops 20 28.2* 20 55.6* – 37.4*
Winter 47 23 Cardiotrops 23 32.4* 2 5.6* – 23.4*
Spring 52 25.5 Multiple 5 7.0* 3 8.3* – 7.5*
Summer 68 33.3
(continued on next page)

2
M. Gharbaoui et al. Journal of Forensic and Legal Medicine 61 (2019) 1–4

Table 2 (continued) We observed that self-poisoning suicide often happened in spring

Females (n=121) Males (n=83) p Total (%)
n % n %
Unprecised 14 19.7* 9 25.0* – 21.5*
Others 9 12.7* 2 5.6* – 10.3*
Pesticides 44 36.4 43 51.8 – 42.6
Insecticides 27 61.4* 34 79.1* – 70.1*
Raticides 16 36.4* 9 20.9* – 28.7*
Caustic 6 5.0 3 3.6 – 4.4
products
Butane gas 0 0 1 1.2 – 0.5
*Frequency according to the toxicant type.
threats was reported in 22.1% of cases. None of the victims left a suicide
note. The motive of suicide was unknown in 48.8% of the cases. Among
the known motives a decompensation of a mental disease (18.7%) and a
familial conflict (21.7%) were the most frequent.
Self-poisoning was mostly secondary to drugs (52.5%) or pesticides
(42.6%) ingestion. In addition, 9 victims ingested a caustic product
(4.4%). In a single case, the victim inhaled butane gas.
Drugs (n = 107) were represented in most of the cases by psycho-
tropics in (37.4%) and cardiotropics (23.4%). Self-poisoning with in-
gestion of more than one drug were observed in eight cases (Table 2).
Pesticides ingested were insecticides (70.1%), raticide (28.7%) in-
cluding aluminum phosphide in two cases.
4. Discussion
Victims of self-poisoning in North Tunisia, were mostly women,
aged between 20 and 39 years, single, unemployed, without a known
medical history, committing suicide by ingesting a psychotropic drug in
a private home with no clear motives nor a suicidal note.
This pattern contrasted with identified suicide victims in Tunisia as
a whole, which involved mostly young males committing suicide fol-
lowing a mental illness decompensation or financial problems.2
In Tunisia, self-poisoning suicide was the third suicidal mode found
after hanging and self-immolation.2 However, it was the first suicidal
mode for women.
Studies have shown that self-poisoning suicide was the most
common method of suicide in Asia.7,8,10 For example self-poisoning
suicide was the primary suicide method in China, India, Pakistan,
Bangladesh, and Sri Lanka,10 with a particular trend for self-immolation
as a favorite suicidal mode for women in the Indian subcontinent
(India, Bangladesh, Pakistan …), explained by cultural and accessibility
reasons.12 Whereas in Europe it was considered to be the third suicidal
mode for women.1,10 In Dakar, self-poisoning was the second way of
suicide after hanging and the favorite way of suicide for women due to
accessibility of toxicants (especially drugs).13,14
Actually, the predominance of female victims, was explained by the
fact that toxicants, were widely considered as an non-violent way of
death, with a preferential use by women compared to men who would
use more direct and violent modes such as hanging and jumping from
height.5,14 This pattern was not absolute, in Great Britain for example,
during the early 2000's, studies reported that men committed self-poi-
soning suicide more than women but they still prefer intoxication by
gassing to drugs overdose.15 However, official statistics of suicide in
2016, showed figures similar to our study, with a decrease in the pre-
valence of self-poisoning for both males and females and a higher
proportion of females using this suicide method (36.2% of females
versus 18.3% of males).16
Toxic suicides happened between 20 and 29 years in most cases of
our study, which is comparable to previous reports. The young age of
the victims could be explained by the early maturity and the vulner-
ability of (female) adolescents.4
then summer. This report was similar to studies conducted in Iran10 and
the USA.4 However, in Europe, there were no seasonal variations in self-
poisoning suicides reported.17
In our study, drugs were the most used toxicants (52.5%) with a
particular trend to psychotropics (19.6%) followed by cardiotropics.
This was comparable to studies in Europe,14,18 in Iran where two-thirds
of intentional toxic suicides were committed by drugs10 and in Brazil
where drugs represented 31.45% of toxic poisoning.19 It was reported
that completed toxic suicides are associated with psychotropic drugs
then to polypharmacy.20 A French study reported that paracetamol was
the most used substance in toxic suicides followed by benzodiazepines.9
In our study, we noted three cases of paracetamol intoxication. The use
of drugs is therefore a matter of accessibility. Our results, suggested that
suicide victims used either their prescribed medications or those of
their relatives.
Pesticides were estimated to cause approximately one third of the
world's suicides in 2002 with a majority of the cases in the pacific
ocean, East Asia and Africa regions.6 An Indian study21 found that re-
striction of pesticide availability and accessibility had the potential to
reduce pesticide suicide. Actually, since the late 1980's, it was re-
commended to delay access to means of suicide, in order to prevent the
proportion of suicides.22 In 32 countries including Asia and Europe, the
use of paraquat was banned. In Japan and Korea, an important number
of suicide attempts using this type of herbicide was noted.7 In our study,
pesticides ingested were insecticides (70.1%), raticides (28.7%). This is
similar to a Brazilian study where insecticides were the most used
pesticides (organophosphates)(37.7%) followed by raticides (15.7%).19
The use of aluminum phosphide was noted in two cases of our study.
This fumigant pesticide is used in agriculture and has no specific anti-
dote.23 It is used in the Indian subcontinent but also in Albania as a
toxic self-poisoning product by rural agriculturists due to its availability
and its fatal outcome.24,25 In our study, we found a case of suicide by
butane gas. This suicidal mode is not common and would be related to
severe mental disease.
Other substances were reported in cases of self-poisoning in other
countries but not observed in Tunisia such as carbon monoxide gas,
formic acid, burning charcoal and car exhaust gases.26–28
In conclusion, fatal self-poisoning casualties in Tunisia are fre-
quently young, single, unemployed women who would use psycho-
tropic or cardiotropic drugs. This pattern would help filling a gap in
data from the Arab and North African countries permitting a global
picture of self-poisoning suicides to be drawn. This pattern, would also
allow planning targeted preventive measures for this vulnerable po-
pulation.
Funding sources
None.
Conflicts of interest
All authors declare having no financial nor personal relationships
with other people or organizations that could inappropriately influence
their work.
References
1. WHO. WHO suicide data. http://www.who.int/gho/publications/world_health_
statistics/en/; 2016 Access date 06 march 2018.
2. Ben Khelil M, Gharbaoui M, Farhani F, et al. Impact of the Tunisian Revolution on
homicide and suicide rates in Tunisia. Int J Publ Health. 2016;61(9):995–1002.
https://doi.org/10.1007/s00038-016-0834-8.
3. Ben Khelil M, Zgarni A, Ben Mohamed M, et al. A comparison of suicidal behavior by
burns five years before and five years after the 2011 Tunisian Revolution. Burns.
2017;43(4):858–865. https://doi.org/10.1016/j.burns.2016.10.014.
4. Zakharov S, Navratil T, Pelclova D. Suicide attempts by deliberate self-poisoning in
children and adolescents. Psychiatr Res. 2013;210(1):302–307. https://doi.org/10.

3
M. Gharbaoui et al.
1016/j.psychres.2013.03.037.
5. Jørs E, Christoffersen M, Veirum NH, Aquilar GC, Morant RC, Konradsen F. Suicide
attempts and suicides in Bolivia from 2007 to 2012: pesticides are the preferred
method - females try but males commit suicide!. Int J Adolesc Med Health.
2014;26(3):361–367. https://doi.org/10.1515/ijamh-2013-0309.
6. Gunnell D, Eddleston M, Phillips MR, Konradsen F. The global distribution of fatal
pesticide self-poisoning : systematic review. BMC Publ Health. 2007;7:357. https://
doi.org/10.1186/1471-2458-7-357.
7. Lee J, Hwang I, Kim J, et al. Common pesticides used in suicide attempts following
the 2012 paraquat ban in Korea. J Kor Med Sci. 2015;30:1517–1521.
8. Konradsen F, Van Der Hoek W, Peiris P. Reaching for the bottle of pesticide - a cry for
help. Self-inflicted poisonings in Sri Lanka. Soc Sci Med. 2006;62(7):1710–1719.
https://doi.org/10.1016/j.socscimed.2005.08.020.
9. Vaillant J Le, Pellerin L, Brouard J. Intoxications médicamenteuses volontaires chez
58 adolescents : étude prospective sur l’impact somatique et les complications bio-
logiques. Arch Pediatr. 2016:1–7. https://doi.org/10.1016/j.arcped.2016.02.009.
10. Najafi F, Beiki O, Ahmadijouybari T, et al. An assessment of suicide attempts by self-
poisoning in the west of Iran. J Forensic Leg Med. 2014;27:1–5. https://doi.org/10.
1016/j.jflm.2014.07.003.
11. National Institute of Statistics T. Institut national de la Statistique - Tunisie.
Available at: http://www.ins.nat.tn/indexfr.php, Accessed date: 6 September 2018.
12. Kanchan T, Menon A, Menezes RG. Methods of choice in completed suicides: gender
differences and review of literature. J Forensic Sci. 2009;54(4):938–942. https://doi.
org/10.1111/j.1556-4029.2009.01054.x.
13. Soumah MM, Eboué BA, Ndiaye M, Sow ML. Aspects épidémiologiques du suicide à
Dakar. Pan Afr Med J. 2013;15:10. https://doi.org/10.11604/pamj.2013.15.10.
2221.
14. Taktak Ş, Uzun I, Balcioǧlu I. Gender differences in completed suicides in Istanbul,
Turkey. J Affect Disord. 2013;145(3):394–399. https://doi.org/10.1016/j.jad.2012.
05.055.
15. Camidge DR, Wood RJ, Bateman DN. The epidemiology of self-poisoning in the UK.
Br J Clin Pharmacol. 2003;56(6):613–619. https://doi.org/10.1046/j.1365-2125.
2003.01910.x.
16. Office of National Statistics. Suicides in the UK: 2016 registrations. Available at:
https://www.ons.gov.uk/peoplepopulationandcommunity/
Journal of Forensic and Legal Medicine 61 (2019) 1–4
birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/
2016registrations#suicide-methods, Accessed date: 8 September 2018.
17. Christodoulou C, Douzenis A, Papadopoulos FC, et al. Suicide and seasonality. Acta
Psychiatr Scand. 2012;125(2):127–146. https://doi.org/10.1111/j.1600-0447.2011.
01750.x.
18. Gonçalves S, Lucas J, Costa T, Eiras L, Santos JC. Suicide and forensic toxicology
results : retrospective study of the cases from the south branch of national institute of
legal medicine and forensic sciences ( 2007 – 2012 ). IJCNMH. 2015;2(Suppl. 1):P63.
19. Rodrigues de Moura Luiza Taciana, de Morais Ramon José Leal, Dias Ana Cleide
Silva, CNGB. Epidemiological profile of cases of pesticide poisoning. J Nurs UFPE.
2014;8. https://doi.org/10.5205/reuol.5927-50900-1-SM.0807suppl201419.
20. Takeuchi T, Takenoshita S, Taka F, Nakao M, NomuraK. The relationship between
psychotropic drug use and suicidal behavior in Japan: Japanese adverse drug event.
Pharmacopsychiatry. 2017;50(02):69–73.
21. Mohanraj R, Kumar S, Manikandan S, Kannaiyan V, Vijayakumar L. A public health
initiative for reducing access to pesticides as a means to committing suicide : findings
from a qualitative study. Int Rev Psychiatr. 2014;26:445–452. https://doi.org/10.
3109/09540261.2014.924094.
22. Clarke RVG, Lester D. Suicide : Closing the Exits. Springer Verlag; 1989.
23. Saha JK, Azad KA, Hossain MZ, et al. Aluminium phosphide poisoning cases in a
Tertiary care hospital. J Dhaka Med Coll. 2014;23(1):3–6.
24. Chaudhary S, Momin SG, Vora DH, et al. An epidemiological study of fatal alumi-
nium phosphide poisoning at rajkot. IOSR J Pharm. 2013;3(1):17–23.
25. Sulaj Z, Drishti A, Çeko I, Gashi A, Vyshka G. Fatal aluminum phosphide poisonings
in Tirana (Albania), 2009 - 2013. Daru. 2015;23(1):8. https://doi.org/10.1186/
s40199-015-0090-0.
26. Chung WSD, Leung CM. Carbon monoxide poisoning as a new method of suicide in
Hong Kong. Psychiatr Serv. 2001;52(6):836–837. https://doi.org/10.1176/appi.ps.
52.6.836.
27. Öström M, Thorson J, Eriksson A. Carbon monoxide suicide from car exhausts. Soc
Sci Med. 1996;42(3):447–451. https://doi.org/10.1016/0277-9536(95)00104-2.
28. Lee AR, Ahn MH, Lee TY, Park S, Hong JP. Rapid spread of suicide by charcoal
burning from 2007 to 2011 in Korea. Psychiatr Res. 2014;30(3):518–524. https://doi.
org/10.1016/j.psychres.2014.06.037 219.