Factors With Deliberate Self Poisoning Health Essay

Abstraction
Aims: The aims of this survey were to find the hazard factors and life stressors that are prevailing among the acetaminophen deliberate self-poisoning ( DSP ) instances, to place gender differences in the associated factors, and to find the prevalence of psychiatric diagnosing and the forms and types of psychotherapeutic intercessions provided by head-shrinkers.
Methods: This is a cross-sectional survey, a retrospective descriptive instance reappraisal of hospital admittances for Datril DSP. Factors With Deliberate Self Poisoning Health Essay.
Consequences: There were 177 incidences of DSP during the survey period. The average age of the instances was 23.1 ± 7.3 old ages and 84.1 % of them were females. The hazard factors were more significantly associated with males: chronic ethyl alcohols intake ( P = 0.04 ) , higher reported dose ingested ( P = 0.01 ) , higher latency clip ( P = 0.04 ) , and longer infirmary stay ( P = 0.03 ) . The most normally reported psychotherapeutic intercessions used by head-shrinkers were psychoeducation of the patient, followed by referral to a psychiatric clinic, household psychoeducation, and psychoactive medicine. Sertraline ( SSRI ) was the most often prescribed antidepressant.
Decisions: Males have been shown to utilize more toxic doses and to detain intervention due to high latency clip. Most DSP patients have different life stressors and psychiatric diagnosings that may be associated with changing grades of self-destructive purpose. All patients showing following DSP need to be carefully screened for psychiatric unwellness. Randomised controlled surveies need to be conducted on DSP patients with psychiatric unwellness to find which interventions are effectual.
Keywords: Acetaminophen ; Deliberate self-poisoning ; Gender ; Life stressors, Psychiatric.
1. Introduction
Deliberate self-poisoning ( DSP ) is recognized as a major cause of self-destruction around the universe ( Eddleston, 2000 ; Wilkinson et al. , 2002 ; Camidge et al. , 2003 ) . Acetaminophen is the most common drug employed in DSP in many states ( Zaidan et al. , 2002 ; Camidge et al. , 2003 ; Watson et al. , 2004 ) , including Malaysia ( Fathelrahman et al. , 2006 ; Fathelrahman et al. , 2008 ) . Several factors contribute to the usage of Datril in DSP, including its broad handiness as an nonprescription analgetic drug and the absence of legal ordinance and equal information sing its possible consequence ( Hawton et al. , 1996 ; Camidge et al. , 2003 ) . Therefore, cognition of the general form of Datril toxic condition in a peculiar part would assist in early diagnosing of poisoning instances, which in bend should ensue in a decrease of morbidity and mortality.

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Acetaminophen is quickly and wholly absorbed after unwritten disposal. It exhibits a big first-pass consequence with consumption and metamorphosis in the liver. Acetaminophen overdose is normally distinguished by mild early GI disturbance shortly after consumption ( Zyoud et al. 2010 ) . In fact, in big doses acetaminophen is capable of doing both hepatic failure ( McGregor et al. , 2003 ; Pajoumand et al. , 2003 ) and nephritic failure ( Consuming et al. , 2010 ) . The toxicity of Datril is related to the production of the reactive intermediate N-acetyl-pbenzoquinonimine ( NAPQI ) by the hepatic cytochrome P450 system. When the production of NAPQI exceeds the capacity to detoxicate it, as can happen in overdose, the extra NAPQI binds to cellular constituents and can do the decease of hepatocytes ( Dart et al. , 2006 ) . Factors With Deliberate Self Poisoning Health Essay. Coma and lactic acidosis, if they occur, are by and large a consequence of fulminant hepatic failure and develop after 2-3 yearss. Massive Datril consumption, nevertheless, has been reported to do terrible metabolic acidosis and coma early after consumption ; even in the absence of hepatic failure ( Roth et al. , 1999 ; Wiegand et al. , 2010 ) . Acute nephritic failure is a accepted manifestation of acetaminophen toxicity. Importantly, the pathophysiological footing for Datril nephrotoxicity appears to be distinguishable from that of hepatotoxicity, and the happening of acute nephritic failure is unrelated to the grade of liver hurt ( Mour et al. , 2005 ; Consuming et al. , 2010 )
Factors associated with DSP include socio-economic ( e.g. income, Literacy, instruction degree, business and criterion of life ) , cultural ( i.e. an incorporate form of human cognition, belief, and behaviour that depends upon the capacity for symbolic idea and societal acquisition ) , spiritual ( e.g. deficiency of spiritual strong belief to be a hazard factor for self-destruction such as Islam provides clear opinions against self-destruction. The Koran purely prohibits self-destruction, keeping that it is an inexcusable wickedness. Islam besides forbids the usage of intoxicant, which is a known hazard factor for self-destruction ) , and wellness factors ( e.g. many patients who self-poison, including striplings, have psychiatric upsets. The most common diagnosings are depression, intoxicant or drug maltreatment, anxiousness and eating upsets. Personality upsets, peculiarly of the boundary line line and dissocial type, are besides common ) ( Fathelrahman et al. , 2006 ; Vijayakumar L et al. , 2008 ; Lifshitz and Gavrilov, 2002 ) .
These variables vary harmonizing to the features of the poisoned patient and pick of toxic agent ( Aghanwa, 2001 ; Lifshitz and Gavrilov, 2002 ) . Other variables that may impact the pick of substance used include demographic features of the self-poisoned victim like age, gender, and ethnicity ( Aghanwa, 2001 ; Hawton et al. , 2003a ) . Gender has been good documented as a socio-demographic correlative that is significantly associated with self-destructive behavior and is one of the most reported forecasters of self-destruction ( Hawton, 2000 ; Fekete et al. , 2005 ) . Our intent is to reexamine the socio-demographic, economic, psychiatric, familial, etc. characteristics in our population and compare them across genders. Factors With Deliberate Self Poisoning Health Essay. Possibly this information can be used to test or foretell hazard of acetaminophen DSP. Factors associated with DSP have received less attending in the literature, and there are no antecedently published surveies sing the hazard factors among patients with acetaminophen overdose in the universe. Designation of hazard factors related to acetaminophen poisoning should take to prioritization of these mark patients in any intercession and psycho-educational programmes.
The aims of this survey were ( 1 ) to find the hazard factors that are prevailing among the Datril DSP instances, ( 2 ) to place gender differences in the associated factors, ( 3 ) to depict the nature of life stressors lending to acetaminophen DSP in patients showing to a general infirmary, ( 4 ) to measure the frequence of these jobs by gender, and ( 5 ) to find the prevalence of psychiatric diagnosing and the forms of psychotherapeutic intercessions provided by head-shrinkers and other mental wellness suppliers in everyday psychiatric pattern scenes in Malaysia among patients with acetaminophen DSP.
2. Methods
2.1. Settings and Study Design
We conducted a cross-sectional experimental survey of all patients with acetaminophen overdose admitted to a 1200-bed infirmary located in the northern part of Malaysia. The infirmary provides wellness attention and exigency intervention for all unwellnesss and accidents. All facets of the survey protocol, including entree to and usage of the patients ‘ clinical information, were authorized by the medical moralss commission and the local wellness governments before induction of this survey.
2.2. Participants and Data Collection
All of the back-to-back patients who were admitted to the Hospital over a three-year period from 1 January 2006 to 31 December 2008 for the primary diagnosing of Datril overdose were retrospectively studied. A computing machine generated list was obtained from the Hospital Record Office. We identified our instances harmonizing to the T-codes of the International Classification of Diseases 10th alteration ( ICD-10 ) . All DSP patients with diagnostic codification T 39.1 ( acetaminophen overdose ) were included in the survey. Diagnosis of DSP was based on the head-shrinker appraisal reported in medical studies. The exclusion standards included inadvertent Datril overdose.
Information was collected on a specially designed data-collection signifier and included age, gender, ethnicity, matrimonial position, stated day of the month and clip of overdose to cipher the latency clip ( latency clip: calculated from the clip of consumption to the clip the patient was presented at the infirmary ) , measure of Datril ingested, whether other drugs had been co-ingested, GI decontamination such as tummy wash and activated wood coal, clip of admittance, clip of discharge, whether there was any recent life stressors ( e.g. , boy- or girlfriend relationship, household, matrimonial, fiscal, employment, legal, or analyze jobs ) , any recent wellness job ( e.g. , history of physical or psychiatric unwellnesss ) , history of intoxicant usage, or old self-destructive effort. Patterns of psychiatric diagnosing and psychotherapeutic intercessions ( i.e. psychological or pharmacological intercessions ) were recorded. Factors With Deliberate Self Poisoning Health Essay.
Datas on serum Datril concentration measurings were obtained from the infirmary ‘s curative drug monitoring ( TDM ) research lab service. Patients were categorised into two groups based on whether they were supra or below the ‘possible toxicity ‘ intervention line ( 150 mg/L at four hours and 5 mg/L at 24 hours ) ( Rumack et al. , 1981 ) . A ‘possible toxicity ‘ line 25 % below the standard Rumack-Matthew nomograph was proposed to let for possible mistakes in plasma checks and consumption times ( Rumack and Matthew, 1975 ; Rumack et al. , 1981 ) .
2.3. Statistical analysis
Datas were entered and analysed utilizing the Statistical Package for Social Sciences plan version 15 ( SPSS ) . Data were expressed as agencies ± SD for uninterrupted variables and as frequences for categorical variables. The Chi square or Fisher ‘s exact trial, as appropriate, was used to prove the significance between categorical variables. The independent samples t-test was used to compare the agencies of uninterrupted variables. Variables were tested for normalcy utilizing the Kolmogorov-Smirnov trial. Variables that were non usually distributed were expressed as medians ( lower-upper quartiles ) . Statistical significance was considered at P & A ; lt ; 0.05.
3. Consequences
3.1. Representativeness of survey population
During the period of survey, 177 instances of Datril DSP were identified. As noted in Table 1, Malays represented 89 ( 50.3 % ) of the poisoned patients, followed by Indians, stand foring 43 patients ( 24.3 % ) , and Chinese, stand foring 40 ( 22.6 % ) . Other cultural groups consisted of aliens from other neighboring Asiatic states. One hundred and 49 ( 84.2 % ) of the instances were females and 28 instances ( 15.8 % ) were males ; giving a female: male ratio of 5.3: 1. The informations were reviewed by age of the patients with the consequence summarized by decennary. Eighty-eight instances ( 49.7 % ) were 20-30 old ages of age, 66 instances ( 37.3 % ) were & A ; lt ; 20 old ages of age, and 23 instances ( 13 % ) were aged 30 old ages or supra. The mean age of the instances was 23.1 ± 7.3, with a scope of 13.6-53 old ages. Among males and females, the greatest Numberss of DSP instances were noted in the 20-30 twelvemonth age group.
Consequences of univariate analysis in 177 patients harmonizing to demographic features position on admittance are shown in Table 2 stratified by gender. In our survey, there were no important differences between males and females in age, ethnicity, matrimonial position, employment, figure of ingested agents, history of psychiatric unwellness or chronic unwellness, or history of suicide effort. Acetaminophen self-poisoning exposures that involved male patients were associated with chronic ethyl alcohols intake ( P = 0.04 ) , higher reported dose ingested ( P = 0.01 ) , higher latency clip ( P = 0.04 ) , and longer infirmary stay ( P = 0.03 ) . Our survey found that there were no patients had a history of diagnosed substance maltreatment.
Acetaminophen was implicated entirely in 159 ( 89.8 % ) instances and co-ingested with other agents in 18 ( 10.2 % ) instances.Factors With Deliberate Self Poisoning Health Essay.  The average ( interquartile scope ) clip from the last consumption to first hospital admittance was 5 hours ( 3-10 hours ) . The average ( interquartile scope ) measure of Datril ingested was 10 g ( 6 – 15 g ) ( Table 2 ) . 174 petitions of serum acetaminophen supervising were identified from the TDM research lab paperss. Acetaminophen concentrations could non be interpreted in three instances largely due to late presentations. The average ( interquartile scope ) serum acetaminophen concentration was 65 mg/ L ( 18.5 – 142.6 mg/ L ) . Acetaminophen concentrations were below the ‘possible toxicity ‘ intervention line and above the ‘possible toxicity ‘ intervention line in 88 ( 50.6 % ) and 86 ( 49.4 % ) instances, severally ( Figure 1 ) . There were no important differences between males and females in serum Datril concentration.
Initial direction included tummy wash, which was performed in 108 ( 61 % ) instances. Activated wood coal was given while patients were in the Accident and Emergency section ; it was given as individual or multiple doses in 131 instances ( 74 % ) . Intravenous N-acetylcysteine ( NAC ) was given to 91 patients ( 51.4 % ) after Datril degrees were estimated. Overall, two patients were admitted to the intensive attention unit but no patient died or needed a liver graft as a consequence of the Datril overdose. Besides, merely one patient with Datril overdose was presented to the infirmary with damage in degree of consciousness upon admittance.
3.2. Frequency and nature of life stressors stratified by gender
There were many life stressors among instances. Merely 6 males ( 21.4 % of males ) and 31 females ( 20.8 % of females ) were reported with assorted life stressors doing hurt and lending to the episode of Datril DSP and merely 22 males ( 78.6 % of males ) and 114 females ( 76.5 % of females ) were reported with a individual life stressor. A job in a relationship with a boy- or girlfriend was the most common job ( 29.9 % ) reported by all instances followed by jobs with household relationships ( 24.3 % ) , jobs with academic accomplishment ( 16.4 % ) , job with employment ( 7.3 % ) , and fiscal job ( 7.3 % ) . few patients were reported jobs in relationships with friends and legal job ( 4.5 % and 0.6 % , severally ) . The most common jobs reported among females were those related to boy- or girlfriend relationships, whereas the most common jobs reported among males were those related to household relationships. Factors With Deliberate Self Poisoning Health Essay. There were no important differences between these precipitating factors and gender type ( Table 3 ) .
3.3. Psychiatric diagnosing
The distribution of psychiatric nosologies of 177 patients with acetaminophen DSP are shown in Figure 2. The most common major psychiatric diagnosing on admittance for patients was adjustment upsets ( 54.8 % ) , followed by impulsivity ( 28.81 % ) , major depression ( 7.9 % ) , and anxiousness ( 1.7 % ) . Two patients were diagnosed with both schizophrenic disorder and anxiousness. There were no important differences between males and females in the type of psychiatric diagnosing.
3.4. Forms and types of psychotherapeutics provided
Table 4 shows that 170 patients ( 96.1 % ) were having some signifier of psychotherapeutic intercessions ( i.e. psychological or pharmacological intercessions ) from the psychiatric services ( contact with a head-shrinker, clinical psychologist, or other member of a community mental wellness squad ) . The most normally reported curative techniques used by head-shrinkers were psychoeducation of the patients ( 89.3 % ) , followed by referral to a psychiatric clinic ( 72.9 % ) and household psychoeducation ( 39 % ) . We are unable to look into the quality of non-physical intervention. Eighteen patients ( 10.2 % ) were prescribed a psychoactive medicine with 15 ( 8.5 % ) receiving antidepressants. Among the antidepressant medicines, sertraline hydrochloride 25 mg day-to-day ( SSRI ) was the most often prescribed ( 14/18 instances, 77.7 % ) . Four ( 2.3 % ) patients were besides prescribed anxiolytic agents ( Xanax, clonazepam, and Ativan ) . Two patients were besides prescribed antipsychotic agents ( sulpiride and Triavil ) . No patients were having tricyclic antidepressant. No patients were besides having newer antidepressant such as venlafaxine and duloxetine. In our survey, there were no patients on psychiatric medicines or mood-stabilizing agents prior to their DSP. There were no important differences between males and females in the forms and types of psychotherapeutic intercessions provided. Factors With Deliberate Self Poisoning Health Essay.
4. Discussion
Acetaminophen has been one of the most on a regular basis used drugs in Malaysia for decennaries ; nevertheless, there is limited epidemiological informations in Malaya about the existent magnitude of DSP with this drug, its hazard factors, life stressors potentiating the DSP, and related psychiatric intercession. The present survey was conducted to find the hazard factors and life stressors that are prevailing among the Datril DSP instances, to place gender differences in the associated factors, and to find the prevalence of psychiatric diagnosing and the forms of types of psychotherapeutic intercessions provided by head-shrinkers in 177 back-to-back patients with acetaminophen overdose collected retrospectively from the records register. Among all acetaminophen instances in our survey, the female to male ratio was found to be 5.3: 1, which represented the established form in the bulk of self-poisoning studies ( Von Mach et al. , 2003 ; Novack et al. , 2005 ) . Females are more likely to take a less violent method for suicide efforts such as self-poisoning ( Camidge et al. , 2003, Hawton et al. , 2003a ) . The form of DSP ( mean age about 23 old ages ) is consistent with a form of young person self-destructions reported in several states ( Zaidan et al. , 2002 ; Schmidt, 2005 ) .
Our consequences indicate that important differences in demographic variables exist between males and females who attempt suicide. Males were significantly more likely to hold a chronic ethyl alcohol consumption, a higher reported dose ingested, higher latency clip, and longer infirmary stay. In our survey, males had a significantly higher rate of chronic intoxicant consumption. A direct association between chronic intoxicants consumption and suicidal behavior tends to be a gender-specific characteristic among males ( Zaidan et al. , 2002 ; Suokas et al. , 2005 ; Sudhir Kumar et al. , 2006 ) . Interventions targeted at those with alcohol jobs may be a utile scheme in males at hazard of self-destruction. Factors With Deliberate Self Poisoning Health Essay.
Males had higher sums of Datril ingested in our survey, and hence the extended sums ingested expose the male patients to higher hazard. Similar decisions were reported by other research workers ( Harriss et al. , 2005 ; Sudhir Kumar et al. , 2006 ; Hawton, 2007 ) . In the UK surveies, it has besides been shown that males use more deadly methods of DSP, frequently ensuing in decease ( Hawton, 2007, Haw and Hawton, 2008 ) . If so, the intervention and followup of female and male self-destruction patients should be gender-specific, and male patients may necessitate more attending. Furthermore, a survey in the USA that indicated that substance maltreatment is besides related to a high incidence of self-destructive behavior ( Roy, 2001 ) . A similar survey in Italy found that 8.5 % of the patients in their sample had a history of diagnosed substance maltreatment ( Mauri et al. , 2005 ) . Our survey found that there were no patients had a history of diagnosed substance maltreatment.
The current survey found that long infirmary stay was associated with attempted self-destruction among males, and this gender difference was statistically important. This determination is in understanding with another published survey which showed that the length of hospital stay among patients with toxic condition was affected by gender, with infirmary corsets being longer among males ( Satar, 2005 ) . The high prevalence of long infirmary stay after acetaminophen overdose among males might be due to detain in arrival clip at the exigency section and the higher sums ingested by males.
A job in a relationship with a boy- or girlfriend was the most common life stressors reported by all instances followed by jobs with household relationships. This determination is consistent with those reported by old research workers ( Fathelrahman et al. , 2006 ; Haw and Hawton, 2008 ) . A survey in the UK showed that a job in the relationship with a spouse or partner was the most common job reported by both males and females. Problems with household relationships and with friends every bit good as employment and fiscal troubles were often reported by both genders. Males reported more jobs with employment, fundss, lodging, legal, intoxicant and drugs, whereas females reported more jobs with household relationships, psychiatric upset, jobs with feeding, the effects of childhood sexual maltreatment and self-mutilation ( Haw and Hawton, 2008 ) .Factors With Deliberate Self Poisoning Health Essay.  Those interpersonal jobs are the most common type of life stressors reported by DSH patients has been antecedently reported in other surveies from Oxford ( Hawton et al. , 1997, 2003b ) and in another topographic point in the UK ( Milnes et al. , 2002 ) . Our survey found that there were no important differences between these precipitating factors and gender type. A survey in the UK showed that a big figure of jobs was reported by male calculated self-harm patients ( Milnes et al. , 2002 ) .
Our consequences show that the most common clinical diagnosing among medically treated suicide triers of both genders was adjustment upset followed by impulsivity ( one type of personality upset ) and major depression. There were no important differences in mental unwellnesss between males and females. This determination is consistent with those reported by a old survey ( Haw et al. , 2001 ) . Studies in the UK showed that many patients who self-poison have psychiatric upsets. The most common diagnosings are depression and anxiousness. Some patients have psychotic upsets ( Haw et al. , 2001, Hawton, 2007 ) . Another survey in Italy showed that the bulk ( 66 % ) of their patients had a history of a antecedently diagnosed psychiatric upset: a temper upset in 35 % of instances, a personality upset in 15 % , schizophrenic disorder in 9 % , and others ( including anxiousness and eating behavior upsets ) in the staying 7 % ( Mauri et al. , 2005 ) . As pointed out in old surveies, many of these patients were found by structured clinical diagnostic interviews to hold accommodation upset ( Fekete et al. , 2005, Sudhir Kumar et al. , 2006 ) , impulsivity ( Haw et al. , 2001 ) , and a current major depressive episode or anxiousness upset ( Hawton, 2000 ; Skogman et al. , 2004 ; Sudhir Kumar et al. , 2006 ) .

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Our consequences show that the most normally reported curative techniques used by head-shrinkers were psychoeducation of the patient, followed by referral to a psychiatric clinic, psychoeducation of the household, and psychoactive medicine. Merely 18 patients ( 10.2 % ) were being prescribed psychoactive medicine. This determination is consistent with those recommended by old research workers ( Bennewith et al. , 2002 ; Hepp et al. , 2004 ; Burns et al. , 2005 ; Skegg, 2005 ; Hawton, 2007 ) . A reappraisal of the published surveies indicates that psychological therapy, particularly cognitive therapy and problem-solving, is effectual in take downing the hazard of repeat of self-harm and cut downing depression, hopelessness, and self-destructive ideation. Psychiatric upsets require intervention by the usual attacks. Psychotropic medicine may be unsafe in those who are self-poisoned and should be used merely when necessary ( Hawton, 2007 ) . Factors With Deliberate Self Poisoning Health Essay. This determination may explicate why these medicines were used in few instances in our survey. In Italy, a systematic reappraisal of experimental surveies found that the relation between exposure to SSRIs and the hazard of self-destruction is influenced by age. Exposure to SSRIs decreased the hazard of self-destruction by over 40 % among grownups and decreased the hazard by over 50 % among aged people. However, among striplings, exposure to SSRIs about doubled the hazard of self-destruction ( Barbui et al. , 2009 ) . A survey in the USA showed that used the General Practice Research Database provided no grounds of such hazard of self-destruction in grownups who were prescribed SSRIs compared with those prescribed tricyclic antidepressants ( Jick et al. , 2004 ) . Several mechanisms may underlie the association between SSRI antidepressants and self-destruction ( Healy and Whitaker, 2003 ) . During initial therapy, the hazard of self-destruction may increase as some parts of depression resoluteness ( e.g. , psychomotor deceleration ) , thereby stimulating the patient to suicide ( Nutt, 2003 ) . Patients may besides develop akathisia-like symptoms during intervention with SSRI antidepressants, which may raise the hazard of self-destruction ( Kasantikul, 1998 ) .
Although this survey is the first one of its type, there were some restrictions in this survey. One possible restriction of the diagnosing attack was documented by the medical record that the psychiatric diagnosings were ascertained utilizing a elaborate clinical interview and non a structured diagnostic instrument. Using a clinical interview may take to under-detection of mental upsets in this sample, although there is a hazard that utilizing structured diagnostic agendas may ensue in the over-diagnosis of mental upsets in suggestible patients ( Haw et al. , 2003 ) . Interestingly, we observed that the bulk of persons were referred to psychiatric clinics after infirmary discharge for farther follow-up and intervention. Besides, they include the retrospective nature. Registry informations were obtained by chart reappraisal, and although the procedure was systematic with written informations definitions and go oning quality control processs, abstraction mistakes were possible to happen. Factors With Deliberate Self Poisoning Health Essay.
5. Decision and Recommendation
In decision, males have been shown to utilize more toxic doses and to detain intervention due to high latency clip. Most DSP patients have different life stressors and psychiatric diagnosings and may be associated with changing grades of self-destructive purpose. Further research on the optimum attention of these patients and multidisciplinary attacks to acetaminophen DSP bar are needed. Identifying gender-specific features may assist in understanding the complex difference in the attitudes of society towards males and females who harm themselves. Consideration of gender differences may let more specific designation of those at hazard and bar of self-destruction. This portion needs more research, and possibly qualitative surveies may give information about gender-specific factors and notify hereafter epidemiologic research. Therefore, effectual psychological intervention of patients showing with acetaminophen DSP, concentrating on psychosocial jobs, is likely to be more of import. This highlights the demand for increased instruction for doctors who work in the exigency section on the proper attention of patients who present with Datril overdose. In add-on, all accident and exigency section staff who manage DSP patients need to cognize how to carry on a brief psychosocial appraisal, particularly with respect to placing hazard factors for repeat of self-destruction efforts and for self-destruction ( Hickey et al. , 2001 ) .
Recognitions: The writers would wish to thank the Universiti Sains Malaysia ( USM ) for the fiscal support provided for their research. The aid of the medical and record office staff is appreciatively acknowledged.
Conflict of involvements: We would wish to declare that there was no struggle of involvements in carry oning this research. Factors With Deliberate Self Poisoning Health Essay.