Clinical and sociodemographic characterization of the suicide attempt in the Los Ríos Region, Chile.

Marcelo Gotelli, José Manríquez, Carolina Zambrano, Esteban Yañez, Reiner Fuentes F.

ABSTRACT


Introduction: Suicidal attempt is one of the most relevant suicide risk factors, knowing associated variables and post-suicide attempt follow-up strategies contributes to preventing suicide. Objective: the objective of this work was to describe the clinical-sociodemographic characteristics of people who present a suicide attempt, and to present a strategy of clinical-epidemiological surveillance that is activated after the suicide attempt. Methods: A cross-sectional design was carried out, involving 170 subjects aged 15 and over admitted to the Unit for People with a suicide attempt between 2015 and 2018 in the Los Ríos region, Chile. Sociodemographic and clinical data, before and after the suicide attempt, were statistically evaluated. Results: The sociodemographic results show a predominance of attempts by women, with a sample that has its place of residence mainly in urban areas. In addition, it was observed that Catholic or evangelical religious affiliation could be associated with a higher risk of suicidal retry (p = 0.014). Conclusions: The clinical factors show that having previous suicide attempts, ongoing depression at the time of the suicide attempt, and partner conflicts are relevant factors to consider. The frequency of suicide and suicide retries in surveillance was low, so strengthening the continuity of care could play a preventive role in the suicide phenomenon.

 

Key words: suicide, suicide attempts, continuity of care.

INTRODUCTION


 

Globally, about 800,000 people commit suicide each year, representing the third leading cause of death for young people aged 15-19 years. Seventy-nine percent of suicides occur in low- and middle-income countries, and attempted suicide is the single most important risk factor(1). Suicide is defined as any self-destructive behavior or act aimed at death, with a strong desire to die and with the knowledge, hope and belief that death can be achieved by the chosen method. Suicide attempt has a similar definition, only that the result is not death(2). In the last 45 years, suicide has increased by 60%; of these cases, 60% visited a doctor in the previous month, and 40% the week before the suicide(1). For every death, there are an estimated 25 non-fatal suicide attempts and millions more who experience suicidal

thoughts.(3)

 

Research has focused on determining variables that allow the creation of predictive models to prevent and intervene in the early stages of the phenomenon(4). In clinical terms, it has been found that at least one third of self-injuries coincide with recent suicide ideation or planning, this being an important marker when talking about suicide(5,6). A clinically significant relationship has also been found between depressive symptoms and hopelessness, with suicide attempts and death(6-8). In addition, alcohol consumption, drug abuse and smoking have been found to significantly increase the risk of suicidal ideation, suicide attempts and completed suicide(9-12). On the other hand, completed suicide in a family member is associated with an eightfold increased risk of suicidal behavior.(13-15)

 

As a whole, suicidal behavior is more frequent in women, double that of men(16). Other related aspects are associated with absent parents, family dysfunction, low self-esteem, recent suicidal ideation, individual distress, personal dissatisfaction and reasons for living, particularly those related to beliefs in one’s own abilities and coping skills, as well as dysfunction in anger management.(10,12,16,17,18,19)

 

In Chile, one person dies by suicide every 5 hours, the mortality rate is 10.3 per 100,000 inhabitants, and in the Los Ríos Region 12.5 per 100,000 inhabitants. In men it is 4.8 times higher than in women, despite the fact that in recent years there has been an increase in the number of female suicides(20). The suicide phenomenon increases in the spring season, in the months of November and December, on weekends and in the morning(9). Hanging is the most common method of suicide, followed by the use of firearms and explosives in men, and poisoning in women(9,20). In recent years, the rate in rural areas has doubled compared to urban areas.(20)

 

Within the framework of the national suicide prevention program, epidemiological surveillance tables were implemented in 2012. In the Los Ríos Region, in 2015 the “Unit for People with Suicide Attempts”, hereinafter UPI, was created, a pioneering intervention and surveillance strategy(21). This unit operates in Hospital Base Valdivia, and receives notifications of suicide attempts from the Region. Depending on the case, the affected person and a trusted person or family member are provided with support, guidance and follow-up by telephone or in person, to ensure a better opportunity for care and continuity

of care.

 

The objective of this study is to report the results of the clinical-epidemiological surveillance conducted by the IPU and to make a clinical-sociodemographic description of people who presented suicide attempts in the Los Ríos Region, during the years 2015

and 2018.

 

MATERIALS AND METHODS


 

Study design

A quantitative methodology with a cross-sectional design was used. The participants corresponded to persons who attempted suicide in the Los Ríos Region and who were notified from the emergency services. The main inclusion criterion was having presented at least one episode of suicide attempt in the last month. A semi-structured interview with a validated and calibrated assessment instrument was administered to each patient on admission. The interviewers were trained prior to the start of the study in order to achieve the highest level of concordance. The information was obtained from notifications and clinical records. The study population is a purposive sample of the total number of people under follow-up for suicide attempts, corresponding to the records of the base hospital of Valdivia, eliminating cases with incomplete data.

 

Instruments

The data collection instrument corresponded to a form based on the “Protocol of Structured Interview Psychological Autopsy”, written by Gómez A, Ibañez C. and Gómez M(22); For the calibration of the questionnaire we proceeded to the training of the reception staff of admission of patients referred for suicide attempt in the Region of Los Ríos, in order to achieve the highest concordance among the interviewers. In addition, the internal consistency was determined and the questions were validated through the opinion of experts and the instrument was applied

inter-examiner.

 

The variables included were: clinical data such as history of chronic and psychiatric diseases in the subjects, together with associated treatments (continuous or refractory) and previous hospitalizations, previous suicide attempts, eating habits, sexual risk behaviors, alcohol and drug consumption and history of previous suicide attempts. We also inquired about a history of suicide attempts or completed suicides in parents. Sociodemographic information such as sex assigned at birth, sexual orientation, age, commune of residence, marital status, level of schooling, occupation, characteristics of the family structure, religion, sexual orientation, health network used. In addition, data were requested from the person accompanying the subject admitted to the IPU.

 

In addition, with respect to the suicide attempt, contextual information such as date, place and method used, clinical description prior to the suicide attempt, possible triggering factors and actions that led to clinical care after the suicide attempt were recorded.

 

Statistical analysis

From the data obtained, a data spreadsheet was created in Excel 2013 V15.0® software. The description of the results and analysis were obtained with STATA 12.0® statistical

software.

 

For the characterization of both the suicide attempt and the associated factors, results were obtained from summary measures (average and standard deviation), as well as relative frequencies for the description of the categories of each variable. All results are presented in tables.

 

For bivariate analysis, Pearson’s chi-square test was performed for categorical variables. Analysis was performed for suicide attempt through dichotomous categorization (“first suicide attempt event” vs “more than one suicide attempt event”) and discrete categorization (“number of suicide attempt events”). Associations were determined with each of the variables collected and a significance level of ? < 0.5 was

considered.

 

The study was unanimously approved by the scientific ethics committee of the Valdivia Health Service.

 

RESULTS


 

Sociodemographic description

The sample consisted of 170 people, 24.12% of whom were men and 75.88% were women, with a mean age of 31.7 years (SD=15.87). The marital status of 59.4% were single and 8.9% were living alone. A total of 28.2% had incomplete high school education and 87.6% identified themselves as heterosexual. In addition, 82.3% indicated living in urban areas and 12.9% felt they belonged to the Mapuche people. In terms of religious affiliation, 40.5% identified themselves as Catholic, followed by 30.5% who declared themselves evangelical. The results are presented in Table 1.

 

Clinical history

Among the most relevant psychiatric history of the subjects studied, we found the presence of concomitant depressive disorder (42.94%), family psychiatric history (45.29%) and history of diagnosed psychiatric pathology (54.12%) and affective disorder (53.53%). The summary is shown in Table 2.

Characteristics of the suicide attempt

The 48.24% (n=88) presented previous attempts at the time of admission, while the most important triggering factor prior to the suicide attempt was “partner conflict or breakup” (55.29%). In addition, the most frequently described method was “drug intake” (65.29%). The characteristics are presented in Table 3.

Analysis of suicide attempt with respect to variables recorded at admission.

 

Table 4 shows the results of the Chi-square test for each variable studied, as well as the statistical significance (p<0.05), finding a statistical difference in the “Ethnicity” variables (p=0.01).

In addition, analysis of the variables was performed with respect to the number of suicide attempts of the subjects studied, finding significance in “ethnicity” (p=0.034) and “religion” (p=0.014). No other statistical associations were found in the Chi-square

test (Table 5).

DISCUSSION


 

In this study, clinical and sociodemographic characteristics of people who were treated after a suicide attempt in the IPU were described.

 

Regarding sociodemographic characteristics, a large part of the sample were young adult women without a history of previous attempts and single. Among the clinical characteristics, in line with the literature, the results show that at least 42% of the people who attempted suicide had depressive symptoms at the time of the suicide attempt, reinforcing the relevance of asking about suicidal thoughts when there are depressive symptoms(8,10,16). Similar to other characterizations of suicide attempts, in this research it was observed that 45% have family members with psychiatric antecedents.(23,24)

 

In the characterization of the suicide attempt, relational conflicts appear as a relevant trigger. Nearly 55% identified a couple conflict as a trigger, which is in line with what is indicated in other studies(25). It was also observed that the most frequent method of the attempt was the ingestion of drugs, which coincides with other Latin American experiences in this line of research.(26,27,28)

 

Regarding the number of previous attempts, the variables of ethnicity and religious affiliation stand out. Regarding the ethnicity variable, this result may be due to the fact that a significant part of the sample did not report feeling that they belonged to any ethnic group, which may have interfered with the results. Regarding the variable of religious affiliation, although in the national literature, religiosity and spirituality have been reported as a protective factor for suicidal risk in depressive women(29) and a lower risk of suicidal behavior in religious adolescents(30); our results suggest that after the first attempt, the religious variable may play a role in the risk of suicide reattempt. These results show the relevance and need to continue exploring the variables of religiosity and its relationship with suicidality in future studies in the area.

Some studies report that 18-30% of patients with a suicide attempt will present a reattempt within 2 years, 60% within 6 months and 70% within the first year after the attempt, and mortality due to suicide after the attempt fluctuates between 5-30% (31,32,33,34,35,36). However, in our follow-up, 0.36% consummated suicide, and 7% presented subsequent reattempts, with a continuity of care coverage close to 85%, compared to other studies in which 45% of patients are referred to a psychiatrist and about 25% continue care afterwards.(37)

 

This study is not without limitations. First, since the research design is cross-sectional, the clinical evolution of the participants over time is unknown. Secondly, we do not have complete information on all the cases, which is why, although the assessment guideline was applied cross-sectionally, for clinical reasons the psychiatric interview explores the dimensions in a heterogeneous manner as required. Thirdly, although the instrument was based on the one recommended by the Chilean health authority to be applied in the study of adult subjects with suicide attempt, for future research it is suggested to adapt the evaluation instrument to handle cultural and social variables with greater precision, for example, in religious adscription it is not precise if the person participates or not in a religious space. Fourthly, there are still suicide attempts in the region that are not investigated and therefore were left out of this research, either because they are not notified or because they do not consult after the attempt.

 

Finally, despite the considerations expressed above, we believe that the results of this research, and the context from which they arise, show an experience of clinical and epidemiological follow-up, focused on people with suicidal risk that can serve as an effective model of clinical and research intervention for the approach and prevention of people with suicidal attempts and therefore, with high risk of suicidality.

 

Acknowledgments: To the patients and their families who received care and were monitored, since without them this task would not be possible.

To the Los Ríos Health Service, Department of Mental Health of the Health Service, Base Hospital Valdivia, Psychiatry Service of the Base Hospital Valdivia and Seremi de Los Ríos, and its Mental Health and Epidemiology areas, institutions that in alliance contributed to the development of this project.

 

To all those who participated in the data collection and review process at the beginning of the research, M.J. Haydar, A.Wagner, T. Silva.

 

To the entire group of the Chilean Alliance against Depression, who participated in initial discussions and reflections that contributed to focus the study, among them C. Álamo, M. Morandé, J.C. Olivares, C. Heskia, D. Urrutia, A. Ordoñez, M. Wentzel, F. Retamal, J. Santander, A. Bilbao and especially to Dr. T. Baader as leader of this organization who motivated to carry out this type of research.

MARCELO GOTELLI et.al.

REFERENCES


 

  1. 1. Suicidio [Internet]. Organización Mundial de la Salud, 2019 [citado 26 octubre 2020]. Disponible en: https://www.who.int/es/news-room/fact-sheets/detail/suicide
  2. 2. Baader T, Urra E, Millán R, Yáñez L. Algunas consideraciones sobre el intento de suicidio y su enfrentamiento. Revista Médica Clínica Las Condes [Internet]. 2011 [citado 1 diciembre 2020];22(3):303–309. Disponible en: https://doi.org/10.1016/S0716-8640(11)70430-8
  3. 3. Ribeiro JD, Franklin JC, Fox KR, Bentley KH, Kleiman EM, Chang BP, et al. Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychological Medicine. Cambridge University Press; 2016;46(2):225–36.
  4. 4. Belsher BE, Smolenski DJ, Pruitt LD, Bush NE, Beech EH, Workman DE, Morgan RL, Evatt DP, Tucker J, Skopp NA. Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation. JAMA Psychiatry. 2019 Jun 1;76(6):642-651. doi: 10.1001/jamapsychiatry.2019.0174. PMID: 30865249.
  5. 5. Klonsky ED, May AM, Glenn CR. The relationship between nonsuicidal self-injury and attempted suicide: converging evidence from four samples. J Abnorm Psychol. 2013 Feb;122(1):231-237. doi: 10.1037/a0030278. Epub 2012 Oct 15. PMID: 23067259.
  6. 6. Barroilhet Sergio, Fritsch Rosemarie, Guajardo Viviana, Martínez Vania, Vöhringer Paul, Araya Ricardo et al. Ideas autolíticas, violencia autoinfligida, y síntomas depresivos en escolares chilenos. Rev. méd. Chile [Internet]. 2012 Jul [citado 2020 Dic 07]; 140(7): 873-881.
  7. 7. Valdivia Mario, Silva Daniel, Sanhueza Félix, Cova Félix, Melipillán Roberto. Prevalencia de intento de suicidio adolescente y factores de riesgo asociados en una comuna rural de la provincia de Concepción. Rev. méd. Chile [Internet]. 2015 Mar [citado 2020 Dic 07] ; 143( 3 ): 320-328.
  8. 8. Ribeiro, J. D., Huang, X., Fox, K. R., & Franklin, J. C. (2018). Depression and hopelessness as risk factors for suicide ideation, attempts and death: meta-analysis of longitudinal studies. The British journal of psychiatry: the journal of mental science, 212(5), 279–286. https://doi.org/10.1192/bjp.2018.27
  9. 9. Nahuelpán E. El suicidio en chile: Análisis del fenómeno desde los datos médico legales. Período 2000-2010. Actualización datos periodo 2011-2017. Santiago de Chile: Unidad de Estadísticas y Archivo Médico Legal de Chile 2018. Pp. 4-61.
  10. 10. Valdivia Mario, Silva Daniel, Sanhueza Félix, Cova Félix, Melipillán Roberto. Prevalencia de intento de suicidio adolescente y factores de riesgo asociados en una comuna rural de la provincia de Concepción. Rev. méd. Chile [Internet]. 2015 Mar [citado 2020 Dic 07]; 143( 3 ): 320-328.
  11. 11. Darvishi N, Farhadi M, Haghtalab T, Poorolajal J. Alcohol-related risk of suicidal ideation, suicide attempt, and completed suicide: a meta-analysis. PLoS One. 2015 May 20;10(5):e0126870. doi: 10.1371/journal.pone.0126870. Erratum in: PLoS One. 2020 Oct 29;15(10):e0241874. PMID: 25993344; PMCID: PMC4439031.
  12. 12. Silva Daniel, Vicente Benjamín, Saldivia Sandra, Kohn Robert. Conducta suicida y trastornos psiquiátricos en Chile, un estudio poblacional. Rev. méd. Chile [Internet]. 2013 Oct [citado 2020 Dic 07] ; 141( 10 ): 1275-1282.
  13. 13. Mann JJ, Currier DM. Stress, genetics and epigenetic effects on the neurobiology of suicidal behavior and depression. Eur Psychiatry. 2010 Jun;25(5):268-71. doi: 10.1016/j.eurpsy.2010.01.009. Epub 2010 May 6. PMID: 20451357; PMCID: PMC2896004.
  14. 14. Diaconu G, Turecki G. Family history of suicidal behavior predicts impulsive-aggressive behavior levels in psychiatric outpatients. J Affect Disord. 2009 Feb;113(1-2):172-8. doi: 10.1016/j.jad.2008.03.028. Epub 2008 May 27. PMID: 18504057.
  15. 15. Departamento de salud mental división de prevención y control de enfermedades subsecretaría de salud pública. Programa nacional de prevencion del suicidio Orientaciones para su Implementación. Santiago de Chile: Ministerio de Salud; 2013. pp. 5–37.
  16. 16. Barroilhet Sergio, Fritsch Rosemarie, Guajardo Viviana, Martínez Vania, Vöhringer Paul, Araya Ricardo et al. Ideas autolíticas, violencia autoinfligida, y síntomas depresivos en escolares chilenos. Rev. méd. Chile [Internet]. 2012 Jul [citado 2020 Dic 07] ; 140(7): 873-881.
  17. 17. Barros Jorge, Morales Susana, Echávarri Orietta, García Arnol, Ortega Jaime, Asahi Takeshi et al. Suicide detection in Chile: proposing a predictive model for suicide risk in a clinical sample of patients with mood disorders. Rev. Bras. Psiquiatr. [Internet]. 2017 Mar [cited 2020 Dec 07]; 39( 1 ): 1-11.
  18. 18. Morales S, Fischman R, Echávarri O, Barros J, Armijo I, Moya C, Maino M, Núñez C. Vivencia-expresión de la rabia y razones para vivir en un grupo de pacientes chilenos con riesgo suicida. Revista Iberoamericana de Psicología y Salud [Internet]. 2016 [citado 15 octubre 2020];7(2):60–68.
  19. 19. Florenzano U Ramón, Valdés C Macarena, Cáceres C Eugenio, Santander R Sylvia, Aspillaga H Carolina, Musalem A Claudia. Relación entre ideación suicida y estilos parentales en un grupo de adolescentes chilenos. Rev. méd. Chile [Internet]. 2011 Dic [citado 2020 Dic 07] ; 139( 12 ): 1529-1533.
  20. 20. Bustamante F, Ramirez V, Urquidi C, Bustos V, Yaseen Z, Galynker I. Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010. Crisis. 2016;37(1):21-30. doi: 10.1027/0227-5910/a000357.
  21. 21. ORD 775 Departamento de salud pública y planificación, vigilancia de intento suicida.
  22. 22. Gómez A, Ibáñez C, Gómez M, Nuñez c, Opazo R. Autopsias psicológicas de treinta suicidios en la IV Región de Chile. Revista chilena de neuro-psiquiatría. Revista chilena de neuro-psiquiatría. 2014;(52):9–19.
  23. 23. del Toro Kondeff, M., González, Y. H., & Huerta, B. D. (2012). Caracterización de la conducta suicida en adolescentes del municipio Cerro, 2009-2010. Revista del Hospital Psiquiátrico de La Habana, 9(2).
  24. 24. Cortés Alfaro, A., Aguilar Valdés, J., Suárez Medina, R., Rodríguez Dávila, E., & Durán Rivero, J. S. (2011). Factores de riesgo asociados con el intento suicida y criterios sobre lo ocurrido en adolescentes. Revista Cubana de Medicina General Integral, 27(1), 33-41.
  25. 25. Evans R, Scourfield J, More G. Gender, Relationship Breakdown, and Suicide Risk: A Review of Research in Western Countries. Journal of Family Issues [Internet]. 2016 [citado 18 noviembre 2020];(37):2239–2264.
  26. 26. Valle Ampié, W. M. (2016). Abordaje de intento suicida en pacientes atendido en el Hospital Alemán Nicaragüense del 1 Enero 2013 a Diciembre del 2015 (Doctoral dissertation, Universidad Nacional Autónoma de Nicaragua, Managua).
  27. 27. Bautista, K. P. H., & Ponce, O. (2019). Características Epidemiológicas del Intento Suicida en Adolescentes. Acta Pediátrica Hondureña, 9(2), 932-937.
  28. 28. Garcia Ruiz, R. E. (2019). Factores de riesgo en pacientes con intento suicida ingresados en el Hospital Psicosocial Abril 2017-Diciembre 2018 (Doctoral dissertation, Universidad Nacional Autónoma de Nicaragua, Managua).
  29. 29. Taha N, Florenzano R, Sieverson C, Aspillaga C, Alliende L. Spirituality and religiosity as a protective factor in depressive women with suicidal risk: expert consensus. Revista chilena de neuro-psiquiatría. 2011;(49):347–360.
  30. 30. Florenzano R, Valdés M, Cáceres E, Santander S, Armijo L, Bergman V, Trapp A. Religiosidad, conductas de riesgo y salud mental en adolescentes de Santiago de Chile. Revista Chilena de Salud Pública. 2008;(12):83–92.
  31. 31. Bostwick JM, Pabbati C, Geske JR, McKean AJ. Suicide Attempt as a Risk Factor for Completed Suicide: Even More Lethal Than We Knew. Am J Psychiatry. 2016 Nov 1;173(11):1094-1100. doi: 10.1176/appi.ajp.2016.15070854. Epub 2016 Aug 13. PMID: 27523496; PMCID: PMC5510596.
  32. 32. Irigoyen M, Porras-Segovia A, Galván L, Puigdevall M, Giner L, De Leon S, Baca-García E. Predictors of re-attempt in a cohort of suicide attempters: A survival analysis. J Affect Disord. 2019 Mar 15;247:20-28. doi: 10.1016/j.jad.2018.12.050. Epub 2018 Dec 18. PMID: 30640026.
  33. 33. Christiansen E, Jensen BF. Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: a register-based survival analysis. Aust N Z J Psychiatry. 2007 Mar;41(3):257-65. doi: 10.1080/00048670601172749. PMID: 17464707.
  34. 34. Sawa M, Koishikawa H, Osaki Y. Risk Factors of a Suicide Reattempt by Seasonality and the Method of a Previous Suicide Attempt: A Cohort Study in a Japanese Primary Care Hospital. Suicide Life Threat Behav. 2017 Dec;47(6):688-695. doi: 10.1111/sltb.12326. Epub 2016 Dec 28. PMID: 28030756.
  35. 35. Bostwick JM, Pabbati C, Geske JR, McKean AJ. Suicide Attempt as a Risk Factor for Completed Suicide: Even More Lethal Than We Knew. Am J Psychiatry. 2016 Nov 1;173(11):1094-1100. doi: 10.1176/appi.ajp.2016.15070854. Epub 2016 Aug 13. PMID: 27523496; PMCID: PMC5510596.
  36. 36. Cooper J, Kapur N, Webb R, Lawlor M, Guthrie E, Mackway-Jones K, Appleby L. Suicide after deliberate self-harm: a 4-year cohort study. Am J Psychiatry. 2005 Feb;162(2):297-303. doi: 10.1176/appi.ajp.162.2.297. PMID: 15677594.
  37. 37. hen-Ju L, Hsin-Chin L, Fang-Ju S, Shu-I W, Shen-Ing L. The characteristics, management, and aftercare of patients with suicide attempts who attended the emergency department of a general hospital in northern Taiwan. Journal of the Chinese Medical Association [Internet]. 2014 [citado 7 diciembre 2020];(77):317–324. Disponible en: https://doi.org/10.1016/j.jcma.2014.02.014.
  38.  


HOW TO QUOTE?


(2024). Clinical and sociodemographic characterization of the suicide attempt in the Los Ríos Region, Chile..Journal of Neuroeuropsychiatry, 57(4).
Recovered from https://www.journalofneuropsychiatry.cl/articulo.php?id= 132
2024. « Clinical and sociodemographic characterization of the suicide attempt in the Los Ríos Region, Chile.» Journal of Neuroeuropsychiatry, 57(4). https://www.journalofneuropsychiatry.cl/articulo.php?id= 132
(2024). « Clinical and sociodemographic characterization of the suicide attempt in the Los Ríos Region, Chile. ». Journal of Neuroeuropsychiatry, 57(4). Available in: https://www.journalofneuropsychiatry.cl/articulo.php?id= 132 ( Accessed: 22mayo2024 )
Journal Of Neuropsichiatry of Chile [Internet]. [cited 2024-05-22]; Available from: https://www.journalofneuropsychiatry.cl/articulo.php?id=132

 

DOWNLOAD PDF VERSION