Suicide Attempters Versus Ideators: A Comparative study of Life Events And Psycho-Socio Demographic Determinant Factors

“SUICIDE COMPARATIVE STUDY

DEMOGRAPHIC

THE TAMILNADU In partial

GOVERNMENT STANLEY THE TAMILNADU

A Dissertation on

“SUICIDE ATTEMPTERS VERSUS IDEATORS:

STUDY OF LIFE EVENTS AND PSYCHO DEMOGRAPHIC DETERMINANT FACTORS”

Submitted to

TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY partial fulfilment of the requirements

For the award of degree of M.D. (PSYCHIATRY)

(Branch-XVIII )

STANLEY MEDICAL COLLEGE & HOSPITAL TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY,

CHENNAI, TAMILNADU.

APRIL 2016

IDEATORS: A

PSYCHO-SOCIO FACTORS”

UNIVERSITY

HOSPITAL

UNIVERSITY,

CERTIFICATE

This is to certify that this dissertation titled “SUICIDE ATTEMPTERS VERSUS IDEATORS: A COMPARATIVE STUDY OF LIFE EVENTS AND PSYCHO-SOCIO DEMOGRAPHIC DETERMINANT FACTORS” submitted by Dr.KISLAYA RAKESH.

to the faculty of Department of Psychiatry, Stanley Medical College, The Tamil Nadu Dr. M.G.R. Medical University, Chennai, in partial fulfilment of the requirements in the award of degree of M.D. (PSYCHIATRY) Branch -XVIII for the April 2016 examination is a bonafide research work carried out by her during the period of Feb 2015 to July 2015 at Government Stanley Medical College & Hospital, Chennai, under the direct supervision and guidance of Prof. Dr. W. J. ALEXANDER GNANDURAI, M.D. DPM., Professor and Head of the department, Department of Psychiatry at Stanley Medical College, Chennai.

Prof. Dr .W.J.ALEXANDER GNANADURAI, M.D., DPM., Professor and HOD,

Department of Psychiatry,

Government Stanley Medical College and Hospital, Chennai – 600 001.

Dr.ISAAC CHRISTIAN MOSES M.D., DEAN

Government Stanley Medical College and Hospital,

Chennai – 600 001.

CERTIFICATE

This is to certify that this dissertation titled “SUICIDE ATTEMPTERS VERSUS IDEATORS: A COMPARATIVE STUDY OF LIFE EVENTS AND PSYCHO-SOCIO DEMOGRAPHIC DETERMINANT FACTORS” submitted by Dr. Kislaya Rakesh is an original work done in the Department of Psychiatry, Government Stanley Medical College and Hospital, Chennai in partial fulfilment of regulations of The Tamil Nadu Dr. M.G.R. Medical University, for the award of degree of M.D.(PSYCHIATRY) Branch –XVIII, under my guidance and direct supervision during the academic period 2013-2016.

GUIDE:

Prof. Dr .R. SARAVANAJOTHI M.D., Associate Professor,

Department of Psychiatry,

Government Stanley Medical College and Hospital,

Chennai –600 001.

DECLARATION

I, Dr. KISLAYA RAKESH, hereby declare that this dissertation entitled “SUICIDE ATTEMPTERS VS. SUICIDE IDEATORS:

A COMPARATIVE STUDY OF LIFE EVENTS AND PSYCHO- SOCIO-DEMOGRAPHIC DETERMINANT FACTORS” is a bonafide and genuine research work carried out by me during the period of Feb 2015 to July 2015 at Government Stanley Medical College andHospital, under the expert supervision of Prof. Dr .R. Saravanajothi, M.D., Associate Professor, Department of Psychiatry, Government Stanley Medical College, Chennai. This thesis is submitted to The Tamil Nadu Dr .M.G.R. Medical University in partial fulfilment of the rules and regulations for the M.D. degree examinations in Psychiatry to be held in April 2016.

Place : Chennai

Date: Dr. Kislaya Rakesh

ACKNOWLEDGEMENT

I render my deepest gratitude to my mentor and guide, Dr. W.J. Alexander Gnanadurai, MD, DPM, Professor and Head of the Department of Psychiatry. I was fortunate to have a learned guide to give me the freedom to explore on my own with constant guidance when i was in doubt.

I would like to thank Dr. R. Saravanajothi , MD, Associate Professor for constant and unfailing guidance, support and interest in this thesis.

I would like to thank Dr. M.M.Ilyas, MD, D.P.M, Assistant Professor and & Dr. Hariharan MD, Assistant Professors for their keen interest and support and overview during my thesis and tenure as post graduate.

I am ever grateful to the unstinting love and support of my family without whom this endeavour would not have been successful.

Even though suicide attempt and ideation are one of the most distressing events in a lifetime i will ever be thankful and in awe of the strength displayed by my patients and their families in giving consent and being eager participants in this study.

I express my thanks to all my fellow post-graduate colleagues for their kind co-operation, help and unwavering support in my endeavour.

I deeply thank the teachers and college staff of Stanley Medical College for their extensive support during the course of my post-graduate training.

Dr. Kislaya Rakesh

CONTENTS

Serial number Title Page number

1 Introduction 1 – 8

2 Aims and Objectives 9

3 Review of Literature 10 – 22

4 Materials and Methods 23 – 28

5 Results 29 – 66

6 Discussion 67 – 72

7 Conclusion 73

8 Limitations 74

9 Recommendations 75

10 Bibliography

11 Annexures

LIST OF TABLES

No.

Title Page

No.

1 Marital Status of the Respondents 33

2 Substance Use in Patients 42

3 Presumptive Stressful Life Events Scale 49

4 Desirable/Undesirable/Ambiguous 51

5 Alcohol dependence 53

6 Non-Parametric tests to compare various parameters between cases and control (PSLES)

56 7 Non-Parametric tests to compare various parameters between

cases and control (MSSI and ICD-10 Alcohol Dependence)

57 8 Non-Parametric tests to compare various parameters between

cases and control (Psychiatric diagnosis and previous h/o attempt)

58

9 Non-Parametric tests to compare various parameters between cases and control

59 10 Chi-square tests for independence between alcohol use and

family history and alcohol use & intoxication at the time of attempt

60

11 Chi-square tests for independence between stressful life events

& suicidal intent, suicidal intent & mental illness.

61

12 Correlation tests between PSLES and MSSI 62

13 Difference in marital status between cases and control 63 14 Non-parametric tests for marital status, family type and

alcohol dependence

64 15 Correlation tests between MSSI and Alcohol dependence 65 16 Correlation tests between marital status and severity of intent

in cases and control

66

LIST OF FIGURES

No. Title Page

No.

1 Age distribution across case and control N=112, cases=60, control=52

30

2 Gender distribution 31

3 Religion 32

4 Marital Status 34

5 Sexual orientation 35

6 Family type in cases and control 36

7 Children 37

8 Socioeconomic Status of the participants 38

9 Family history of alcohol dependence 39

10 Family history of mental illness in Percentage 40

11 Family history of suicide 41

12 Substance use in patients 43

13 Previous history of attempt in cases 44

14 Method of suicide attempt 45

15 Intoxication at time of attempt 46

16 Chronic illness in patients 47

17 Psychiatric diagnosis 48

18 PSLES 50

19 Desirable/Undesirable/Ambiguous 52

20 MSSI results 53

21 Alcohol dependence 55

ABSTRACT

Introduction

Over one million people die of suicide worldwide every year. The national average is 11/1 lac population. Chennai tops the list of metros with the highest suicide rate. There is a need to identify factors that push a person from the ideational level to attempting suicide.

Objectives

To study the socio-demographics, intent and preceding events in people with suicidal ideas compared to suicide attempters.

Methodology

112 patients, 60 attempters and 52 ideators were chosen for the studying the age group of 18-60 after getting consent. A comparative study of the two groups was done. SPSS software was used for statistical analysis.

Conclusion

Significant differences were found in the two groups being compared in age, gender, marital status and alcohol dependence. Within each group significant differences were found on comparing the relation between stressful life events experienced by a patient and severity of suicidal ideation and mental illness and suicidal ideation.

Chapter 1 Chapter 1 Chapter 1 Chapter 1 Introduction Introduction Introduction Introduction

1

INTRODUCTION

The term Suicide was first used by the English author, Sir Thomas Browne in 1642 in his treatise “Religio Medici”¹.The word originated from SUI (of oneself) and CAEDES (murder).Suicide is a multifactorial cause of morbidity and mortality across all stages of a person’s life and is reported across the world irrespective of religion, culture , race, health practices and attitudes.

Parasuicide- was a term introduced by Kreitman & colleagues (1977) to describe patients who injure themselves by self mutilation or ingesting substances in excess of prescribed or generally recommended therapeutic dose.

The term does not include that death was the desired outcome².

Suicide attempters were defined by O’Carrol (1995) as “the potential self injurious behaviour with a non fatal outcome for which there is evidence (explicit or implicit) that the person intended at some level (non zero) to kill himself/herself.”

Over one million people die by suicide worldwide each year. The global suicide rate is 16 per 100,000 population. On average, one person dies by suicide every. 40 seconds, and someone is left to cope with the aftermath.

Suicide is an important issue in the Indian context. More than one lakh (one hundred thousand) lives are lost every year to suicide in our country. In the last two decades, the suicide rate has increased from 7.9 to 10.3 per 100,000. There is a wide variation inthe suicide rates within the country. The southern states of

2

Kerala, Karnataka, Andhra Pradesh and Tamil Nadu have a suicide rate of > 15 while in the Northern States of Punjab, Uttar Pradesh, Bihar and Jammu and Kashmir, the suicide rate is < 3 per lac population. This variable pattern has been stable for the last twenty years. Higher literacy, a better reporting system, lower external aggression, higher socioeconomic status and higher expectations are the possible explanations for the higher suicide rates in the Southern states³.

The five states viz. Tamil Nadu, West Bengal, Andhra Pradesh, Maharashtra and Karnataka have registered consistently higher number of suicidal deaths during the last few years. The majority of suicides (37.8%) in India are by those below the age of 30 years. The fact that 71% of suicides in India are by persons below the age of 44 years imposes a huge social, emotional and economic burden on our society⁴.

2,450 people in Chennai took their lives in 2013, making the city the metro with highest number of suicides in the year. Chennai has now topped the list for a third successive year, with statistics by the National Crime Records Bureau showing that the number of suicides in the city increased by 12% from last year.

3

Methods by which cultures. Poisoning

were the common methods In Chennai, the love. Leaping to death hanging, poisoning

4

which people attempt suicide differs across

Poisoning (36.6%),hanging(32.1%)and self immolation(7.9%) methods used to commit suicide.

the most commonly stated reason for suicide death is the most prevalent form of suicide,

and self-immolation⁵.

across countries and immolation(7.9%)

suicide is failure in suicide, followed by

5

Two large epidemiological verbal autopsy studies in rural Tamil Nadu reveal that the annual suicide rate is six to nine times the official rate. If these figures are extrapolated, it suggests that there are at least half a million suicides in India every year.

It is estimated that one in 60 persons in our country are affected by suicide. It includes both, those who have attempted suicide and those who have been affected by the suicide of a close family or friend. Thus, suicide is a major public and mental health problem, which demands urgent action.

Although suicide is a deeply personal and an individual act, suicidal behaviour is determined by a number of individual and social factors it is best understood as a multidimensional, multifactorial malaise.

Ever since Esquirol wrote that “All those who committed suicide are insane” and Durkheim proposed that suicide was an outcome of social and societal situations, the debate of individual vulnerability versus social stressors in the causation of suicide has divided our thoughts on suicide⁶. Emile Durkheim said “the suicide rate varies inversely with the integration of social groups of which the individual forms a part” .He described different types of suicide:

• Egoistic,

• Anomic,

• Altruistic and

• Fatalistic.

6 Characteristi

cs

Egoistic Altruistic Anomic Fatalistic

Nature of the individual

High

individualisati on and

isolation . not strongly

integrated with society

Insufficient individualisati on.

Excessively integrated to society

Violent accusations and counter accusations between self and significant others.

Rules and regulations excessively regulate the individual

Nature of society

within religion within politics within family

specific classes in society like soldiers, national (hara- kiri) religious (sati)

prone to sudden social and economic changes, societies with high divorces

Prison cults, slaves,childles s married women

Effect of individual in society

interactions in the individual

apathy, depression in individual with no basis in life.

mystical enthusiasm, obliged, appreciation by society

Balance of persons’

integration into society is suddenly disturbed. eg- divorce, financial loss.

social integration does not protect individual.

The more the integration the more the suicide rate

7

Divorce, dowry, love affairs, cancellation or the inability to get married (according to the system of arranged marriages in India), illegitimate pregnancy, extramarital affairs and such conflicts relating to the issue of marriage, play a crucial role, particularly in the suicide of women in India. Poverty, unemployment, debts and educational problems are also associated with suicide⁷.

Mental disorders occupy a premier position in the matrix of causation of suicide. Although social drinking is not a way of life in India, alcoholism plays a significant role in suicide in India. Alcohol dependence and abuse were found in 35% of suicides.Around30-50% of male suicides were under the influence of alcohol at the time of suicide and many wives have been driven to suicide by their alcoholic husbands. Not only were there a large number of alcoholic suicides but also many had come from alcoholic families and started consumption of alcohol early in life and were heavily dependent⁸.

Suicidal thoughts, also known as suicidal ideation are thoughts about how to kill oneself, which can range from a detailed plan to a fleeting consideration and does not include the final act of killing oneself. The majority of people who experience suicidal ideation do not carry it through. Some may, however, make suicide attempts. Some suicidal ideations can be deliberately planned to fail or be discovered, while others might be carefully planned to succeed.

8

According to a Finnish study, almost twenty percent of people who actually died by suicide had discussed their aim with a doctor or other health care professional during their last session⁹.

Attempted suicide is a common clinical problem seen in the general hospital setting. There are 10 to 20 times as many suicidal attempts as suicidal deaths. People with psychiatric illness have ten fold increased risk of suicide as compared to people without illness. Unfortunately, it is not possible to predict suicidal behaviour with certainty. The relationship between experience of problematic life events and suicidal behaviour has been recognised.

Although most patients who voice or admit to suicidal ideation when questioned do not go onto complete suicide, some of these patients will go on to commit suicide. Hence, suicidal ideation warrants thorough evaluation—

both at the time when suicidality is expressed as well as periodically thereafter.

The best way to prevent suicide is to ask patients more specific questions about recent stressors and their thoughts and attitudes about suicide, and then to treat the patients accordingly. Families must be an integral part of treatment planning. Medication and individual or family therapy are often indicated.Thereisaneedtodescribefactorsthatmayconvertideatorstoattempters.

Chapter 2 Chapter 2 Chapter 2 Chapter 2 Aim Aim

Aim Aim and Objectives and Objectives and Objectives and Objectives

9

AIMS AND OBJECTIVES

1. To study the socio demographic data, psychiatric disorder and precipitating events in suicide attempters and those with ideation in a general hospital.

2. To find out the pattern of suicides with respect toage, gender, sexual orientation and substance use.

3. To find out the stressful life events leading upto suicide attempts

4. To find out methods of attempting suicide.

5. To study the Psychosocial, cultural and precipitating factors for suicide in relation to age and gender with a view to formulating some preventive strategies

Chapter 3 Chapter 3 Chapter 3 Chapter 3

Review of Literature Review of Literature Review of Literature Review of Literature

10

REVIEW OF LITERATURE

A systematic review of existing literature was done using established databases; Eric, PsycINFO, PubMed, and Google Scholar to examine previous studies on socio demographic characteristics, psychiatric disorders, precipitating events, pattern of suicide, stressful life events leading upto suicide attempts, modes of suicide, psycho-social cultural and precipitating factors for suicide in relation to age and gender and mode of attempt in suicide attempters and those with ideation in a general hospital. The review yielded comprehensive information on the above parameters of suicide.

Defining suicide

Our study defines suicide as an act of deliberately killing oneself; a non- lethal and intentional act of self-inflicted harm, injury or poisoning is defined as a suicide attempt whereas a range of behaviours including planning for suicide and suicide ideation are classified under suicidal ideation.

The global burden

The impingement of suicide on mankind is statistically visible on a global scale accounted by being the second predominant cause of death in the age group between 15 and 29 years. Though a preventable cause of death, every 40 seconds witnesses a suicide excluding the unreported number of attempts to suicide. It has a cross-cultural and multidimensional impact across all the strata of the society with a major impact on the groups that already face marginalisation and discrimination. This compounds the agony of human

11

development in the low and medium income countries (around 75% of all suicides). Global statistics accounts for 800 000 deaths by suicide with disastrous effects on families, peers and on the society as a whole¹⁰.

In order to tackle this phenomenon, the World Health Organisation (WHO) developed a Mental Health Action Plan, which was adopted in May 2013 by the Sixty-sixth World Health Assembly, targeting a 10% reduction in the suicide rates globally by 2020¹¹.

Epidemiological presentment

There is no large scale high-quality statistics on suicide due to institutional fallacies in capturing the exact prevalence of suicides, suicide attempts and suicidal behaviours. Under reporting, inadequate differentiation between self inflicted harm with suicide intent and those without coupled with illegalisation and stigmatisation has led to various gaps in estimating the exact burden¹². However, WHO Global Health Estimates acts as the primary source of data through its WHO mortality database. With an age-standardized rate of suicide at 11.4 per 100 000 persons per year, suicide related deaths are at 804 000 (1.4%) globally with a majority of the population from the low- and middle-income countries (LMICs) making it the 15^th leading cause of death¹³.

Suicide rates vary by age and sex. The highest incidence of suicide deaths is seen above 70 years of age, lowest in the age group less than 15 years and wide-variation in rates between 15 and 70 years¹⁴. An 8.5% of deaths in the age group of 15-29 years are attributed to suicide against 4.1% of all deaths in the age group of 30-49 years¹⁵.

12 Suicide attempts

Previous studies show that suicide attempts against suicidal deaths have a telling impact on the social and economic parameters. It has a cogent influence in terms of healthcare use, economic losses incurred, psychosocial impact, long-term disability, and a subsequent issues arising out of repeated attempts. Research shows that people who commit suicide have previous attempts. So it is used as a predictor of vulnerability to suicide. The prevention strategies are designed and developed to identify the individuals with previous attempts to provide comprehensive suicide prevention services.

Evidence-based data on medically treated suicide attempts

One of the major sources of information on suicide attempts and its consequences is the hospital medical records. Hospitals see a good number of patients with suicide attempts in the form of pesticide poisoning, self-inflicted harm, hanging, drug overdose, etc. Dismally, there are a number of methodological fallacies in capturing this information. There is no actual benchmark that decides the quality of evidence-based data on suicide.

Additionally, a few of the suicide deaths never reach hospitals and some of them are closed by the kith and kin as natural death which skews the national data relating to suicide from the hospitals and healthcare providers.

In order to sort this issue, other violent deaths should be considered along with formal suicides to identify hidden suicides (Prichard and Amanullah, 2007)¹⁶

13 Suicide in India

Our prime source of statistical information comes from the National Crime Records Bureau (NCRB) for national estimates. While WHO estimates 170000 deaths from India, the NCRB reports only 135 000 deaths in 2010. This report is in-comprehensive as it is grounded primarily on the reports of police¹⁷. A published report in Lancet, June 2012, places the number of suicides at 187,000 in 2010¹⁸. This discrepancy in reporting has led to gaps in the knowledge of exact prevalence of suicide in India. Previous twenty years saw a surge in suicide rates from 7.9 to 10.3 per million populations with a high concentration in the southern regions. Tamil Nadu, West Bengal, Andhra Pradesh, Maharashtra and Karnataka together account for 56.2 % of the reported suicides with an alarming continuously rising trend, says the National Crime Records Bureau (NCRB). The farmers’suicide receives a noteworthy mention in India, as it is one of the high contributors to suicide mortality in the rural setting¹⁹. Yet, a reliable system to quantify suicide related deaths is essential in the light of Government of India 12th Year Plan for 2012–17 which includes strategies to tackle mental health problems²⁰.

A national representative mortality study (Million Death Study (MDS)²¹ -one of the few nationally-representative studies of the causes of death in any low or middle-income country) of the 1.1 million homes in 6671 random areas nationally was conducted between 2001 and 2003. The parents of the male suicide victims (completed) were the predominant interviewees (22%), followed by wife (21%) and neighbours (10%). For females, other relatives,

14

followed by husband, 16% and neighbours 12%, constituted 20%. All the victims were above the age of 15 years. Other household members formed the remaining interviewees.

The survey demonstrated the attribution of 2684 deaths (around 3%) to suicide. Majority of the suicides happen between the ages of 15 to 29 years with a higher prevalence in females (56%) than males (40%). The cumulative risk of committing suicide for a 15 year old in India is 1.3% before he celebrates his 80^th birthday. Men have a higher risk compared (1.7%) to the female counterparts (1.0%). Southern India demonstrates a higher risk (Females=1.8% and males=3.5%). The study also throws light on the society stratification with a higher risk in the educated groups. Poisoning was the common cause of suicidal death, which is principally attributed to pesticide poisoning.

Between January 2008 and October 2012, a retrospective study to evaluate suicide cases in Lucknow was carried out among a sample of 5204 cases (males n=2946, 56.61% and females n=2258, 43.38%)²². The rates of suicide were 21.55-24.23 per million populations between 20 to 60 years of age. This study displays the gender difference in the modes of suicide with a predominance of violent methods in males.

Risk factors in suicide²³

A complex interplay of social, personal, interpersonal and cultural factors are suspected in the etiology of suicide. The following list enumerates few of the individual factors that are directly or indirectly attributed to suicide.

15 Individual risk factors

Individual emotional intelligence, coping mechanisms, vulnerability, threshold to face life events decide the response to the stress. This stress poorly handled increases the probability of inculcating suicidal attitudes and thereby behavior.

Previous suicide attempt

This remains as one of the most predominant predictor of suicide.

Subjects with one of more previous attempts at suicide tend to nurture suicidal tendencies. The incidence of premature death is high even with a single uncompleted suicide attempt.

Mental disorders

Ninety percent of suicidal deaths in the developed countries are attributed to mental disorders. But this frequency is considerably low in developing countries like India. It is observed that people who die by suicide have psychiatric comorbidity with a variance in suicidal risks depending on the type of behavior. Depression (4%) and alcoholism (7%) constitute the major share in the psychiatric comorbidity, whereas bipolar (8%) and schizophrenia (5%) constitute another part of the spectrum. Higher the number of comorbidity, greater is the risk of suicidal ideation and completed suicides.

Affective disorder is the most commonly attributed factor for suicide among other risk factors placing the lifetime risk at 6%, which is 20 times higher than depression and 12 times greater than dysthymia.

16 Harmful use of alcohol and other substances

An estimated 25-50% of all suicides have an association with problematic substance use with a positive relationship between substance use and suicides. 22% of all suicidal deaths are attributed to alcoholism followed by other substances like cannabis, heroin and nicotine.

Job or financial loss

Individual suicide risk increases with the changing landscape of the economy. Job losses, mortgage, failed loans, recession, financial crisis increase the risk of suicide. In addition, these events act as stressors increasing the chances of suicidal ideation.

Hopelessness

Lack of motivation to live, failure to achieve leads to cognitive derangement and acts as a factor in inculcating suicidal thoughts and behavior.

Most suicide cases are seen in association with depression.

Chronic pain and illness

Chronic illness and pain fuelled by psychiatric comorbidity like depression, etc is found to cause suicide 2-3 times higher than the general population. These chronic illnesses include cancer, diabetes, hypertension and other diseases associated with neuro-degeneration, psychological and physical disability.

17 Family history of suicide

The incidence of a history of suicide in a family increases the vulnerability and decreases the threshold for suicidal ideation. The sorrow in addition to guilt, shame, anger, distress and anxiety may compound the vulnerability to suicide. Stigma and disruption of family dynamics may affect the individual’s access to healthcare providers. Few of them even developed psychiatric comorbidity caused by the sudden death of a family member by suicide.

Attempted suicide and repeated attempts

Nrugham L, Holen A, Sund AM in 2015 reported a longitudinal study on non-attempters, attempters and repeaters of suicide attempts in relation to stressful life events and their levels of depression symptoms in an extracted subset that was followed up from adolescence into early adulthood. Participants were high school students (T1, n = 2464, mean age = 13.7 years, 50.8% female, 88.3% participation) who were re-assessed with the same questionnaire after a year (T2Q)²⁴. A subset was interviewed and assessed diagnostically face-to- face based on the high scores on Mood and Feelings Questionnaire (MFQ) at T2I (n = 345, 94% participation). This subset was quantitatively studied again after 5 years (same questionnaire) on 252 participants with mean age of 20 years that constituted 73% participation. Results illustrated that repeaters of suicide attempts are more depressed and reported more stressful life events.

Variations in three domains of stressful events were also reported.

18

Another comparative study in 2003 by Beautrais AL Suicide and Serious Suicide Attempts in Youth compared risk factors for suicide and medically serious nonfatal suicide attempts among youth less than 25 years of age²⁵. Three groups were examined: individuals who committed suicide (N=60), individuals who made serious suicide attempts (N=125), and nonsuicidal community comparison subjects (N=151). Suicidal and nonsuicidal subjects were compared in terms of sociodemographic, childhood, family, psychosocial, and psychiatric factors. Suicides were characterized by male gender, lack of educational qualifications, mood disorder, history of mental health care, and stressful life events. Except for gender, similar risk factors were associated with serious suicide attempts. Suicides and serious suicide attempts were discriminated by gender and mood disorder. Gender differences between suicides and nonfatal suicide attempts were explained by gender differences in methods used to attempt suicide.

Family history of suicide

Between 1949 and 1969, Runeson B, Åsberg M. (2003) studied family history of suicide among suicide victims comparing the rates of suicide in family members of suicide victims and comparison subjects who died of other (N=8,396)²⁶. The comparison group comprised persons of the same age who died of other causes (N=7,568).First-degree relatives of the suicide victims (N=33,173) and comparison subjects (N=28,945) were identified. Among families of the suicide victims there were 287 suicides, representing 9.4% of all deaths in family members. Among comparison families there were 120

19

suicides, 4.6% of all deaths. A backward stepwise logistic regression (conditional) was performed to study the specific effects of a family history of suicide and of psychiatric care in the first-degree relatives of the suicide victims and comparison subjects. The difference was significant.

Previous psychiatric care and suicide in a family member predicted suicide in the logistic regression model. The main finding of the study is that the rate of suicide was significantly higher in the families of suicide victims than in the families of comparison subjects. Nevertheless, the strongest risk factor for suicide in the families was mental disorder, defined by previous psychiatric inpatient care. The strong connection between suicide and mental disorder is well established. But still, a family history of suicide was a significant risk factor independent of severe mental disorder.

Stress and suicide

The relationship between stress and subsequent illness has been explored through various studies. Wolf (1950), Schmale and Engel (1967), Holmes and Rahe (1967)²⁷ observed a positive relationship whereas a weaker relationship was seen in other studies [Brown et al (1973)²⁸, Uhlenhuth and Paykel (1972)²⁹, Patrick et al (1978)]³⁰. In the light of the previous studies, it is observed that patients’cues may point us towards their propensity to commit suicide. Stengel (1964) states that suicide intent points to potential completed suicide and has an “appeal for help”³¹. Farberow and Schneidman (1965)³² and Schneidman (1967)³³, emphasized the presence of verbal and nonverbal cues in persons planning for suicide. Stress definitely has a telling impact on suicides.

20 Stress, depression and Suicidal intent

In order to explore the relationship between stress, depression and suicide intent, a study of patients admitted to a hospital in India was carried out among 33 males and 23 females [Jain V, Singh H, Gupta SC & Kumar S (1994)]³⁴. Though a small sample size, yet following findings throw light on depression (37.5%) with 39.28% of them was showing suicide intent.

Statistical tests showed a significant correlation between suicidal intent, hopelessness and depression.

Psychiatric diagnosis

The presence of psychiatric illness is demonstrable in various studies of suicide and attempted suicide³⁵. The results vary between 9.5 to 24.9%, with one study reporting major depression, bipolar disorder and schizophrenia cumulatively adding up to 24% with substance abuse of 18%³⁶. Another study showed alcohol dependence, depression, schizophrenia and other disorders adding upto 11.6% of the prevalence of psychiatric disorders in people with attempted suicide³⁷.

The incidence of suicide attempt was 16.6% in a sample of people with major depressive disorder with a positive correlation to depression in another study³⁸. A study in rural India again revealed alcohol dependence and adjustment disorders as common psychiatric illness in 100 patients with suicides³⁹. Suicide attempters show mood disorders and alcohol abuse with rates as high as 93% and related neurotic disorders in 14.5%⁴⁰.

21 Modes of suicide

The modes of suicide in the Indian context have been researched widely.

Rao VA. (1965) Reported poisoning as commonest method with an estimated number of 43 in a million population as attempters⁴¹. Gajalakshmi et al in 2007 observed poisoning as the common mode of suicide followed by hanging and self-immolation⁴². But Saddichha et al in 2010 reported hanging and insecticide poisoning in men and self-immolation and hanging inwomen⁴³. Chavan et al in 2008⁴⁴ also showed that 72.2% attempt hanging whereas Khan et al., 2005⁴⁵ showed hanging and self- immolation in men and women respectively as common modes. Soman et al., 2009 reported jumping in front of a train along with other modes⁴⁶. Bhatia (2000) reported Poisoning in attempters and hanging in completers as the most common method⁴⁷s. Another study also showed Poisoning as Commonest method in attempters (Suresh Kumar, 2004)⁴⁸. Jena et al in 2004 reported life- time prevalence rates of Suicidal ideation (1.7%), Suicide attempt (8%) against 1 year prevalence rates of Suicidal ideation (11.7%) and Suicide attempt (3.5%)⁴⁹.

22 Multidisciplinary approach to suicide

Observing the multidimensional and multifactorial system of suicide, any attempt to tackle this issue should be a trans-disciplinary approach. The following study attempts to answer few questions on socio demographic characteristics, psychiatric disorders, precipitating events, pattern of suicide, stressful life events leading upto suicide attempts, modes of suicide, psycho- social cultural and precipitating factors for suicide in relation to age and gender and mode of attempt in suicide attempters and those with ideation in a general hospital.

Chapter 4 Chapter 4 Chapter 4 Chapter 4

Materials and Methods Materials and Methods Materials and Methods Materials and Methods

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MATERIALS AND METHODS

The study was conducted in Government Stanley Medical College and Hospital.

From February 2015 to July 2015, a comparative study among a consecutive sample of 112 respondents was done.

The study received ethics approval from the institutional review board of the medical college and hospital.

Patients and their relatives were informed of the purpose and nature of this study and voluntary consent from the patients and relatives was obtained. Survey questionnaires were administered in Tamil in private rooms that were mutually convenient for the interviewees and interviewers.

No personal identifying information was collected.

Study design

• Comparative study of suicide attempters vs. patients with manifest suicidal ideation.

• Consecutive cases registered for suicide attempt.

• Consecutive cases registered in Psychiatry OPD with manifest suicidal ideation.

Period of study:

• Feb2015toJuly2015.6months.

24 Source of data:

Psychiatry OPD and Indoor admission by patients presenting with suicide attempt.

Data collection:

After obtaining informed consent from patients of suicide attempt attending the Psychiatry OPD, they were interviewed and assessed using various scales. Datawas recorded for this purpose.

For every case of attempted suicide every consecutive patient visiting Psychiatry OPD with manifest suicidal ideation was recruited in the study after obtaining informed consent.

Information is obtained from patient and reliable informant. Socio demographic and other details will be obtained using a questionnaire designed for this study.

INCLUSION CRITERIA FORATTEMPTERS:

1. Participants willing to provide informed consent for the interview and assessment

2. Suicide attempters visiting general hospital with attempt in the past 48 hours

3. Cases visiting psychiatry OPD after suicide attempt in the past 48 hours

4. Age between 18-60

25

INCLUSION CRITERIA FOR IDEATORS:

1. Participants willing to provide informed consent for interview and assessment

2. Cases visiting psychiatry OPD with manifest suicide ideation 3. Age between18-60

EXCLUSION CRITERIA FORATTEMPTERS:

1. Those who did not give consent 2. Age below 18 and above60

EXCLUSION CRITERIA FORIDEATORS:

1. Participants not willing to give consent 2. Age below 18 and above60

3. History of suicide attempt in the past INSTRUMENTSUSED:

A semistructured Proforma withvariables including education, socio- economic status, occupation, age, and gender, precipitating events, family background and method of attempt.

• Diagnosis of psychiatric conditions was made using ICD 10criteria

• Suicide Intent Questionnaire for including patients as having manifest suicidal ideation

• MSSI Modified scale for suicide ideation

• PSLES (Gurmeet Singh) for assessing stressful life events

26

International Classification of Diseases (ICD)⁵⁰

The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes.

This includes the analysis of the general health situation of population groups.

It is used to monitor the incidence and prevalence of diseases and other health problems, proving a picture of the general health situation of countries and populations.

ICD is used by physicians, nurses, other providers, researchers, health information managers and coders, health information technology workers, policy-makers, insurers and patient organizations to classify diseases and other health problems recorded on many types of health and vital records, including death certificates and health records. In addition to enabling the storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States. Finally, ICD is used for reimbursement and resource allocation decision-making by countries.

All Member States use the ICD, which has been translated into 43 languages. Most countries (117) use the system to report mortality data, a primary indicator of health status.

27

SUICIDE INTENT QUESTIONNAIRE- SIQ⁵¹

The SIQ is a ten item questionnaire that was used as a screening tool to include individuals with manifest suicidal ideation in the study. The scale assesses whether or not the individual is communicating the harboured intent to commit suicide not the severity of the ideation. This was also done to ensure patients with suicidal ideation were adequately responsive to be administered the MSSI to assess the severity of suicide ideation. The study included only those individuals scoring more than 5 that was taken as the cut-off for communicators. i.e. these people harboured suicidal ideation and upon query were openly willing to discuss it.

MSSI

In order to provide a valid measure of suicidal ideation, Beck, Kovacs, and Weissman (1979) developed the Scale for Suicidal Ideation (SSI), a 19- item scale designed to be rated by a clinician after a clinical interview⁵². To increase the utility of the SSI, we modified the original scale in several ways, including:

a) addition of several item s assessing other aspects of suicidal thinking not assessed by the SSI;

b) modification of the ratings points to increase their specificity and range;

c) addition of standardized prompt questions for each item and a standardized sequence for the item s, so that the scale could be administered by paraprofessional research assistants;

28

d) development of initial screening items and scores that allow the scale to be administered in a time-effective manner, and (e) selection of items for final inclusion in the scale based on internal consistency and relationship with criterion ratings.

Reliability ⁵³

An internal consistency of 0.87 for N=91 was observed comparable to Miller et al in 1986. A stability estimate of 0.65 with p<0.001 for N=80 was obtained over a two week interval.

A concurrent validity with correlation of 0.74 for N=11 and p<0.0001was found between the interview scores on SSI and the self-report suicide ideation on MSSI.

PSLES

This scale was developed for use in Indian population by Gurmeet Singh et al. It consists of a list of 51 life events that are stressful. The events maybe present over a lifetime and over the past year. There are ten events considered as desirable stressful events such as marriage, pregnancy and ten that are undesirable such as death of spouse or divorce. The rest of the items are ambiguous i.e their perceived stress is the same but they maybe viewed as desirable or undesirable by the patient. The total scoring was accordingly designed to give scores indicating the presence of low, mild to moderate or severe stressors⁵⁴.

29

STATISTICAL ANALYSES

Statistical analysis was done using computerized software(SPSS 22)⁵⁵. Descriptiva statistics like frequencies, percentages, means and standard deviations was computed. Chi square tests for independence, correlation tests and Mann Whitney U test was done for different variables and parameters.

Chapter 5 Chapter 5 Chapter 5 Chapter 5

Results Results Results Results

In a sample of were suicide attempters comparative group, being

Figure 1: Age distribution

The age distribution compared to 38.5% in

70.

26.7

Cases

Age distribution in percentage

30

FINDINGS

of 112 participants, 60 subjects were takes attempters against 52 subjects who were

being individuals with manifest suicidal ideation.

distribution across case and control N=112, control=52

distribution in case was 70% in the age group in the control group.

38.5

26.7

42.3

3.3

19.2

Cases Control

Age distribution in percentage

18-29 30-45 46-60

takes as cases who were chosen as the

ideation.

N=112, cases=60,

group of 18-29 years

19.2

Gender distribution

The above figure and male to female

cases and control respectively.

percentage of 68.3, compared to females.

same having 1.7 percent

30.

Gender distribution in percentage

31 distribution

Figure 2: Gender distribution

figure depicts the gender distribution among TG. Thirty per cent and 61.5 per cent of respectively. The number of male cases is whereas there is a reduction in males ales. Male to female TG case and control are percent and 5.8 percent respectively.

61.5 68.3

32.7

1.7

Case Control

Gender distribution in percentage

Female Male Male to female TG

among females, males of the females are is more, hitting a in control when are more or less the

32.7

5.8

Control

Religion

The above figure control and cases. In

On the other hand, Christian 11.5 in cases.

11.7 11.5

11.7 Contr

ol

Case

Religion in Percentage

32

Figure 3: Religion

figure represents religion. Hindu religion In control, Christians are more when compared

Christian and Muslims are equal by sharing

15.4

11.7 11.5

11.7

71.2

Religion in Percentage

Christian Muslim Hindu

religion is more in both compared toMuslims.

sharing a percentage of

71.2

76.7

Religion in Percentage

33 Marital Status

The following figure shows the marital status of cases and control.

Married individuals among cases are slightly above single with a percentage of 46.7. Separated is very less when compared to married and single. Similarly in control, married is more when compared to single and separated.

Marital Status Case Control

Single 45 26.9

Married 46.7 48.1

Separate 8.3 5.4

Widow / Widower - 1.9

Remarried - 7.7

Table 1 : Marital Status of the Respondents

0.

12.5 25.

37.5 50.

62.5

Single

34

Figure 4: Marital Status

Married Separated widow/widower

Marital Status

widow/widower Remarried

Sexual orientation The following Heterosexual is the

3.3 per cent and bisexual increase in homosexua

0.

22.5 45.

67.5 90.

Sexual Orientation in Percentage

35

following chart provides the information on sexual highest in both cases and control. In case, bisexual is 6.7 per cent, whereas, in control, homosexual when compared to bisexual by 1.9 per

Figure 5: Sexual orientation

Sexual Orientation in Percentage

sexual orientation.

case, homosexual is control, there is an per cent.

Sexual Orientation in Percentage

Homosexual Hetrosexual Bisexual

Family type

Figure

In the chart, Nuclear is more than

0.

1.8 3.5 5.3 7.

Family type in Percentage

36

Figure 6: Family type in cases and control

the two family types; joint and nuclear than joint in case and it is less in control by 2.5

Case Control

Family type in Percentage

control

nuclear are represented.

2.5 per cent.

Joint Nuclear

Patients with and without

The above is per cent among cases

0.

25.

50.

75.

100.

Patients having or not

37 without children

Figure 7: Children

a pictorial representation of patients having cases and 59.6 per cent among the control group.

Patients having or not having Children (in

Percentage)

Nil Yes

having children: 43.3 group.

Patients having or not

Socioeconomic Status

Figure

The chart explains As far as case is concerned middle. On the other

middle.

0.

25.

50.

75.

100.

38 Status

8: Socioeconomic Status of the participants

explains the social economic status among concerned 75 percent is in the lower and 25 other hand, among control 76.9 per cent lower

75.

25.

SES (in Percentage)

Lower Middle

participants

case and control.

25 per cent in the lower and 23.1 percent

76.9 23.1

SES (in Percentage)

39 Family history of alcohol dependence

Figure 9: Family history of alcohol dependence

The family history of alcohol dependency is explained in the above chart in which 43.3 per cent among case and 36.5 among control percent show a history of alcohol dependence.

56.7 63.5

43.3 36.5

Case Control

F/H/O alcohol dependence (in Percentage)

Nil Yes

Family history of mental

Figure 10:

The bar chart cent is among case and

0.

Control

Case

F/H/O mental illness (in Percentage)

40 mental illness

10: Family history of mental illness in Percentage represents family history of mental illness

and 19.2 per cent is among control.

22.5 45. 67.5

F/H/O mental illness (in Percentage)

Percentage

illness in which 10 per

90.

Yes Nil

Family history of suicide

The above chart shows 15 per cent among

0.

25.

50.

75.

100.

Case

F/H/O suicide

41 suicide

Figure 11: Family history of suicide

chart represents the family history of suicide.

among cases and 7.7 per cent among control.

Case Control

F/H/O suicide

suicide. The chart control.

Nil Yes

42 Substance use in patients

Substance Use Case Control

No 53.3 86.5

Alcohol 10 7.7

Smoking 5 -

More than one 31.7 3

Table 2 : Substance Use in Patients

The table depicts the substance use in patients. Both, in cases and control, more number of patients do not consume any substance. The intake of alcohol and smoking is 10 per cent and five per cent respectively. 31.7 per cent consume more than one substance. Conversely, in control 7.7 per cent drink alcohol and 3 per cent consume more than one substance i.e. drinking along with smoking or oral tobacco use.

0.

22.5 45.

67.5 90.

112.5

Case

Substance use in patient (in percentage)

43

Figure 12: Substance use in patients

Case Control

Substance use in patient (in percentage)

No Alcohol Smoking More than one

Previous history of

Figure

The chart represents a huge difference in attempting suicide had

0.

15.

30.

45.

60.

Nil

Previous h/o attempt in percentage

44 attempt in cases

Figure 13: Previous history of attempt in cases

represents previous history of attempts. Among in the number of attempts 1 and 2-3. Most had a history of at least one previous attempt

1 2-3.

Previous h/o attempt in percentage

cases

Among cases, there is Most of the patients attempt.

Case

45 Method of suicide attempt

Figure 14: Method of suicide attempt

The pie chart illustrates the current method of attempts of cases. Rat killer intake is the highest with 30 per cent. Overdose is the second highest followed by hanging and organophosphate. 6.7 per cent follow kerosene intake.

Conversely cutting/slashing and acid intake share an equal weightage of 5 per cent.

20%

12%

18%

5%

7%

30%

5% 3%

Current Method of Attempt

Overdose

Organophosphate Hanging

Cutting/Slashing Kerosene intake Rat killer intake Acid intake

Other means/ unknow

46 Intoxication at the time of attempt

Figure 15: Intoxication at time of attempt

The chart illustrates the intoxication at time of attempt of the cases. 38.3 per cent of cases were intoxicated at the time of attempt.

Nil 62%

Yes 38%

Intoxication at time of attempt of

cases

Chronic illness in patients

Figure Patients with Malignancies , Coronary having a long term

Chronic illness is predominant chronic illness.

0.

22.5 45.

67.5 90.

112.5

Chronic illness in patients (in percentage)

47 patients

Figure 16: Chronic illness in patients chronic illnesses like Diabetes Mellitus, Coronary artery disease etc for more than a year

illness. The chart represents chronic illness predominant in controls with 28.8 % having

Case Control

Chronic illness in patients (in percentage)

Mellitus, Hypertension, year were coded as illness in patients.

having a history of

None Yes

Psychiatric diagnosis

The chart represents case is 28.3 per cent and personality disorder less among case. Conversely, schizophrenia are less

0.

17.5 35.

52.5 70.

Case

Psychiatric diagnosis

48 diagnosis

Figure 17: Psychiatric diagnosis

represents the psychiatric diagnosis. Rate of depression and control is 61.5 percent. Substance use

disorder is 16.7 per cent. Anxiety and schizophrenia Conversely, substance use, personality disorder, less among control when compared to depression.

Case Control

Psychiatric diagnosis (in percentage)

Nil

Depression Substance use Personality disorder Anxiety

Schizophrenia

depression among use is 21.7 per cent schizophrenia are very disorder, anxiety and depression.

Depression Substance use Personality disorder Anxiety

Schizophrenia

49 Presumptive Stressful Life Events Scale

Stress Score Case Control

Low 3.3 -

Moderate 50 34.5

Severe 46.7 65.4

Table 3 : Presumptive Stressful Life Events Scale

The above tablet provides PSLES results. The moderate stress is high in both control and case. Severe stress is 46.7 and 65.4 per cent among case and control respectively. Among cases only 3.3 per cent is with low stress.

0%

25%

50%

75%

100%

Case

PSLES (in percentage)

50

Figure 18: PSLES

Case Control

PSLES (in percentage)

Severe

Moderate stress Low stress

51

Desirable/Undesirable/Ambiguous Stress Factors

Type of Stressful Factors

Case Control

Ambiguous 36.7 32.7

Desirable > Undesirable 8.3 -

Undesirable > Desirable 55 67.3

Table 4 : Desirable/Undesirable/Ambiguous

The table provides the information on ambiguous, desirable and undesirable stressful life events. Most of the patients had undesirable stressful events more than desirable events at 55%. Cases also had high stress scores only with ambiguous events predominating with 36.7% as opposed to only 32.7 % in controls.

52

Figure 19: Desirable/Undesirable/Ambiguous

0.

17.5 35.

52.5 70.

87.5

Case Control

D/U/A in Percentage

Ambiguous

Desirable>Undesirable

Modified Scale for Suicidal

The bar chart controls is more or Severe intent is seen moderate intent is the intent are at 23.1 and

0.

Severe

Mild-moderate

Low

MSSI (in percentage)

53 Suicidal Ideation

Figure 20: MSSI results

chart shows the MSSI results. Severe intent less the same with a minor difference seen in 28.3 per cent in cases. On the other

the highest among control at 50 per cent. The and 26.9 per cent respectively in the attempters.

12.5 25. 37.5 50. 62.5

MSSI (in percentage)

intent in cases and difference of 1.7 per cent.

other hand, mild- The low and severe attempters.

62.5

Control Case

54 Alcohol Dependence

Diagnosis Case Control

Yes 33.3 9.6

No 66.7 90.4

Table 5 : Alcohol dependence

The table depicts alcohol dependency. Among case, 33.3 per cent are alcohol dependent and 9.6 per cent among control. (t-test)