PSYCHOSOCIAL FACTORS INVOLVED IN FIRST ATTEMPT SUICIDE OF YOUNG ADULTS
Dissertation submitted to
The Tamilnadu Dr MGR Medical University, Chennai 600 032 in part fulfillment for
MD in PSYCHIATRY
Department of Psychiatry Tirunelveli Medical College
Tirunelveli 627011
APRIL 2011
CERTIFICATE
This is to certify that this work titled “Psychosocial factors
involved in first attempt suicide of young adults” submitted by Dr. G. Anbazhagan, as a thesis in part fulfillment of the requirements
for the M.D degree in Psychiatry of The Tamilnadu Dr. M.G.R Medical University, has not previously formed the basis for award of any other degree or diploma to the candidate. This work is a record of the candidate’s personal effort. The study was conducted between August 2009 & February 2010.
Professor&Head DEAN Department of Psychiatry Tirunelveli Medical College Tirunelveli Medical College Tirunelveli 627 011
DECLARATION
I, Dr. G.Anbazhagan, solemnly declare that dissertation titled
“Psychosocial factors involved in first attempt suicide of young adults”
is a bonafide work done by me at Tirunelveli Medical College, Tirunelveli, during the period from August 2009 to February 2010 under the guidance and supervision of Dr. C.Ramasubramanian, M.D.D.P.M, Professor of Psychiatry, Tirunelveli Medical College.
This dissertation is submitted to The Tamilnadu Dr. M.G.R Medical University, towards part fulfillment for M.D. Branch – XVIII Psychiatry part- III examination.
Place: Tirunelveli-11
Date: Dr. G.Anbazhagan
ACKNOWLEDGEMENT
I sincerely thank Dr.N.Palaniappan M.D, Dean, Tirunelveli Medical College for permitting me to do this study.
I sincerely thank Prof. Dr.C.Ramasubramanian M.D., D.P.M., department of psychiatry for his guidance and supervision in this study.
I am thankful to Assistant Professor. Dr.A.Shanmugiah M.D.,D.P.M., department of psychiatry for his immense guidance and help throughout this study.
I extend my gratitude to Assistant Professor Dr.G.Ramanujam M.D, who has been a source of inspiration and motivation and for his guidance and help.
I thank Dr.R.Rajaraman Msc,M.Phil,Phd, Assistant Professor cum Clinical Psychologist, who has guided me in completing this dissertation.
I record here my appreciation of the trust and co operation rendered by my patients and their families, by consenting to participate in this study.
I would like to thank Dr.Pethuru M.D., S.P.M for his assistance and supervision in the statistical analysis.
I am grateful to my family members for their kind help and encouragement right from the beginning of the study.
CONTENTS
Chapter Page no
1. Introduction 1
2. Review Of Literature 3
3. Aim Of the Study 25
4. Materials and Methods 26
5. Results 34
6. Discussion 52
7. Summary and Conclusions 59
8. Limitations 61
9. References 62
10. Appendices 66
1
INTRODUCTION
Suicide is the conscious act of self induced annihilation. It is conceptualized as a continuum ranging from suicidal ideation and communication to suicide attempts and completed suicide. It is a complex phenomenon associated with psychological, biological and social factors.
Currently, suicide is considered as one of the leading causes of death worldwide. International data from the World Health Organization indicate that suicide occurs in approximately 16.7 per 100,000 persons per year, and accounts for 1.5 percent of all deaths. The suicide rate among young adults has been rising and they are currently the group at high risk in developed and developing countries. In particular, countries in transition, such as Asia are showing an alarming rise in youth suicide.
According to the estimation done by WHO in the year 2000, India &
China are responsible for 30 percent of suicide committed worldwide.
India ranks second next to China in the total number of suicides and ranks forty five in suicide rate.
A large proportion of suicides 41 percent are committed by young adults in the age group of 15-29 years. Youngsters below the age of 14 are responsible for 3.6 percent of all suicides which leaves 90 percent of
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the suicide committed by persons between 15 – 59 years. This figure refers to only successful suicides.
In contrast, attempted suicide is 8 to 10 times higher than the number of successful suicides (Frierson R L, Melikian M, Wadman PC).
The suicide risk among persons who attempted suicide is forty times higher than in the general population (Harris EC, Barraclough B) and the risk persist for many years. Similar to suicide, attempted suicide is much more likely to occur in the 15-34 age groups. The reason being, various biological changes take place within their body system, development of one’s personality and the psychosocial stressor events they undergo like change of school, entry into a college, marriage, unemployment, job related stresses etc.
With this background, it was intended to study the socio demographic, psychosocial and personality factors that were associated with young adults who attempted suicide for the first time in their life, because it provides a measure of the mental health status in the population studied and allow recognition of specific groups or communities in greater need of mental health services.
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REVIEW OF LITERATURE
Definitions
Suicidal thoughts or ideation:
The suicidal ideation or thought refers to the occurrence of any thoughts about self destructive behavior, whether or not death is intended (WHO, 1986). Such thoughts may range from vague ideas about the possibility of ending one’s life at some point of time in the future to very concrete plans of committing suicide.
Attempted suicide:
Attempted suicide was viewed as a conscious or subconscious act of communication addressed to others (Stengel, 1975). It can be conceived of as an alarm signal, showing distress and appealing for help.
It is defined as, “an act with a non-fatal outcome in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause self-harm, or deliberately ingest a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired, via the actual or expected physical consequences”.
4 Suicide
Under the sociological perspective, Durkheim considered suicide as “all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result” (Durkheim, 1897).
From the psychological perspective, Shneidman defined suicide as
"a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who define an issue for which suicide is perceived as the best solution” (Shneidman, 1985).
The adopted definition of suicide from the WHO is as follows:
“ Suicide is an act with a fatal outcome which the deceased, knowing or expecting a fatal outcome, had initiated and carried out with the purpose of provoking the changes he desired” (WHO/EURO,1986).
Suicidal process
Any suicidal act is preceded by a process that might start with fleeting suicidal thoughts, then progresses through more concrete plans to subsequent suicide attempts and finally to completed suicide (Van Heeringen, 2001). The development of the suicidal process depends upon an interaction between environmental factors and diathesis. The suicidal
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process is affected by numerous factors on an individual, interpersonal and societal level. It also depends on culture and physical environments.
(Wasserman, 2001) The suicidal process can be interrupted due to treatment but it may also abate spontaneously.
Suicide intent
According to Aaron T Beck, suicidal intent is defined as the seriousness or intensity of the patient's wish to terminate his or her life.
Although a minimal association was found between the degree of suicide intent and the degree of lethality of the attempt, the accuracy of expectations about the likelihood of dying was found to moderate the relationship between suicide intent and lethality. Specifically, higher levels of suicide intent were associated with more lethal attempts but only for those individuals who had more accurate expectations about the likelihood of dying from their attempts.
Suicidal communication
Suicidal communication can occur at any point in the suicidal process. The manner in which other people respond to a person’s suicidal communication may afford some protection against suicidal behavior (Farberow and Shneidman, 1961). According to Shneidman, the directness of communication in a self-destructive situation may range
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from no communication to quite direct communication. Shneidman notes that it is very unusual for a person to give no indication of his intention to kill him or herself. At times, intense feelings of conflict or desperation may be expressed, and this behavior indicates a plea for help. At other times, feelings of hopelessness and helplessness may appear. Sometimes a suicide note explains the action. At times the content of suicidal communication includes pessimistic reflections on the state of the world and philosophic ideas about the meaning of life in general. The content of communication varies depending on each individual. Sometimes the communication is very explicit and sometimes it is more subtle (Farberow and Shneidman, 1961).
Types of suicidal communication
Suicidal communication can be divided into direct and indirect verbal, direct and indirect non-verbal communication. Direct verbal suicidal communication refers to clear and directly expressed suicidal intentions. This form of expression is found among those whose intention is to take their own lives. Indirect verbal suicidal communication is the expression, in various ways, of the feeling that one's situation is hopeless, that life has no meaning and that there is no solution to current problems.
Direct non-verbal suicidal communication includes various kinds of preparations for suicide. Examples of direct non-verbal suicidal
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communication may be the collection of drug prescriptions or medicines, buying insecticides, writing a farewell letter etc. Indirect non-verbal suicidal communication comprises withdrawal, deliberate self-isolation, rupturing ties with family and friends, or taking concrete steps to put personal affairs in order (Wasserman, 2001.).
The construct of hopelessness
Hopelessness has emerged as a powerful cognitive variable connecting depression and suicidal behavior. Early empirical studies revealed a significant association between hopelessness and degree of suicide intent in suicide attempters (Beck, Kovacs, & Weissman, 1975).
Hopelessness is usually defined as negative expectancies about the future and has been proposed as central in the understanding and prediction of suicidal behavior. According to Beck’s formulation, hopelessness is a cognitive factor characterized by pervasive negative expectancies which is believed to be among the core features of depression. Thus, the cognitive set of the depressed individual is characterized by a negative self-concept and a pervasive pessimistic view of the world and the future.
This negativist way of thinking is believed to contribute to the individual’s conclusion that life is not worth living, that it is hopeless trying, and that suicide may become an acceptable or an appropriate solution for his/her problems.
8 Theories of Suicide
In the last two decades, the volume of international research into suicide has increased exponentially (Maris et al., 2000). Much of this research has been developed in an empirical framework in which investigators have examined the role of likely causes and risk factors for suicidal behavior. The explanatory models of suicide developed over the past century may be broadly classified as socio-cultural and psychoanalytic theories.
Socio-cultural approach: Although accounts of suicide date from Greek and Roman times, the most well-known contemporary approach to the study of suicide began little more than a century ago with the publication of Durkheim’s Le Suicide (1987). Durkheim was the pioneer of socio-cultural study in suicide and associated suicide with a person’s involvement and identity in the social network. Durkheim attempted to explain suicide rates in terms of social conditions, and argued that the incidence of suicide varies with the extent of social integration within a given society. In his theory, an individual’s relationship with society is conceptualized by two dimensions, namely social integration and social regulation. High suicide rates result when integration or regulation is too high or too low. It gives rise to his four types of suicide: when social integration is too high, altruistic suicides arises; when it is too low,
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egoistic suicides are the results. When social regulation is too strong, fatalistic suicides take place; when it is too weak, anomic suicides are common (Durkheim, 1897/1951).
Psychoanalytic approach: Psychoanalytic theories of suicide were developed in the last part of the 19th century and first half of the 20th century. These theories argue that suicidal behavior arises from individual and intra psychic sources that are essentially invulnerable to social forces.
Freud explained that since men ambivalently identify with the objects of their own love, when they are frustrated, the aggressive side of the ambivalence would be directed against the internalized person. The main psychoanalytical position on suicide is that it represents unconscious hostility directed toward the introjected love object (Freud, 1917/1963).
Menninger expanded the Freudian model of suicide in his book Man against Himself (1938), and proposed that all suicide involve fundamental dimensions: hate, depression, and guilt. He suggested that suicide involves (1) a wish to kill - murder, (2) a wish to be killed - a murder by the self, and (3) the wish-to-die. Later on, Litman (1989) extended Freud’s theory and suggested that suicide may be caused by other intra psychic factors besides hostility, includes rage, guilt, anxiety, dependency, helplessness and hopelessness.
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Psychological approach: The psychological approach emphasizes suicide as an act driven by the psychological needs of an individual, but the psychological approach has taken into account of other perspectives onto one’s psychological make-up (Maris, 1981).
Shneidman (1996) explained that “the essential nature of suicide is psychological… Suicide is caused by a pain, a certain kind of pain – psychological pain (psychache)”; he also stated that suicide is a “multi- faceted event and that biological, cultural, sociological, interpersonal, intra psychic, logical, conscious, unconscious, and philosophical elements are present, in various degrees, in each suicidal event” (Shneidman, 1996). The psychological approach views suicide as a multi-disciplinary issue, but with an emphasis that suicide is a fatal outcome of one’s psychological pain.
Biochemical approach: The biochemical approach suggests a biological basis for the problem. Autopsy studies and neurobiological studies reported consistent findings of correlation between serotonergic system abnormalities and suicide. Studies in completed suicides reported impairments in serotonin receptors in the brainstem and frontal cortex (Mann et al., 1999) and abnormally low serotonergic activities in the ventral prefrontal cortex (Traskamn-Bendz & Mann, 2000). Such
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impairments may have caused problems in self-control and behavioral inhibition, which would indirectly cause vulnerability to suicide when faced with stressful events. There is growing evidence from twin studies to suggest the genetic heritability of suicidal behavior.
The Stress-Vulnerability Model
In the stress-vulnerability model, the outcome is affected by risk and protective factors in interaction with diathesis. A diathesis for suicidal behavior is held to be the crucial determinant of whether suicidality is manifested under the influence of stress as result of, for example, acute psychiatric or social problems, or a family crisis. From this perspective, individuals at risk for suicide are hypothesized to have various bio-psycho-social vulnerabilities which render them unprepared or ill equipped to handle environmental and social demands or psychological problems. According to Mann et al, genetic make-up as well as acquired susceptibility contributes to a person’s constitutional predisposition for suicidality or diathesis.
Risk Factors
Suicide is rarely the response to a single stress. Instead it is the outcome of a culmination of stressors and adverse life course sequences in a person with few protective factors to draw upon and whose resilience
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may be compromised. The risk factors and the possible cause(s) of suicide or suicidal behavior are usually interwoven and complex.
Regardless, there is a wealth of knowledge and research that attempts to explore the factors that appear to be related to suicide. The following is a summary pattern of suicide.
Gender
More males complete suicide than females by a ratio of approximately 3:1 (Blumenthal, 1990). Males tend to use methods that are more lethal such as hanging and shooting. Females are far more likely to attempt suicide than males, by a ratio of approximately 15:1.
Adolescence and Young Adults
Suicides by those under age 11 are rare. Suicide rates start to increase in adolescence, and continue to rise up to and including the 24- 35 year age group. Suicide is the second leading cause of death among 15-24 year olds. Suicides among the youth and young adult age group have increased over the last forty years, while the overall rate has remained relatively steady (Allebeck et al. 1996). Onset of mental illness and the stressors related to the transition from adolescence to adulthood have been identified as possible factors contributing to youth suicide (Beautrais et al. 1996; Tousignant et al. 1993).
13 Late Middle-aged and Elderly Persons
Suicide rates decrease until approximately age 60-64 years. After that it tends to demonstrate a slight increase. Suicides among older age groups can be expected to rise given that they constitute the fastest growing segment of the population (De Leo et al, 1999). Some factors attributed to high rates of suicides among the elderly are poor health and chronic pain, unemployment, depression, isolation and loss. Losses inherent to mid and older adult life have been identified as one of the most serious risk factors for suicidal behavior in adults. Losses may include marital breakups, death, retirement, loss of autonomy and physical disability (De Leo et al, 1999). Psychological autopsy reports show a gross under-treatment of mental illness in older people who died by suicide. This would strongly suggest that early identification and treatment of mental illness could prevent many suicides in older adults (Duckworth and McBride, 1996).
Marital status
Marriage acts as a protective factor against suicide. Reported rates of suicide among the various categories revealed that among married people the suicide rate is 11/100 000. Marriage appears to be reinforced by having children and the marriage has to be stable. Rates of suicide
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were highest among divorced men (69/100 000) and those who are widowed (40/100 000).
Occupation
Social status predisposes to a greater risk of suicide. Gainful employment generally protects against suicide. Suicide is higher among the unemployed. The suicide rate increases during economic recessions and times of high unemployment, and decreases during times of high employment.
Family Background
Increased risk of suicidal behavior has been identified among those whose background was characterized by dysfunction, and adverse familial conditions such as divorce and family discord, physical and sexual abuse, poverty, and parental violence. The determining factor for the impact of these conditions appeared to be related to length and intensity of the circumstances (Beautrais, 1998). Individuals who have family histories of attempted or completed suicide are themselves at higher risk of suicidal behavior.
15 Habitat
In some countries suicides are more frequent in urban areas, whereas in others they occur more frequently in rural areas.
Socio-economic status and employment
Epidemiological studies consistently show a link between suicide and social disadvantage including low socio-economic status, limited educational achievement and homelessness (Beautrais, 1998).
Physical Illness
Physical illness has been identified in several studies as a contributing factor in suicide, attempted suicide and suicidal thinking through the life span but particularly among older adults. Suicide risk increases where physical illness is accompanied by mental disorder, chronic pain and harmful drug or alcohol use (De Leo et al, 1999).
Mental Health Factors
It has been estimated that mental disorder is associated with an 11- fold increase in the risk of suicide (Harris & Barraclough 1997).
International studies suggest that up to 41% of people who die by suicide have been discharged from psychiatric in-patient settings within the
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preceding 12 months. Up to 9% were in-patients at the time of their death or died on the day of discharge from hospital (Pirkis and Burgess 1998).
Affective Disorders
Individuals with affective disorders are 23 times more likely to display suicidal behavior than those without such a disorder. (Beautrais, 1996). Rates of depression are reported to be as high as 70% among individuals who have completed suicide. 15% of adolescents diagnosed with major depressive disorder, and 10 to 15% of adolescents diagnosed with bipolar disorder, die by suicide (Stoelb & Chiriboga 1998).
Schizophrenia
Suicide is the major cause of death among individuals with schizophrenia, with as many as 1 out of 4 persons with schizophrenia dying from suicide (Conwell, 1998). Individuals with schizophrenia who commit suicide tend to do so during times when symptoms of psychosis are not acute or during remission (Roy 1986). An unrecognized affective disorder is strongly correlated with suicide in people with schizophrenia.
Personality Disorders
An estimated 6.5% of individuals with borderline personality disorder and 5% of those with antisocial personality disorder commit
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suicide. Certain personality traits have been identified as important correlates of increased risk of suicide including obsessive-compulsive traits, perfectionism, and cognitive rigidity (Beck et, al 1985). Individual personality factors cannot be considered alone but must be evaluated within the context of other risk factors. A ten-year longitudinal study concluded that measurement of an individual’s hopelessness is a strong predictor for future suicidal behaviors (Beck et al, 1985). Other personality characteristics that are associated with suicidal behaviors are high levels of anxiety, low self-esteem, high impulsivity, poor problem- solving skills and irrationality (Lester, 1992).
Impulsivity
Impulsivity has been defined as “a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to themselves or others”
(Moeller, Barratt, Dougherty, Schmitz, & Swann, 2001;). Studies estimate that approximately 50% of suicides and nonfatal violent attempts are considered impulsive (Simon et al., 2001). Impulsivity has been found to differentiate past attempters from those with no history of previous attempt and suicidal from non-suicidal inpatients with the same psychiatric diagnosis (Corruble, Damy, & Guelfi, 1999; Horesh et al., 1997). Substance use disorders Impulsivity is a correlate of substance use
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disorders (Moeller et al., 2001). People who use multiple substances appear to be more impulsive than those who are dependent on single substances (Logue, 1995). When intoxicated with substances, people tend to experience short-term increases in impulsivity (Moeller et al., 2001).
Impulsivity, however, remained elevated among substance-using participants after controlling for current substance use, suggesting that there is a trait component to impulsivity (Tcheremissine, Lane, Cherek, &
Pietras, 2003). Taken together, evidence supports that impulsivity increases the risk for substance use-related disorders, and that during periods of intoxication, underlying problems of impulsivity are magnified. It has been shown that comorbid substance use disorders elevate the risk for suicide attempt among people with anxiety disorders, psychotic disorders (Dervaux et al., 2001; Gut-Fayand et al., 2001), panic disorder (Friedman, Jones, Chernen, & Barlow, 1992; Friedman, Smith,
& Fogel, 1999), bipolar disorder (Swann, Dougherty, Pazzaglia, Pham, &
Moeller, 2004), and borderline personality disorder (Yen et al., 2004).
Self-harm and medical history
There is a strong association between suicide and self-harm.
Approximately half of suicides have a history of self-harm (Foster et al., 1997) and this proportion increases to two thirds in younger age groups (Appleby, Cooper, et al., 1999).
19 Adverse life events
Adverse life events such as interpersonal loss or conflict, financial difficulty or serious physical illness can serve as important precipitants of suicide. In a study of young people, those who died by suicide had more interpersonal and life events relating to criminal behavior than living age- and sex-matched control subjects (Cooper et al., 2002). Cavanagh and colleagues (1999) matched case and control subjects on age, sex and diagnosis and found greater interpersonal family adversity as well as greater physical ill health in those who completed suicide.
Historically, there have been two models that have been used widely to describe the cause of suicide, the Stress Model and the Mental Health Model.
The Stress Model suggests that suicide is the result of a situation(s) that the person finds unmanageable. The model supports the theory that all individuals are equally at risk of suicide, regardless of their mental health background (Garland et al 1989).
The Mental Health Model focuses on the evidence that links mental health disorders to suicide and identifies the risk of suicide being largely confined to people who experience mental illness. Proponents of the
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Mental Health Model believe that suicide prevention efforts should be focused upon high-risk groups or individuals who are experiencing mental illness and increasing the availability of mental health services.
The current thinking and research view suicide as an outcome of complex interactions among neurobiological, genetic, psychological, social, cultural and environmental risk and protective factors. No one factor can be attributed in isolation to the outcome of suicide. In an attempt to understand the complex relationship between these factors a number of models of suicide causation have been developed.
Coping skills
Lazarus (1974) defined coping as an effort to manage and overcome demands and critical events that post a challenge, threat, harm, loss, or benefit to a person. Coping generally refers to an individual’s ability to adapt to adverse circumstances. Coping strategies are generally referred to as ‘positive’ or ‘negative.’ Positive coping reduces anxiety associated with a situation and does not harm the individual. These strategies also improve situations into the future, rather than simply provide a quick-fix solution. Negative coping strategies do not solve problems, they are temporary, and they may cause harm to the individual or others. Stress and coping are also related to affect, or emotion. Lazarus
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(1999) maintains that emotion is also affected by cognitive appraisal of events and positive emotions can occur even under dire circumstances (Folkman & Moskowitz, 2000). Further, positive emotions have been shown to be important facilitators to adaptive coping styles and adjustment to various types of stressors (Folkman, 1997).
Protective Factors
Protective factors are those dynamics that lessen, compensate or protect individuals from exposure and impact to risk factors. Research into protective factors, well-being, optimism, connectedness and resilience as related to suicide is limited. The following are some of the factors that have been suggested as protecting against suicide:
• Good problem solving skills
• Help seeking behaviors
• Family and community social support (e.g. marriage)
• Connectedness (e.g. to family, peer group, school or community)
• Secure social identity
• Cultural, religious and personal beliefs that discourage suicidal behavior
• Skills in managing conflicts and dispues
22 Suicide epidemiology in India
Studies of suicide in India have focused primarily on epidemiology, reporting suicide rates and variations within India (Kim &
Singh, 2004; Lester, 2000; Lester, Agarwal & Natrajan, 1999). Official suicide statistics in India are collected by the National Crime Records Bureau, an organization that maintains databases for crimes, and accidental and suicide deaths. Since suicide attempts constitute punishable offences under Section 309 of the Indian Penal Code, 1860 (http://indiacode.nic.in/), suicide cases are reported to the police. This data is published in an annual report, Accidental Deaths and Suicide in India (http://ncrb.nic.in/ADSI2008/home.htm). Given the highly variegated cultural landscape of India, it is not surprising that official data shows great disparities in suicide rates across the country. There are immense variations in beliefs, customs, practices, and attitudes that transcend language and geographical differences. In addition, since Indian society is highly stratified based on economic status, caste, religion and sectarian affiliation, responses to social conditions vary widely across these strata.
According to the National Crime Records Bureau, the suicide rate in India in 2008 was 10.8 per 100,000, which is the same as in previous year. State-wise comparisons show large differences, ranging from 48.2
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in Sikkim to 1.1 in Bihar. The number of suicides reported has increased by 19.4% from 1998 to 2008. The overall female to male ratio was 1.7:1 as compared to 1.8:1 in the year 2007, but among children under 14 years, the ratio was 1:1.04; almost equal numbers of males and females in this age group had committed suicide. Around 35.7% suicide victims were youths in the age group of 15-29 years and 34.8% were middle aged persons in the age group 30-44 years.
The commonest methods for suicide were self poisoning (34.8%) or hanging (32.2%). The most commonly reported causes among males were social and economic while causes for females were more personal and emotional in nature. For about 41.9% of suicides causes were either unknown or listed as “Other”. Family problems were cited as the most common known cause attributing to 23.8% of total suicides. More than 70% of suicide victims were married, more than 40% were educated only up to high school, more than 40% were self employed, and about 20%
were housewives. South India reported higher numbers of suicides.
Although the suicide database shows a low suicide rate compared to other Asian nations such as China and Sri Lanka, these figures may be conservative estimates. (Joseph, Abraham, Muliyil, George, Prasad, et al., 2003). Official suicide mortality and morbidity statistics are unreliable since families often under-report, conceal or attribute suicidal behaviors
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to accidental causes to avoid entanglement in legal issues or escape the consequent stigma and shame (Vijayakumar, 2007). The actual number of suicides and suicide attempts is undoubtedly greater in developing countries like India (Joseph et al., 2003; Ruzicka, 1998).
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AIM OF THE STUDY
1. To assess the socio demographic, psychosocial & personality risk factors in young adults between the age group of 17 and 40, who attempted suicide for the first time in their life.
2. To assess the degree of suicidal intent, the stressful life events they were under and their coping skills to overcome such stressor events.
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MATERIALS AND METHODS
The study was conducted in the Department of Psychiatry at Tirunelveli Medical College Hospital. This hospital is a tertiary care referral center for the urban and rural population of Tirunelveli. 30 patients in the age group between 17 and 40 referred from medical and surgical wards of this general hospital, with history of first attempt suicide were taken up for the study. Patients were recruited for assessment once their general condition was improved. During recruitment, patients fulfilling the inclusion & exclusion criteria were selected after getting informed consent from them. Approximately 90 – 120 minutes were spent for each patient to administer all the instruments.
Study Design:
It is a cross sectional study using the descriptive statistics both qualitative and quantitative analysis of data.
The sampling method used was stratified random sampling.
Inclusion criteria:
1. Individuals with 17 to 40 years of age.
2. Both genders.
3. Individuals who attempted suicide for the first time.
27 Exclusion criteria:
1. History of previous suicide attempt.
2. Independent psychiatric disorder.
3. Family history of major psychiatric disorder.
4. Substance abuse or dependence.
5. General medical and neurological diseases.
Instruments used:
1. Semi-structured socio-demographic pro forma 2. Scales
i) ICD-10 International Personality Disorder Examination
ii) Beck’s Suicide Intent Scale iii) Holmes and Rahe’s Stress scale iv) Brief Cope Inventory
v) Kuppuswami`s SES classification (modified)
Semi-structured socio-demographic pro forma
The pro forma used with socio demographic variables was prepared at Department of Psychiatry, Tirunelveli Medical College. The first part of the pro forma carried information regarding name, age, sex,
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religion, domicile, socio economic status, literacy level, employment status, family type, marital status etc. The second part consisted of details regarding the suicide attempt such as number of attempts, mode & place of attempt, presence or absence of suicide note etc.
The International Personality Disorder Examination (IPDE):
The International Personality Disorder Examination is a multidimensional psychometric trait instrument intended for the clinical diagnostic assessment of personality disorders (apparent for at least five years) in adults. An extension and refinement of the Personality Disorder Examination (Loranger, 1988), the IPDE comprises both a pencil-and- paper self-report Screening Questionnaire, and a separate semi-structured diagnostic Interview rated by the psychiatric or clinical psychological examiner. Both sections of the IPDE are based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) and the International Statistical Classification of Diseases and Health Related Problems, 10th Revision (ICD-10; World Health Organization, 1993) classification systems. The Screening Questionnaire test booklet comprises 77 True/False self-report items, while the DSM-IV and ICD-10 Interview modules comprise 99 items and 67 items, respectively.
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For the IPDE Interview, each item is scored on a 3-point scale (0, 1 or 2), along with a "?" category for when the patient is unable to respond with certainty. Seven of the DSM-IV based items and for 10 of the ICD-10 related items also include a not applicable (NA) category. For each classification system module, the IPDE Scoring Booklet allows for a definite, probable, or negative diagnosis with respect to each personality disorder, along with recording of the number of diagnostic criteria met and a continuous dimensional score (since personality traits are distributed in the population at large, and it is assumed that personality disorders represent the exaggerated extremes of such traits). The IPDE Interview purports to measure 11 DSM-IV classified personality disorders labeled: Paranoid, Schizoid, Schizotypal, Antisocial, Borderline, Histrionic, Narcissistic, Avoidant, Dependent, Obsessive- Compulsive and Not Otherwise Specified. The ICD-10 personality disorders purported to be measured include: Paranoid, Schizoid, Dissocial, Emotionally Unstable (Impulsive Type), Emotionally Unstable (Borderline Type), Histrionic, Anankastic, Anxious (Avoidant), Dependent, and Unspecified. Use of the Screening Questionnaire alone does not allow clinical diagnosis. However, it can be used to exclude patients who do not exhibit any personality disorders, or any specific personality disorder. Here in this study, the IPDE interview module was used.
30 Beck Scale for Suicidal Ideation (BSI)
The Beck Scale for Suicidal Ideation (BSI; Beck and Steer, 1991) is a self-report measure based on the semi-structured interview, the Scale for Suicidal Ideation or SSI (Beck et al., 1979). The SSI was developed for use with adult psychiatric patients. Steer and Beck (1988) suggest that the SSI is appropriate for research with adolescents as well, although very few studies of adolescents have used the SSI (e.g., Kashani et. al., 1991).
The BSI is an easy-to-administer 21-item self-report questionnaire (only 19 of the items are scored) that has promise for greater use with adolescents than the SSI (Beck and Steer, 1991). The authors of the BSI suggest that the instrument is best used to detect and measure severity of suicidal ideation, which is considered to be an indication for suicide risk (Beck and Steer, 1991).
Holmes and Rahe Stress scale:
The scale was developed by the psychologists T.J. Holmes and R.
Rahe, who found that a number of serious physical disorders, such as myocardial infarction, peptic ulcer, and infections, and a variety of psychiatric disorders were associated with an accumulation of 200 or more points on the rating scale within a period of 1 year. It is a scale of 43 common events associated with some degree of disruption of an individual's life. Most disruptive on one's life, according to them was the
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death of a spouse, which warranted 100 points. The lowest rated event was a minor law violation, rated at 11 points.
Brief Cope Inventory:
The Brief COPE is a self-completed questionnaire measuring coping strategies. It is the abridged version of the COPE inventory and presents fourteen scales all assessing different coping dimensions: 1) active coping, 2) planning, 3) using instrumental support, 4) using emotional support, 5) venting, 6) behavioral disengagement, 7) self- distraction, 8) self-blame, 9) positive reframing, 10) humor, 11) denial, 12) acceptance, 13) religion, and 14) substance use. Each scale contains two items (28 altogether). Three composite subscales measuring emotion- focused, problem-focused, and dysfunctional coping have proved useful in clinical research and have content validity. Internal consistency alphas for the scales provided for in the Brief COPE ranged from .52 to .90 (Carver, 1997), which were considered to be acceptable internal reliabilities as supported by the data. The researcher found difficulties to analyze the 14 types of coping styles that generated from the Brief COPE.
In order to provide better understanding between coping and other psychological phenomena, a principal component analysis was conducted so that some of the conceptually similar subscales can be treated as one factor. This analysis resulted in the four broader subscales: (a) problem-
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focused coping, (b) emotional-focused coping, (c) social support coping, and (d) less-constructive coping.
Kuppuswami’s Socio Economic Status Classification
Kuppuswami scale is widely used to measure the socio-economic status of an individual in urban community based on three variables namely education, occupation and income. The modification of Kuppuswami scale meant to determine the socioeconomic status of family based on education and occupation of head of the family and per capita income per month has also been widely used. Recently, Mishra et al have suggested an economic revision of Kuppuswamy's scale in order to account for the devaluation of rupee and is proposed to measure the socio-economic status of the family and is neither based on the individual nor on the head of the family.
Statistical Method:
Data were analyzed using the following statistical methods.
1. Descriptive statistics to express the mean values, frequency distribution & standard deviation.
2. Relationship between suicidal intent and other variables were correlated by Pearson Correlation Coefficient.
3. Student T test was used to compare the groups within the sample.
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4. The predictive value on the scales that were used was analyzed by multiple linear regression.
5. Factor analysis was the method used to analyze Brief Cope Inventory by means of principle component method.
34 RESULTS
Table 1: Frequency of socio demographic variables
Variables Frequency Percent
Age
17- 24 18 60.0
25-34 12 40.0
Gender
Male 4 13.3
Female 26 86.7
Literacy
Illiterate 2 6.7
Primary 2 6.7
Middle 10 33.3
High 10 33.3
College 6 20
Employment status
Employed 11 36.7
Unemployed 6 20
Housewife 9 30.0
Student 4 13.3
Socio-Economic status
Upper Middle 5 16.7
Lower Middle 6 20.0
Upper Lower 19 63.3
Marital status
Married 12 40.0
Unmarried 16 53.3
Divorced 1 3.3
Widow 1 3.3
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Among the sample of 30 adults belonging to the age group between 17 and 40, majority of them were between the age 17 & 24 and they constitute about 60%. Female gender was found to be predominant in the sample when compared to males.
Table 2: Frequency for age & gender
Age Group Frequency Percent Males Females
17-24 18 60 2 16
25-34 12 40 2 10
Total 30 100 4 26
Table 3: Quantitative analysis of Socio demographic profile
Variable N Mean Range Std. deviation
Age 30 23.900 17-34 4.664
All the cases were between the age range of 17- 34 with a mean age of 23.9 and a standard deviation of 4.664.
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Figure 1: Frequency for age
Figure 2: Sex distribution Frequency (GENDER)
Females 87%
Males 13%
Frequency (AGE)
0 0.5 1 1.5 2 2.5 3 3.5
17 18 19 20 21 22 23 24 25 26 27 29 30 32 33 34
Age in years Frequency
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Figure 3: Literacy Level
93.2% were literate and the rest were illiterate. Among the literate, majority of them 86.6% were educated above middle school level.
Figure 4: Employment & Socio-Economic status
6.7% 6.7%
33.3% 33.3%
20%
0 2 4 6 8 10 12
Illiterate Primary Middle High College
0 2 4 6 8 10 12 14 16 18 20
Employed Unemployed Student Housewife Upper middle Lower middle Upper lower
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Regarding the employment and socio economic status, 20% were unemployed and 36.7% were employed. Majority of the suicide attempters belonged to the upper lower socio- economic status.
About 53.3% were unmarried while married individuals constituted about 40% and the rest 6.6% was equally shared by widow and divorcee.
70% of the cases hailed from rural areas and 26.7% were from urban areas.
Figure 5: Marital status
The majority of the suicide attempters were currently living in a nuclear family set up and they constituted about 66.7%. Regarding the religion of the individuals, many belonged to the religion of Hinduism
Frequency (MARITAL)
0 2 4 6 8 10 12 14 16 18
Married 40%
Unmarried 53.3%
Divorced 3.3%
Widow 3.3%
Frequency
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66.7%, while Christians and Muslims constituted 26.7% and 6.7%
respectively.
Figure 6: Domicile
Figure 7: Family type Frequency (DOMICILE))
Rural 70%
Urban 26.7%
Sub Urban 3.3%
Frequency (FAMILYTYPE)
Nuclear 66.7%
Joint 33.3%
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The most reported mode of attempt of suicide was by consuming poison 96.7% and majority have executed their attempt at their home itself. Only one female person had attempted suicide by hanging herself at home.
Personality Disorder:
Table 4: Frequency of cases with Personality Disorder
Personality Disorder
Frequency Percent
Yes 8 26.7
No 22 73.3
Total 30 100
Of the 30 cases, 8 were diagnosed to be having a definite personality disorder which was about 26.7%. Among those 8 cases, 5 cases were found to have anankastic personality disorder (F60.5) according to the International personality Disorder Examination (IPDE).
2 cases were found to have Dependent Personality disorder (F60.7) and one person qualified for Borderline personality disorder Impulsive subtype (F60.30).
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Table 5: Frequency of type of Personality Disorder
Personality Disorder Frequency Percent
F60.30 Borderline Impulsive 1 3.3
F60.5 Anankastic 5 16.7
F60.7 Dependant 2 6.7
Total 8 26.7
Two of the 8 cases were 25 years old and they have qualified the required criteria for their respective personality disorder which have been present for the last 5 years.
Suicidal intent:
Table 6: Beck suicide intent scale scores:
Suicidal intent Frequency Percent
Scores less than 15 20 66.7
Low intent (15-19) 7 23.3
Medium intent (20-28) 3 10.0
High intent (>29) 0 00.0
Total 30 100
Mean 11.552 SD 5.234
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Among the sample group of 30 numbers, 7 people were graded as having low intent, 3 as having medium intent which was measured using Beck’s suicide intent scale. The remaining 20 people scored below 15.
The mean score was 11.552 with a standard deviation of 5.234.
Table 7: Holmes Rahe Stress Scale
Holmes Rahe Score Frequency Percent
Scores less than 150 15 50.0
Slight risk (150) 12 40.0
Moderate risk (150-299) 3 10.0
High risk (>300) 0 00.0
Total 30 100
Mean 35.621 SD 48.364
In the Holmes and Rahe`s Stress scale, 12 people have scored for slight risk for development of illness whereas 3 people have scored for moderate risk. The mean score was 35.621 with a standard deviation of 48.364.
The table 8 shows the correlation between socio demographic variables and suicide intent. The Pearson correlation coefficient of all
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variables with suicidal intent was not statistically significant as the p value was more than 0.05.
Table 8: Correlation between Socio demography & Suicide intent
Variable N r2 p-value
Age 30 0.054 0.219
Gender 30 0.124 0.056
Literacy level 30 0.003 0.781
Employment status 30 0.001 0.872 Socioeconomic status 30 0.047 0.248
Marital status 30 0.001 0.879
Religion 30 0.006 0.676
Domicile 30 0.028 0.375
Dietary type 30 0.029 0.367
Family type 30 0.057 0.204
The correlation between stress and suicidal intent was not
statistically significant as the p-value was above the level of 0.05 (Table 9).
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Table 9: Correlation between Beck suicide intent Scale & Holmes Rahe Stress Scale
N Range Mean SD r2 p value
Beck Suicide Intent Scale 30 2-24 11.96 5.623
0.05 0.234 Holmes Rahe Social
Readjustment Scale
30 0-158 39.70 52.51
Table 10: Comparison of suicide intent scores between the age groups 17-24 & 25-34
Beck Suicide
intent Score
Age in years
t DF p
17-24 25-34
N Mean SD N Mean SD
-1.666 28 0.107 18 10.611 5.054 12 14.00 6.030
On comparing the suicide intent between the two age groups 17-24 and 25 -34 by using two tailed t-test, the computed p value was greater than the significant level of 0.05.
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Table 11: Comparison of Holmes Rahe stress scores between the age groups 15-24 & 25-34
Holmes
& Rahe Stress
Scale
Age in years
t DF p
17-24 25-34
N Mean SD N Mean SD
-2.777 28 0.010*
18 20.111 38.690 12 69.083 58.196
Whereas while comparing the Holmes & Rahe stress scale scores between these two age groups, the mean stress score for the 25-34 age groups was higher and the p value of 0.010 is significant.
Table 12: Descriptive analysis of suicide intent of persons with Personality Disorder
Beck suicide intent score
Observations Mean Std. deviation
8 11.125 7.338
The descriptive analysis of suicidal intent within the personality disorder group showed a mean of 11.125 with a standard deviation of 7.338 which was lower than that of persons without personality disorder.
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Table 13: Comparison of suicide intent between individuals with & without Personality Disorder
Beck Suicide
intent Score 15 &
above
Suicide attempters
t DF p
With PD Without PD
N Mean SD N Mean SD
0.594 8 0.569 3 19.333 1.528 7 18.143 3.237
On comparing the Beck suicidal intent score of 15 & above between the two groups of persons with personality disorder and without personality disorder, it was found that the mean score was more in persons with personality disorder. But it does not have any statistical significance as the p value was above 0.05.
Brief Cope Inventory:
Before doing factor analysis, Bartlett’s Test of Sphericity was done to determine whether or not a factor analysis could be performed on the Brief COPE data set. In this study, Bartlett’s test was significant (p <
.0001) and it was determined that a factor analysis was appropriate.
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Table 14: Bartlett's sphericity test
Chi-square 277.821
DF 91
p-value < 0.0001
In factor analysis, the multivariate variables were reduced to fewer variables called factors by principal component method. The correlation between all pair wise combination of the variables called correlation matrix R was then derived. The correlation matrix provides the correlation for each variable compared to each other variable (Table 16).
The eigen values for all values have been extracted. The extracted eigen values, the % of total variance which each explains, and the cumulated % of total variance explained, was given for each of the extracted factors.
The unrotated factor loadings were given for each variable and all extracted factors with eigen value > 1.
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Table 15: Descriptive statistics of variables of Brief Cope Inventory
Variable Mean SD Std. error alpha
Self distraction 3.567 1.888 0.345 0.762 Active Coping 5.600 2.078 0.379 0.927
Denial 2.433 1.251 0.228 0.859
Substance abuse 2.100 0.548 0.100 0.564 Use of emotional support 5.733 2.651 0.484 0.854 Use of instrumental support 5.700 2.437 0.445 0.900 Behavioral disengagement 5.533 1.697 0.310 0.629
Venting 5.100 2.203 0.402 0.608
Positive reframing 4.833 1.877 0.343 0.828
Planning 5.467 2.224 0.406 0.852
Humor 2.033 0.183 0.033 0.716
Acceptance 5.667 2.090 0.382 0.886
Religion 4.567 1.755 0.321 0.698
Self blame 3.500 2.030 0.371 0.771
In this study, factor analysis yielded five factors with eigen values greater than 1.0 which together accounted for 77.5% of the variance in responding. Then the results were transformed to two factors D1 and D2 by varimax rotation (Table 17). The Cronbach’s alpha of this study 0.755 was similar to the values of many studies including the one by Carver et al. Cronbach’s alpha is a statistic used to measure how well a set of variables measures a single latent construct. It is a measure of internal consistency reliability.
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Table 16: Correlation Matrix (R)
variables 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4
Self distraction 1.000 0 . 3 1 5 -0.020 0.143 0 . 2 5 9 0.263 0.032 0.384 0.212 0.255 0 . 4 4 4 0 . 2 7 7 0 . 2 3 3 0.184 Active Coping 1 . 0 0 0 -0.223 0.218 0 . 4 6 2 0.500 -0.055 0.619 0.787 0.907 0 . 2 1 8 0 . 8 3 4 0 . 0 7 4 0.090 D e n i a l 1.000 -0.065 - 0 . 1 7 2 -0.182 0.245 0.021 -0.174 -0.026 - 0 . 0 6 5 - 0 . 4 9 7 - 0 . 1 3 1 0.441 Substance use 1.000 0 . 1 6 1 0.178 0.163 0.077 0.319 0.215 - 0 . 0 3 4 0 . 2 1 1 - 0 . 2 7 6 -0.140 Emotional supp 1 . 0 0 0 0.958 -0.029 0.471 0.330 0.437 0 . 1 6 1 0 . 3 7 5 - 0 . 2 1 8 0.128 Instru. support 1.000 -0.102 0.571 0.328 0.434 0 . 1 7 8 0 . 3 9 3 - 0 . 1 9 3 0.136 Behavioral. dist 1.000 -0.070 0.083 0.124 - 0 . 2 8 2 - 0 . 0 1 6 0 . 0 2 2 -0.210 V e n t i n g 1.000 0.446 0.532 0 . 2 4 9 0 . 5 3 9 0 . 0 3 8 0.096 Positive refra 1.000 0.787 - 0 . 0 8 4 0 . 6 8 9 - 0 . 0 6 5 -0.086 P l a n n i n g 1.000 0 . 2 1 5 0 . 7 3 9 - 0 . 0 2 6 -0.023 H u m o r 1 . 0 0 0 0 . 2 1 1 0 . 1 5 4 0.047
Acceptance 1 . 0 0 0 0 . 1 3 8 -0.122
R e l i g i o n 1 . 0 0 0 0.276
Self blame 1.000
Table 17: Factors after varimax rotation
Variables D1 D2
Self distraction 0.423 0.478
Active Coping 0.919 0.023
Denial -0.288 0.247
Substance use 0.326 -0.416
Use of Emotional support 0.684 0.143 Use of instrumental support 0.709 0.183 Behavioral disengagement -0.011 -0.408
Venting 0.717 0.273
Positive reframing 0.789 -0.301
Planning 0.863 -0.088
Humor 0.263 0.564
Acceptance 0.848 -0.102
Religion -0.037 0.475
Self blame -0.015 0.690
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Table 18: Pattern matrix:
Variables Problem based coping Emotion based coping Use of Support Active Coping 0.919
Positive reframing 0.789
Humor 0.564
Planning 0.863
Acceptance 0.848
Behavioral disengagement -0.408
Self blame 0.690
Denial
Substance use -0.416
Venting 0.717
Self distraction 0.478
Religion 0.475
Use of Emotional support 0.684
Use of instrumental support 0.709
The component matrix demonstrated the loading of each variable onto each factor with variables loading less than .4 being suppressed. As a result, all variables were included except for denial (Table 18).
Suppression was done to ensure that all factors loading within + 0.4 or – 0. 4. Factor 1 represents problem focused coping, factor 2 represents emotion focused coping and factor 3 represents use of support. On reviewing the 3 factors, problem based coping values were greater than emotional based coping and use of support.
