A STUDY OF RECENT TRENDS IN RISK FACTORS IN ADOLESCENT SUICIDE
ATTEMPTERS INCLUDING MEDIA AND INTERNET
DISSERTATION SUBMITTED FOR DOCTOR OF MEDICINE BRANCH
– XVIII (PSYCHIATRY) MAY 201 8
THE TAMILNADU
DR.M.G.R. MEDICAL UNIVERSITY
CHENNAI, TAMILNADU
CERTIFICATE FROM THE DEAN
This is to certify that this dissertation entitled “A STUDY OF RECENT TRENDS IN RISK FACTORS IN ADOLESCENT SUICIDE ATTEMPTERS INCLUDING MEDIA AND INTERNET” submitted by Dr. DEEPA .N to The Tamil Nadu Dr. M.G.R.Medical University, Chennai is in partial fulfillment of the requirement for the award of M.D.
[PSYCHIATRY] and is a bonafide research work carried out by her under direct supervision and guidance. This work has not previously formed the basis for the award of any degree or diploma.
Dr. MARUTHU PANDIAN, M.S.,FICS.,FRCS., Dean,
GRH and Madurai Medical College, Madurai.
BONAFIDE CERTIFICATE
This is to certify that the dissertation entitled “A STUDY OF RECENT TRENDS IN RISK FACTORS IN ADOLESCENT SUICIDE ATTEMPTERS INCLUDING MEDIA AND INTERNET, is a bonafide record work done by Dr. DEEPA .N under my direct supervision and guidance, submitted to the Tamil Nadu Dr.M.G.R Medical University regulation for M.D Branch XVIII – Psychiatry.
Dr. T. KUMANAN, M.D., D.P.M.,
Professor & Head of the Department, Department of Psychiatry,
Madurai Medical College, Madurai.
CERTIFICATE FROM THE GUIDE
This is to certify that this dissertation entitled “A STUDY OF RECENT TRENDS IN RISK FACTORS IN ADOLESCENT SUICIDE ATTEMPTERS INCLUDING MEDIA AND INTERNET”
submitted by Dr. DEEPA.N to The Tamil Nadu Dr. M.G.R. Medical University, Chennai is in partial fulfillment of the requirement for the award of M.D. [PSYCHIATRY] and is a bonafide research work carried out by her under my direct supervision and guidance. This work has not previously formed the basis for the award of any degree or diploma.
Dr. V.GEETHAANJALI M.D., DCH., Associate Professor,
Department of Psychiatry,
Madurai Medical College,
Madurai
DECLARATION
I, Dr.DEEPA .N ., solemnly declare that the dissertation titled “A STUDY OF RECENT TRENDS IN RISK FACTORS IN ADOLESCENT SUICIDE ATTEMPTERS INCLUDING MEDIA AND INTERNET ” has been prepared by me. I also declare that this bonafide work or a part of this work was not submitted by me or any other for any award, degree, diploma to any other University board either in India or abroad. This is submitted to The Tamilnadu Dr. M. G. R. Medical University, Chennai, in partial fulfillment of the rules and regulation for the award of M.D degree Branch – XVIII (Psychiatry) to be held in April 2018.
Place: Madurai Dr. DEEPA .N
Date:
ACKNOWLEDGEMENT
I am deeply indebted to Professor DR.T.KUMANAN, MD, DPM, Head of the Department and Professor of Psychiatry, Government Rajaji Hospital, Madurai Medical College, Madurai, who has been a source of motivation and encouragement throughout this project.
I sincerely thank The Dean, Dr.MARUTHUPANDIAN, Government Rajaji Hospital, Madurai Medical College, Madurai for permitting me to do this study.
I am extremely grateful to Prof.Dr. Dr.V.Geethaanjali, MD for her immense guidance throughout the study which is indispensable for this research work.
I sincerely thank Prof.,DR. S.Ananda Krishna Kumar MD, DPM
Professor, Department of Psychiatry, Government Rajaji Hospital, Madurai Medical College, for giving his valuable support for completing this study.
I am extremely thank Prof., Dr.S. John Xavier Sugadev, MD, Professor, Department of Psychiatry, Government Rajaji Hospital, Madurai Medical College, for giving his valuable support for completing this study.
I am extremely thankful to my Assistant Professor.,Dr.C.Kavitha MD.,DCH for her valuable guidance through each and every step of this research work.
I express my heartfelt gratitude to Prof.Dr.V.T.PREMKUMAR MD Professor and Head of the Department of MEDICINE, for allowing me to conduct this Research work.
I express my profound gratitude to my Assistant Professors Dr.G.A.Viswanathan MD, DPM, Dr.M.Rajasundari MD(PSY), DCH,who had helped me in completing this dissertation.
I sincerely thank Dr.Prabha Samiraj, Senior Resident, Department of Psychiatry for giving her valuable support for completing this research work.
I express my gratitude to Assistant Professor cum Clinical Psychologist Mr.N.Suresh Kumar, M.A, M.Phil., whose valuable assistance was indispensable for this study.
I express my gratitude to Dr.Kannan, PhD., for helping me with the statistical part of the Dissertation.
And my heartfelt thanks goes to my colleagues, seniors and juniors of the Department of Psychiatry, Madurai Medical College for their constant encouragement and support.
I thank my Family and my friends for their emotional support and understanding.
Most importantly, I gratefully acknowledge the subjects who cooperated to submit themselves for the study.
TABLE OF CONTENTS
S.NO TOPIC PAGE.NO
1 INTRODUCTION 1
2 REVIEW OF LITERATURE 3
3. AIM AND OBJECTIVES 25
4. MATERIALS AND METHODS 27
5. RESULTS AND INTERPRETATIONS 36
6. DISCUSSION 67
7. LIMITATIONS AND CONCLUSION 84
BIBLIOGRAPHY ANNEXURES
PROFORMA & TOOLS USED MASTER CHART
APPROVAL BY ETHICAL COMMITTEE ANTI – PLAGIARISM CERTIFICATE
INTRODUCTION
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INTRODUCTION
Suicide is the act of intentionally causing one’s own death. About 800,000 persons per year die due to suicide (52). In young adults the second leading cause of death is. In India, there is an increasing trend in suicide (17.9/1lakh) (52). In India maximum number of suicides were reported in Maharashtra which was followed by Tamil nadu and west Bengal accounting for 12.7%, 11.8% and 10.9% of total suicides reported in the country respectively (21).
Due to its frequency, coexisting psychiatric, physical problems and, economic toll attempted suicide among adolescents becomes a significant public health concern. Attempters are also a high-risk group for eventual completed suicide. Hence it is important to identify the risk factors associated with suicide in order to prevent suicide in adolescent attempt.
Scope of our study
Our study has been framed to explore recent trends in risk factors in adolescent suicide attempters including the influence of media and internet on adolescent suicide attempt.
This study is designed to find the various risk factors associated with adolescent suicide attempt like physical abuse, sexual abuse, influence of recent conflicts, stressful life events, perceived stress, perceived social support, parental discord/separation/loss, impulsivity, aggression, hopelessness, family history of
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suicide and family history of psychiatric illness, exposure to reporting of suicide in media and influence of internet on adolescent suicide. Risk factors for suicide attempt and completed suicide does not differ much. Therefore studying risk factors in serious suicide attempters are important in preventing completed suicide by modifying the risk factors. Being in a developmentally transitional stage, adolescents will differ from adults. By identifying the various risk factors and its recent trends associated with adolescent suicide attempt , the risk factors can be modified in adolescents well before the attempt and thus adolescent suicide attempt can be prevented and also prevent further suicide attempts in adolescents who have attempted suicide.
REVIEW OF
LITERATURE
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REVIEW OF LITERATURE
1. History
Suicide history dates back to at least to man earliest written records (Socrates or Seneca) or even to pictorial ones. One of the earliest classifications was by Emile Durkheim who divided them into
Egoistic-lonely withdrawn individuals who were insufficiently integrated into their environments
Anomic-out of step by either by life circumstances (e.g. Loss of job or loss of love) Altruistic –died for a cause e.g. Soldier Pythagoras, Aristotle and Plato also condemned suicide.
In roman suicide was never a general offence in law. Patriotic suicide was approved as an alternative to dishonor by Romans.
In middle Ages, the Christian people who attempted suicide were excommunicated and persons who die of suicide were not allowed to be buried in the usual graveyards. Suicide was forbidden by all western religions. During renaissance attitude change towards suicide began slowly which sanctioned suicide under some circumstances. During enlightment period traditional religious attitudes were questioned.
During 19th century the act of suicide had shifted from being viewed as caused by sin to being caused by insanity in Europe. 1879 English law distinguished between suicide and homicide.
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In the Indian context, religious, literary, and cultural variations should be taken into account. In great epics like Mahabharata and Ramayana suicide has been mentioned. Suicide for selfish reasons has been condemned by the Bhagavad Gita .Suicide for religious reasons were encouraged. Sati, is where widowed wife die on the pyre of her husband which was practiced until as recently as the early half of the 20th century.
2. Suicide
Suicide is the act of intentionally causing one’s own death. Suicide is a global burden and affects families, communities and entire countries and has long lasting effect on people left behind. Suicidal behavior is a spectrum ranging from suicidal thoughts to completed suicide.
Suicidal thought or ideation - range from passive thoughts of death to active suicidal ideation.
Suicidal threats- verbalization of suicidal ideation.
Suicide attempt-self destructive behavior with inferred or explicit intent to die.
Aborted suicidal attempt-one in which the individual is interrupted unexpectedly after preparatory behavior
Completed suicide-suicide attempt that results in death.(50)
Relationship between suicide and mental disorders is well documented, many suicides may happen impulsively too at the moment of crisis where the ability to
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deal with life stresses is disturbed, such as financial problems, and illness relationship break-up or chronic pain etc.
In addition, experiencing conflict, disaster, violence, abuse, or loss and a sense of isolation are strongly associated with suicidal behavior (4, 6, 8, 12, 13, 16, 38). Suicide rates are also high amongst vulnerable groups.
3.Etiology of suicide A. Psychological
Edwin Schneidman says that victim has unbearable mental pain,
“psychache,” and how terminally they have narrow perceptions (“tunnel vision”) and they can see only one solution—his or her death.
Sigmund Freud wrote of aggression turned inward when one internalizes a lost object and then turns this rage on oneself.
Karl Menninger wrote of the suicidal triad: A wish to die, a wish to kill, and a wish to be killed—as components of all suicides.
Hopelessness and despair—and ultimately for some, suicide appears to be the only answer.
Presumably, there is no single psychological path to suicide, but rather multiple way in which psychodynamics interact and may lead to such a tragic final outcome. Intense affects, particularly desperation, but also hopelessness and severe anxiety may represent the most important cause of an imminent serious or fatal suicide attempt.
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B.Biological theories:
Biological theories about suicide are commonly linked to studies of depression because this is the mental state most often underlying suicide. Studies of biogenic amine metabolism and later work on serotonin and nor epinephrine levels in the brains of depressed individuals laid the base for a cascade of later studies. The essence of these is that there is a relative deficiency of such neurotransmission at critical sites in the brain that results in depression. This “deficiency” may be due to insufficient production, excessive reuptake of the transmitter at the synapse, or some alteration of the receptor system. Alternatively, some antagonist neurochemical agent may be lowering the effective levels. Although the most studied are serotonin and norepinephrine, other transmitters (e.g., γ-aminobutyric acid [GABA]) or other agents (e.g., G proteins, glutamate receptors, kinases, or brain-derived-neurotrophic factor, as described by Lowe-Ponnsford and Nutt) may also play a role. Numerous studies have found a decreased level of serotonin (5-HT) in the brains of depressed and of 5-hydroxy indoleatic acid (5-HIAA), serotonin's major metabolite, in the cerebrospinal fluid (CSF) of living depressed patients. Depressed individuals who have made suicide attempts or completed suicide have lower levels of 5-HT than depressed patients who are not suicidal. Those who made more violent suicide attempts or completions (e.g., guns, stabbing, or jumping) have lower levels than those employing less violent means (e.g., pills). Many other studies have found decreases for fire setters, gamblers, and impulsive individuals in general, as compared to those of control populations, and this nonspecificity has led some
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investigators to correlate these lowered neurotransmitters with indications of general impulse dyscontrol rather than as being more specific.
C.Biopsychosocial
In addition to studying biogenic amines, an alternative hypothesis relates to the cortical–hypothalamic–pituitary–adrenal (HPA) axis. This system regulates adrenal cortical hormone (steroid) levels and mediates reactions to stress. Charles Nemeroff has reported elevated corticotropin-releasing factor (CRF) concentrations in the CSF and decreased numbers of CRF binding sites in the frontal cortices of patients dying of suicide. Independently, both Nemeroff, at Emory University, and J. John Mann, at Columbia University, have proposed stress-diathesis models of suicide. These says that individuals who are born with a genetically modulated tendencies toward impulsivity (the diathesis), when stressed by external events later in life—particularly when they become depressed—are more likely to harm themselves than those not so predisposed.
Childhood trauma, especially physical or sexual abuse, can predispose individuals who later become depressed to impulsively act on their suicidal impulses. Such events, therefore, may apparently produce the impulsive/aggressive/suicide diathesis if they are early and severe enough or serve as the stressors if they occur later or are somewhat less traumatic.The above two models have represented the leading biopsychosocial theories regarding suicide
A study revealed that attempters experienced more subjective (and not necessarily objective) depression and hopelessness and had more suicide ideation.
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They also perceived fewer reasons for living despite comparable numbers of adverse life events. The predisposed react more strongly to illnesses or other stressors. The suicidal patients also demonstrated lifelong patterns of greater aggressiveness. A past history or family history of attempts may be clues to such an underlying diathesis.
4. Adolescent suicide attempt
Suicide attempts in adolescents have been recognized as a major public health problem not only India but also in other countries all over the world (19), because of their frequency, likelihood for recurrence, health care costs, and high risk for completed suicide.
Many studies have reported association of adolescent suicide attempt with psychiatric disorders, adverse childhood experiences, and family history of suicide attempts and repetition of attempts as important high-risk factors for subsequent suicide (1, 2, 3, 8, 9).
About 10-50% of adolescent suicide attempters reattempted, and that about 11% of these committed suicide. Risk factors for suicide attempt and completed suicide does not differ much. Therefore, studies of serious suicide attempters are important in preventing completed suicide by modifying the risk factors
Being in a developmentally transitional stage, adolescents will differ from adults.
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for example, during adolescence, they struggle to achieve body mastery, gain independence from the family, control sexual and aggressive urges, find new and appealing sexual relationships, and achieve a sense of identity. Adolescents
Start to rely less on their parents for support and more on their peers as they grow older (50).
Also, adolescents differ from adults in their financial status, medical, occupational conditions, social, support networks, coping styles and to the stressors exposed.
Furthermore, suicidal behavior among adolescents occurs in different contexts like family conflict, striving for autonomy, academic and disciplinary problems, and peer relationships disruptions.
Proximal versus distal risk factors
The risk factors for completed suicide overlap with those for suicidal ideation and attempt. The risk factors of suicide are associated with high functional impairment and therefore require to be corrected. Differentiation between important factors that put individuals at risk for suicide immediately and those that do so over their entire lifetime is important. (50)
For example, a history of abuse puts the person in increased lifetime risk for suicidal behavior, whereas living in a place of imminent abuse puts increased risk at the time of assessment.
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In general, proximal risk factors are those that impair the individual's ability to keep from engaging in suicidal behavior: suicidal ideation with high intent and a plan, ongoing substance and alcohol abuse, mood instability, insomnia, psychosis, and a social situation in which the precipitant for suicidal behavior is likely to reoccur. (50)
Suicidal ideation and behavior
The future suicidal behavior is best predicted by current and recent past suicidal behavior. The more serious the previous episode of behavior (high lethality and intent) or suicidal ideation (e.g., with a plan and intent) the greater is the likelihood of an attempt or completion. (50)
Intensity, severity, and intent
Suicide ideation - assessed both with respect to
1. Intensity (i.e., how compelling and how frequent) and
2. Severity (from passive ideation to ideation with intent and a plan).
Suicidal intent -refers to the degree to which the individual with Suicidal ideation intends to carry out a suicidal act;
In attempted suicide, intent refers to the degree to which the individual wished to die.
The level of suicidal ideation is also predictive of future attempts and completions.
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An adolescent who has made an attempt to suicide has a 15 to 30 percent chance of a reattempt within 1 year, with the highest risk for reattempt in the first 3 months after the attempt. (50).adolescent suicide attempters are at a 10- to 60-fold increased risk for completed suicide, with those who make attempts of high lethality and intent at highest risk. (50).
Precipitant
Most common precipitants for suicidal behavior are Parent–child conflict,
Difficulties in peer Romantic relationships,
Disciplinary problems. (50, 4, 5, 6, 8)
The extent of recurrence of precipitants continues to be an increased risk for a reattempt in the suicidal individual.
In younger children and adolescents, common precipitants are parent–child conflict.
In older adolescents common precipitants are romantic or peer difficulties.
(50)
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5. Socio demographic variables and adolescent suicide attempt:
A.Age
Various studies have studied about the relation of age with the adolescent suicide attempt. According to a comparison study done by Yoshitaka kawashima et al (1) the rate of adolescent suicide attempt attempts increase with age. In another study, which compared adolescent suicide and adult suicide the intent of suicide increased with increasing age. (8). The increased rate of ideation with age corresponds to the increased rate of depression in adolescents relative to childhood (8).
Some studies were done in late adolescence and the mean age of adolescent suicide attempt was 17.58% according to one study and mean age of the adolescent suicide attempt was 14.8 ± 1.4 years (range 12-17) according to dilsad foto-ozdemir et al. In some studies mean age was around 16 years .In a study, age of attempted adolescent suicide attempt was earlier when there was family history of suicide (9).Attempted suicide in adolescence was found to be rare before puberty and sharply rises after 14 yrs according to a study (25). According to another study median age of 14.4 years was found (13).Completion are more common in adolescents relative to children because of much greater ability to plan an attempt, as well as the increased risk for both depression and substance abuse disorders.
Comparisons of younger and older adolescent suicide completers show that a much lower proportion of younger completers have a clear psychiatric disorder and that that younger suicide victims show less planning and intent (50).
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B.Gender difference in adolescent suicide attempt
Suicidal attempts are most common in female’s adolescents than male adolescents. a study showed that 75% of suicide attempters were female(1).Another study done by Laurence a. Senseman(3) found that females adolescents attempt are more up to 64.4% .Another study stated a ratio of 1:3(m:f) ie.more than 75% females attempt suicide(6). A study done by J.S. Maras et al (10) showed 81% of female adolescents attempt suicide. Many other studies also showed that female adolescents attempt suicide more often than males (4, 5, 13, and 14).
The overall male: female ratio of adolescent suicide attempt victims for the year 2015 was 68:32. However, the proportion of girls: boys adolescent suicide attempt victims (below 18 years of age) was 47:53 (21). In a study done by C.T.
Sudhir kumar et al (8) the proportion of male and female adolescents attempting suicide was equal.
In males, heavy alcohol use, drug use, and high perceived sadness / hopelessness showed significant effects on the presence of as versus the presence of is only. In females, along with these variables, low academic achievement, poor perceived health status, high perceived stress, and unhealthy coping strategy were also significantly related to the presence of SA versus SI only (4).
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6. Family history and adolescent suicide
A. Family history of suicide in adolescent suicide attempters
Suicide and also suicidal behavior runs in families. Adoption, twin, and family studies have showed that first-degree relatives of suicide victims and attempters are at higher risk for suicidal behavior (50). Even though familial transmission of suicidal behavior is partly mediated by the transmission of psychiatric disorders, there is up to a 4–6-fold increased risk of suicidal behavior in first-degree relatives of suicide attempters or completers even after controlling for the familial transmission of psychiatric disorder. Impulsive aggressive traits appear to play an important part of a diathesis for suicidal behavior and may mediate the familial transmission of suicidal behavior (50). The familial transmission of suicidal behavior was related, also related in part, to the familial transmission of sexual abuse and of impulsive aggression.
In a study done on adolescent suicide attempt by C.T. Sudhir kumar et al (8) family history of attempted suicide was found to be 6.8% and completed suicide was 1.4%. David a Brent et al (9) found that there was increased incidence of attempted suicide in adolescents whose first degree relatives had attempted suicide suicidal attempt. Mary cwik et al (22) found that about 68% of adolescent suicide attempters had a family history of suicide.
Familial loading for suicide attempts may affect rates of transmission as well as age at onset of suicidal behavior and its effect may be mediated by the familial transmission of impulsive aggression. (9). Many other studies also assessed the
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familial loading of suicide and found that family history of suicide was significantly high in adolescent suicide attempters(3,4,13,37,41,44).A study done on suicide attempt in students found that there was no family history of suicide in the adolescent suicide attempters(26).
B.Family history of psychiatric illness in adolescent suicide attempt
The familial transmission of suicidal behavior is mediated partly by the transmission of psychiatric disorders. Family interpersonal relationship problems derived from parental psychiatric illness are important aspects of stressful circumstances experienced by suicidal adolescents. Many studies have studied the relationship between family history of psychiatric illness and adolescent suicide attempt. Many studies have found family history of psychiatric illness as one of the important risk factors for adolescent suicide attempt. A study done on suicide by Nilamadhab kar et al (6) adolescent suicide attempters showed increased family history of psychiatric illness. Another study which compared the adolescent suicide and adult suicide ,family history of psychiatric illness was 5.4% and family history of substance use was 25.7% which was more than the comparative group(8).
Laurence a. Senseman (3) reported family history of psychiatric illness of 38.52% in his study. Highest loading of family history of psychiatric illness was found in cases of adolescent suicide attempts (9). Many other studies also reported increased incidence of family history of psychiatric illness in case of adolescent suicide attempters (18, 41).
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History of a psychiatric disorder in the families was found in 34.4%; 15 female, 7 male adolescents in a study done by Dilsad foto-ozdemir et al (18)
C.Psychiatric disorders in adolescent suicide attempters
The rate of psychiatric disorder is high in adolescent suicide attempt and is 80 percent. Incidence of suicide attempts in adolescence is increased by greater severity, chronicity, and complexity (e.g., comorbidity) of the psychiatric illness.
Majority of psychiatrically ill individuals neither attempt nor is complete suicide, the treatment of psychiatric disorder likely to be necessary but not sufficient to prevent suicidal behavior. (50)
Mood disorders are strongly associated strongly related to adolescent suicide attempts and completions. Approximately 60 percent of adolescent suicide victims had a mood disorder at the time of death (50). Bipolar disorder at times of
Rapid cycling or a mixed state imposes an increased risk for adolescent suicide attempt, both of which are common conditions in younger age than in adult bipolar disorder (50).
Alcohol abuse, conduct disorder particularly in combination with current substance use, anxiety disorder—specifically social anxiety, panic disorder, and posttraumatic, stress disorder offers an increased risk for adolescent suicide attempt.
Schizophrenia has a high lifetime risk for adolescent suicide attempt but usually manifests during young adulthood.
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Eating disorder has an increased risk for a highly lethal adolescent suicide attempt.
One study on adolescent suicide attempt found 93% of male adolescents, and 89% female adolescents have some underlying psychiatric illness (Yoshitaka Kawashima et al (1)).Mood disorders were also most common among adolescents in many studies done on adolescent suicide attempt (2, 3, 9).Another a study found that borderline personality disorder was more common among females adolescents and schizophrenia among male adolescents (1).
D.Parental discord/parental loss/separation
Disruption of relationships and social bonds are found to be one of the main causes of suicidal thoughts and behaviors. The desire for suicide arises from exposure to adverse childhood trauma (e.g., abuse) and dysfunction in household (e.g., parental substance abuse, the lack of social integration, or absence of caring relationships) (50). The research on suicidality has measured these social processes from the perspective of perceptions of social support, belongingness, and interpersonal conflict. Adolescents with high emotional trust in their parents are inclined to disclose troubling thoughts and in turn receive emotional support and practical assistance in managing these thoughts, thereby reducing the risk of adolescent suicide attempt attempts. Holly c Wilcox found parental discord of 90%
in his study (24). Laurence A. Senseman (3) found that 21.30% of parental discord in patients of adolescent suicide attempts. Many other studies reported an increased
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presence of parental discord in adolescent suicide attempters (6, 8, 10, 31, 37, and 41)
Family variables that were also found to contribute to the risk of adolescent suicide attempt attempts were not living with both their parents; this was also reported from a school survey in England. A study done by Lawrence noted that adolescent suicide attempters have high parental separation and parental divorce (11.5%-parental separation, divorced parents-8.17%).many other studies reported that adolescents with parents who were separated , divorced showed more number of attempted suicides (6,8,24,36,37,39,41). A study reported parental loss of 35.6%
in adolescent males attempting suicide(1).Many other studies found that parental loss was very common among adolescents attempting suicide (3,6,13,17,22,25,36,37,44).
7.Conflits and adolescent suicide attempt
The main protective factors against adolescent suicide attempt attempts, which have also been found in other studies was satisfaction with relationships with parents and higher levels of self-esteem. Loneliness and lack of social support are important longitudinal predictors of both adolescent depression and suicide ideation.
A study found friction | tension between parents 40% and divorced parents 17% in cases of adolescent suicide attempt (Laurence a. Senseman (1971) (3)
Insecure attachments may increase vulnerability or decrease resiliency to adolescent suicide attempts, or act simultaneously on both of these processes.
Vulnerability of adolescents to suicide attempts may be increased if insecure
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attachment disrupts social bonds resulting in problems with self-esteem and depressed mood.
8.Impulsivity, aggression, hopelessness Impulsivity
Impulsive aggression, that is, the tendency to respond to frustration or provocation with aggression or hostility, is an important correlate of youthful suicidal behavior that is associated with both attempted and completed suicide above and beyond the risk conveyed by mood disorder. 40 percent of adolescent suicide victims younger than the age of 16 years show no clear evidence for psychiatric disorder, compared to greater than 90 percent of older adolescent suicide victims.
The most common contributory factors are a disciplinary precipitant, and are impulsive suicide attempt (50).
Familial loading for adolescent suicide attempt attempts may be mediated by the familial transmission of impulsive aggression. Adolescents were distinct from other age groups as 90% of them attempted impulsively with only 9% of the attempts being of high potential. Poor impulse control has been reported in adolescent suicidal behaviors (50).
Female adolescents may attempt suicide without any psychiatric symptoms and prior indications of emotional or behavioral problems. It has been pointed out that adolescents may be more impulsive than adults in attempting suicide (Kawashima et al).
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Another study on adolescent suicide attempt too stated that impulsivity is high in adolescent suicide attempt (4).
A study done by David A. Brent et al studied impulsivity using Barest impulsivity scale and Conner’s impulsivity subscale and showed that adolescent suicide attempters had greater impulsivity and may be one of the important reasons for suicidal attempt running in families(9).
In another study female adolescents showed higher impulsivity (1). Many studies studied the relationship between impulsivity and adolescent suicide attempt and showed a strong relationship between impulsivity and adolescent suicide attempt (4, 12, 28, 29, 38, 42, 44). Nilamadhab kar et al found in his studies that 90% of his study subjects showed impulsivity (6).
Aggression
Many studies have studied about the role of aggression in adolescent suicide attempt and found a positive relationship between aggression and adolescent suicide attempt (42, 44). A study done on attempted suicide in offspring’s found a between high degree of aggression in cases of adolescent suicide attempt (David A. Brent et al) (9)
Another study also found that anger and aggression are high in case of adolescent suicide attempt. (Andover et al) (4).
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Hopelessness
There are many studies that have studied about hopelessness as risk factor for adolescent suicide attempt. Hopelessness is an important risk factor in adolescent suicide attempt and contributes more than depression in adolescent suicide attempt.
(8).Another study showed that hopelessness increases the risk of adolescent suicide attempt (4, 37). Some case–control and prospective studies show that Hopelessness or pessimism about the future has been associated with both attempted and completed suicide, although in adolescents, the effect in some studies is attenuated by the effect of depression and also because many attempts are very impulsive and not motivated by a sense of pessimism. (50)
9.Physical and sexual abuse:
Studies have shown a strong association between adverse childhood experiences – such as physical and sexual abuse and suicidal behaviors during adolescence and adulthood. These adverse experiences may contribute to suicidal ideation through increasing internalizing behaviors, such as shame, feelings of depression and social isolation that affect the ability to cope with life stressors. A longitudinal study from South Africa found a strong association between cumulative exposure to adverse childhood experiences and suicidal behavior among adolescents aged 10–18 years. Physical violence from school environment is an important contributor to the overall burden of youth violence in some countries. Studies done by Rajiv radhakrishnan et al (16) showed a strong relationship between physical abuse and adolescent suicide attempt. Many studies done over a period of time
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stresses the importance of physical abuse as risk factor in adolescent suicide attempts (4,6,9,11,12,13,14,15,20,22,23,35,38,41).
Sexual abuse increased the risk for adolescent suicide attempts which was reported by many studies done at various places (4, 6, 9, 13, 15, 20, 38, 41,)
10.Life events
Childhood trauma was most frequent in adolescents attempting suicide. It is known that life events play a major role in adolescent suicide attempts. The life events were mostly failure in examinations and minor violations of discipline with anticipation of negative repercussions. (6).Failure in examinations has been associated with suicidal behavior. As the outcome of examinations virtually decides an individual’s future, failures become extremely stressful. (6).Increased stress is very common in adolescent suicide attempters. They report 4 times more levels of major negative events past month/previous year (8). The varied type of stressful life events include deaths and separations of relatives, Illness, hospitalization, multiple family moves etc.‘Failure in Examination’ (1,360) and ‘Illness’ (904), were the main causes of suicides among adolescents (below 18 years of age) (21).More stressful life events were reported to be associated with adolescent adolescent suicide attempt.(4,13,14,16,18,22,26,27,31,44).Dillard foto et al reported in his study that 82.8% of subjects in his study have faced stressful life events in near past (18).In another study various stressful life event including parental loss were found to be risk factors for adolescent suicide attempt (Kawashima et al.)
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11.Exposure to suicide attempt/suicide of others (including media report of suicide) and its relationship with adolescent suicide attempt
Exposure to a suicide and suicide attempt has been shown to increase the risk for adolescent suicide attempt and also acts as a precipitating factor for adolescent suicide attempt and many regulations have been made regarding media reporting of suicide. The mass media is believed to be one of the most important sources of information and is instrumental in the formation of attitudes and beliefs in the public.
High literacy rate and large readership indicate the Magnitude of potential for media influence on an average Keralite (Ramadas et al (45).After a press report of suicide from a particular spot narrating the method adopted, many suicides have been found to have occurred in the same spot and in the similar manner (R. Ponnudurai) (47) 12.Internet and chatting
In modern era the usage of internet for various purposes is more and adolescents are using internet commonly. Internet usage has risen after using mobile phones as it gives an easy access from the place you are. The usage of chat to be in touch with known and unknown persons also shows an increasing trend. Increasing cases of group suicides of strangers who meet over internet has been reported in Japan since last decade.
The victims are normally young and meet over the internet through number of suicide related sites and chat rooms where participants are online, not to dissuade, but to support one another in their desire for suicide. Fears was raised in the UK over link between suicide and internet, after 5981 internet suicides were reported in
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2012. Perhaps such people are still looking for a companionship, even after death.
Recently a great alarm has been raised by the blue whale suicidal game and many adolescents have died playing the game and some have been rescued. Many studies have studied the relationship of adolescent suicide attempt and internet(49,53,58,60). A study reported that internet had both positive and negative influence on adolescent suicide attempt (49).
AIM AND OBJECTIVES
25
AIM AND OBJECTIVES
AIMS AND OBJECTIVES:
1. To study the psychological stressor, psychiatric morbidity in adolescent suicide attempters .
2. To assess the relationship between impulsivity, aggression and hopelessness and suicide attempt in adolescents.
3. To assess the relationship between adolescent suicide attempt and family history of psychiatric illness/suicidal attempt .
4. To study the gender differences in adolescent suicide attempters.
5. To assess the relationship between internet use/mobile use and adolescent suicide attempt.
6. To assess the relationship between suicide exposure in media and adolescent suicide attempt.
HYPOTHESIS
• Adolescent suicide attempters have significant family H/O psychiatric illness and suicide when compared with non attempters.
• Adolescent suicide attempters have significant parental discord/ separation, loss of parent when compared with non attempters.
• Adolescent suicide attempters have significant life events when compared with non attempters.
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• Adolescent suicide attempters have significant physical and sexual abuse when compared with non attempters.
• Adolescent suicide attempters have significant impulsivity, aggression and hopelessness when compared with non attempters.
Suicide attempt is higher in female adolescents than for male adolescents.
Adolescent suicide attempters have a significant use of internet/chatting.
Media reporting of suicides acts as a precipitating factor in adolescent suicide attempts.
MATERIALS AND
METHODS
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MATERIALS AND METHODS
INCLUSION CRITERIA:
1. Cases of adolescent attempted suicide.
2. Age 12 to 19 years.
3. Adolescent suicide attempters whose parents /guardian /themselves gave informed consent for subjecting them for the study
• Controls-adolescents of age 12 to 19 yrs who has not attempted suicide and whose parent/guardian/themselves gave informed consent for subjecting them to study.
EXCLUSION CRITERIA:
1. Age less than 12 and more than 19 years.
2. Patients with MR.
3. Adolescent suicide attempters whose parents/guardian/themselves do not give informed consent for subjecting them for the study.
METHODOLOGY:
A sample of 55 consecutive adolescent suicide attempters of age 12 to 19 years admitted as inpatients were selected as cases and 53 adolescents of age 12 to 19 years who have not attempted suicide were selected as controls for the study.
Among them 2 adolescents suicide attempters did not consent for the study.So the study was conducted on a sample of 53 patients and 53 controls.
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OPERATIONAL DESIGN:
1. The study was conducted at Government Rajaji Hospital, Madurai, a tertiary care centre for 3 months.
2. The study was approved by Institutional Ethical Committee, Government Rajaji Hospital, Madurai.
3. The study is designed as a case control study.
4. The sample was chosen from adolescent suicide attempters of age 12 to 19 yrs admitted as inpatients for therapeutic purposes were selected as cases and 53 adolescents of age 12 to 19 who have not attempted suicide were selected as controls for the study.
5. Every consecutive adolescent suicide attempters admitted in the medicine ward were Selected .
6. The subjects and their parents/gaurdians were explained about the nature of the study and informed consent was obtained.
7. Socio demographic details and a detailed history were collected from the patient and a reliable informant using a semi-structured proforma.
8. Complete physical examination including neurological evaluation and detailed mental status examination was done.
9. All the subjects were administered Kuppusamy’s Socio economic scale 10. The subjects who have attempted suicide were administered Becks suicide
intent scale.
11. All subjects were assessed with Presumptive stressful life event scale Perceived stress scale, Multidimensional Scale of Perceived Social Support,
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Becks hopelessness scale, Barratt impulsiveness scale, Buss-Perry Scale, Hospital anxiety depression scale, Internet addiction test
12. Likewise 53 consecutive adolescent suicide atempters and 53 controls were assessed.
STATISTICAL DESIGN:
Statistical design was formulated using the data collected as above, for each of the scale and socio-demographic variables. Statistical analysis was done using SPSS (Statistical Package for Social Studies) version 14.0. The central values and dispersion were calculated. In comparison of the data for categorical variables chi- square and for numerical variables student t test were used. Correlation among variables was studied using Pearson’s correlation coefficient.
TOOLS USED:
1. Proforma
2. Kuppusamy rating scale for socioeconomic status 3. Becks suicide intent scale
4. Presumptive stressful life event scale 5. Perceived stress scale
6. Becks hopelessness scale 7. Barratt impulsiveness scale 8. Buss-Perry Scale
9. Hospital anxiety depression scale(HADS).
10. Multidimensional Scale of Perceived Social Support 11. Internet addiction test
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1.Proforma:
Proforma includes personal demographic details, present history, past history, family history, recent conflicts in adolescence, history of physical abuse, sexual abuse, parental discord, parental separation an parental loss, exposure to suicide/suicide attempt of others(including media reported),internet use, physical and mental status examination.
2. Kuppusamy Socio Economic Status Scale:
Kuppuswamy scale is widely used to measure the socio-economic status of an individual based on three variables namely, education, occupation and income. It was originally proposed in 1976. The scale was revised in 2012 were the monthly family income was modified based on current consumer price index. (BP Ravi Kumar et al, 2012).
3.Becks Suicide Intent Scale:
The suicide intent scale was developed by Aaron T. Beck and his colleagues at the University of Pennsylvania for use with patients who attempt suicide but survive. It is important to understand a patient's will to die in order to assess the severity of the suicide attempt. Some attempted suicides are carried out with little to no intention of cessation of life, while others clearly have no other goal. The suicide intent scale is an attempt to redefine the meaning of attempted suicide, placing them on a scale based on intent.
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Another factor that plays an important role, but is not listed on the scale below, includes the chosen method of attempted death. Hangings and firearms is clearly more effective tools of suicide, the damages much more difficult to reverse.
Suicide by poisoning, on the other hand, is less likely to be successful. This, however, is not the case in less developed nations, where access to emergency treatment is less possible and there is greater access to more deadly poisons such as pesticides. These factors must be also taken into consideration.
Scoring:15-19 Low Intent ;20-28 Medium Intent;29+ High Intent 4. Presumptive Stressful Life Events Scale:
It was originally devised by Gurmeet Singh et al in 1983 as a modification of the Holmes and Rahes social readjustment rating Questionnaire, for use in the Indian population. Due to the simplicity of the scale, it can be administered to illiterate population as well. The scale items were divided into personal or impersonal, desirable or undesirable and ambiguous. It consists of 51 items. It measures the mean number of stressful life events in the adult population in their lifetime and in the past year. The norms obtained on studying the Indian population indicated that an average Indian experiences about ten stressful life events, without suffering much physical or psychological distress. They experience an average of two stressful life events in one year. The study also indicated that neurotics were likely to report a higher number of life events. They also scored a higher stress score for the same event, as compared to the normal subjects.
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5.Perceived Stress Scale
The Perceived Stress Scale (PSS) by Sheldon Cohen is the most widely used psychological instrument for measuring the perception of stress. It is a measure of the degree to which situations in one’s life are appraised as stressful. Items were designed to tap how unpredictable, uncontrollable, and overloaded respondents find their lives. The scale also includes a number of direct queries about current levels of experienced stress.The items are easy to understand, and the response alternatives are simple to grasp. Moreover, the questions are of a general nature and hence are relatively free of content specific to any subpopulation group. The questions in the PSS ask about feelings and thoughts during the last month. In each case, respondents are asked how often they felt a certain way.
Scoring: PSS scores are obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2
= 2, 3 = 1 & 4 = 0) to the four positively stated items (items 4, 5, 7, & 8) and then summing across all scale items. A short 4 item scale can be made from questions 2, 4, 5 and 10 of the PSS 10 item scale.
6.Beck’s Hopelessness Scale (Aaron T.Beck, 1974)
The Beck Hopelessness Scale (BHS) is a 20-item scale for measuring negative attitudes about the future. Beck originally developed this scale in order to predict who would commit suicide and who would not.
Scoring: Scoring is straightforward; one simply adds up each of the items marked in the direction keyed for "hopelessness." Using the scoring template, one counts the number of blackened circles that show up under the circles on the
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template. The user bases his or her interpretation on the total scale score. Reliability:
The manual reports KR-20 coefficients (measures of the scale's internal consistency) ranging from .82 to .93.Validity: Concurrent validity.
7.Barratt impulsiveness scale:
The Barratt Impulsiveness Scale, Version 11 (BIS-11; Patton et al., 1995) is a 30 item self-report questionnaire designed to assess general impulsiveness taking into account the multi-factorial nature of the construct. The structure of the instrument allows for the assessment of six first-order factors (attention, motor, self- control, cognitive complexity, perseverance, cognitive instability) and three second- order factors (attentional impulsiveness [attention and cognitive instability], motor impulsiveness [motor and perseverance], nonplanning impulsiveness [self-control and cognitive complexity]). A total score is obtained by summing the first or second-order factors. The items are scored on a four point scale (Rarely/Never [1], Occasionally [2], Often [3], Almost Always/Always [4]).2nd Order Factor Item Content -Attentional Impulsiveness (8 items) ,Motor Impulsiveness (11 items), Nonplanning Impulsiveness (11 items),reversed item scored for 4, 3, 2, 1
8.Buss-Perry Scale:
The Buss–Perry Aggression scale was designed by Arnold Buss and Mark Perry, professors from the University of Texas at Austin It is a 29 item questionnaire where participants rank certain statements along a 5-point continuum from
"extremely uncharacteristic of me" to "extremely characteristic of me." The scores are normalized on a scale of 0 to 1, with 1 being the highest level of aggression.[2]
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The questionnaire returns scores for 4 dimensions of aggression:
Physical Aggression
Verbal Aggression
Anger
Hostility
1-9 are for Physical Aggression; 10-14 are for Verbal Aggression; 15-21 are foranger; 22-29 are for Hostility.
9. Hospital Anxiety And Depression Scale:
Hospital Anxiety and Depression Scale (HADS), developed to identify states of anxiety, depression, and emotional distress, is a self assessment scale and applied among patients who are being treated for an array of clinical disorders (Zigmond &
Snaith et al) It has a total of 14 items, with responses scored on a scale of 0-3, with 3 signifying elevated symptom frequencies (Goodinson et al.). Score for each subscale for depression and anxiety ranges from 0 to 21 with scores categorized as:
Normal (0-7)
Borderline abnormal (8-10) Abnormal (11-21)
Higher Scores on the whole scale assesses emotional distress with scores ranging from 0- 42, where higher scores representing distress. It takes on an average 2 to 5 minutes to complete and is done by the patients themselves. HADS requires the person to answer to
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the questions in relation to how they felt in the past week. HADS scale possesses good psychometric properties in requisites of inter correlation, homogeneity, factor structure, and internal consistency.
10.Multidimensional Scale of Perceived Social Support:
The Multidimensional Scale of Perceived Social Support is a measure of how much support a parent feels they get from family, friends and significant others.
Scoring the 12 questions relating to the extent to which they feel they have support of their family, friends and a special person. Each of these forms a separate subscale relating to perceived support from a significant other, from friends and from family.
Total Score can also be calculated.
11. Internet addiction test:
The Internet Addiction Test (IAT; Young, 1998) is a 20‑item 5‑point scale that measures the severity of self reported compulsive use of the internet. Total internet addiction scores are calculated, with possible scores for the sum of 20 items ranging from 20 to 100.The scale showed very good internal consistency, with an alpha coefficient of 0.93 in the present study.
According to Young’s criteria, total IAT scores 20-39 represent average users with complete control of their internet use, scores 40-69 represent overuses with frequent problems caused by their internet use,and scores 70-100 represent internet addicts with significant problems caused by their internet use.
RESULTS AND
INTERPRETATIONS
36
RESULTS AND INTERPRETATION
TABLE 1: TABLE SHOWING THE AGE ,SEX,RESIDENCE AND RELEGION DISTRIBUTION OF CASES AND CONTROL
S.NO VARIABLE
CASES(N=53) CONTROL(N=53)
n % n %
1 AGE
12 to 13 YRS 3 5.7 3 5.7
14 to16 YRS 18 33.9 23 43.4
17 to 19 YRS 32 60.4 27 50.9
2 SEX MALE 23 43.4 28 52.8
FEMALE 30 56.6 25 47.2
3 RESIDENCE
RURAL 21 39.6 33 62.3
URBAN 32 60.4 20 37.7
4 RELEGION
HINDU 45 84.9 39 73.6
CHRISTIAN 5 9.4 9 17.0
MUSLIM 3 5.7 5 9.4
From the above table, it is inferred that majority (60.4%) of adolescent suicide attempters belongs to the age group between 17 to 19 years. From the table, it is inferred that majority of the adolescent suicide attempters were females(56.6%) and that majority of adolescent suicide attempters belonged to urban population(60.4%) and majority of them belonged to Hindu religion(84.9%).
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CHART1- SHOWING THE AGE DISTRIBUTION OF CASES AND CONTROL
CHART-2 SHOWING THE SEX DISTRIBUTION OF CASES AND CONTROL
CASES
CONTROLS 0
10 20 30 40 50 60 70
RURAL
URBAN
CASES CONTROLS 0
10 20 30 40 50 60
MALE FEMALE
CASES CONTROLS
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CHART3- SHOWING THE RELEGION DISTRIBUTION OF CASES AND CONTROL
CASES
CONTROLS 0
20 40 60 80 100
HINDU
CHRISTIAN
MUSLIM
CASES CONTROLS
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TABLE : 2 TABLE SHOWING THE EDUCATION,OCCUPATION,SOCIO ECONOMIC STATUS,MARITAL STATUS,TYPE OF FAMILY DISTRIBUTION
S.NO VARIABLE
CASES(N=53) CONTROL(N=53)
n % n %
1 EDUCATION
PRIMARY 8 15.1 9 17.0
MIDDLE 12 22.6 16 30.2
HIGH SCHOOL 11 20.8 14 26.4
POST HIGH
SCHOOL
22 41.5 14 26.4
2 OCCUPATION
UNEMPLOYED 37 69.8 44 83.0
EMPLOYED 16 30.2 9 17
3 SOCIO
ECONOMIC STATUS
UPPER LOWER 41 77.4 44 83.0
LOWER MIDDLE
12 22.6 9 17.0
4 MARITAL
STATUS
MARRIED 4 7.5 4 7.5
UNMARRIED 49 92.5 49 92.5
5 TYPE OF
FAMILY
NUCLEAR 39 73.6 45 84.9
JOINT 14 26.4 8 15.1
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From the table it is inferred that majority of the adolescent suicide attempters have post high school education (41.5%) and majority of adolescent suicide attempters were unemployed (69.8%) and that majority of adolescent suicide attempters were belonging to upper lower socio economic class (77.4%) and majority of the adolescent suicide attempters were unmarried (92.5%) and majority of adolescent suicide attempters were from nuclear family(73.6%).
CHART 4- SHOWING THE EDUCATION DISTRIBUTION AMONG CASES AND CONTROLS
0 5 10 15 20 25 30 35 40 45
PRIMARY MIDDLE HIGH SCHOOL POST HIGH SCHOOL
CASES CONTROLS
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CHART 5- SHOWING THE OCCUPATION DISTRIBUTION AMONG CASES AND CONTROLS
CHART 6 SHOWING THE TYPE OF FAMILY AMONG CASES AND CONTROLS
0 10 20 30 40 50 60 70 80 90
UPPER LOWER LOWER MIDDLE
CASES CONTROL
0 20 40 60 80 100 120 140 160 180
NUCLEAR JOINT
CONTROL CASES
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TABLE :3 TABLE SHOWING THE FAMILY HISTORY OF PSYCHIATRIC ILLNESS AMONG CASES AND CONTROLS
S.NO VARIABLES
CASES (N=53)
n
CONTROL (N=53)
n
PEARSON CHI - SQUARE
χ2
P VALUE
1 PRESENT 31 12 14.126** 0.000
** = p<0.01
From the above table statistically significant difference is found between the 2 groups with respect to family history of psychiatric illness ,from this we infer that , there is significantly higher positive family history of psychiatric illness among adolescent suicide attempters , when compared to controls.
CHART 7- SHOWING THE FAMILY HISTORY OF PSYCHIATRIC ILLNESS AMONG CASES AND CONTROLS
0 5 10 15 20 25 30 35
FAMILYH/O PSYCHIATRIC ILLNESS controls
cases
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TABLE: 4 TABLE SHOWING THE FAMILY HISTORY OF SUICIDE AMONG CASES AND CONTROLS.
S.NO
VARIABLE S SUICIDE
CASES (N=53)
n
CONTROL (N=53)
n
PEARSO N CHI - SQUARE
χ2
P value
1 PRESENT 13 5 4.283* 0.038
*= p< 0.05, ** = p<0.01
From the above table statistically significant difference is found between the 2 groups with respect to family history of suicide, from this we infer that, there is significantly higher positive family history of suicide among adolescent suicide attempters, when compared to controls.
CHART 8- SHOWING THE FAMILY HISTORY OF SUICIDE AMONG CASES AND CONTROLS
0 2 4 6 8 10 12 14
FAMILY H/O SUICIDE CONTROLS
CASES
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TABLE 5: TABLE SHOWING THE FAMILY HISTORY OF SUBSTANCE USE AMONG CASES AND CONTROLS
S.NO VARIABLE
CASES (N=53)
n
CONTROL (N=53)
n
PEARSON CHI - SQUARE
χ2
P value
1 PRESENT 28 19 3.096 0.078
*= p< 0.05, ** = p<0.01
From the above table we infer that adolescent suicide attempters and controls do not differ with regard to family history of substance use.
CHART 9-SHOWING THE FAMILY HISTORY OF SUBSTANCE USE AMONG CASES AND CONTROLS
0 5 10 15 20 25 30
FAMILY H/O SUBSTANCE USE CONTROLS
CASES
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TABLE: 6 TABLE SHOWING SUBSTANCE USE AMONG CASES AND CONTROLS
*= p< 0.05, ** = p<0.01
From the above table it is inferred that adolescent suicide attempters and controls do not differ with regard to substance use.
TABLE: 7 TABLE SHOWING THE PSYCHIATRIC ILLNESS AND PREVIOUS HISTORY OF SUICIDE ATTEMPT AMONG CASES AND CONTROLS
S.
NO
VARIABLE
CASES (N=53)
n
CONTRO L (N=53)
n
PEARSON CHI - SQUARE
χ2
P value
1
SUICIDE PRESENT
7 4
0.913 0.339
2 PSYCHIATRIC ILLNESS
PRESENT 2 1
0.343 0.558
*= p< 0.05, ** = p<0.01 S.NO VARIABLE
CASES(N=53) n
CONTROL(N=53) n
PEARSON CHI - SQUARE
χ2
P value
1 PRESENT 8 9 0.070 0.791
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From the above table we infer that adolescent suicide attempters and controls do not differ with regard to history of psychiatric illness and past history of suicide attempt.
TABLE: 8 TABLE SHOWING THE OCCURRENCE OF RECENT CONFLICTS AMONG CASES AND CONTROLS
S.NO VARIABLE
CASES (N=53)
n
CONTROL (N=53)
n
PEARSON CHI - SQUARE
χ2
P value
1 PARENTS 25 9
23.770** 0.000
2 SIBLING 2 2
3 FRIENDS 5 5
4 SIGNIFICANT
OTHERS
8 1
*= p< 0.05, ** = p<0.01
From the above table statistically significant difference is found between the 2 groups with respect to conflicts, from this we infer that, there are significantly higher conflicts among adolescent suicide attempters, when compared to controls.
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CHART 10- SHOWING THE OCCURRENCE OF RECENT CONFLICTS AMONG CASES AND CONTROLS
TABLE :9 TABLE SHOWING THE PHYSICAL ABUSE AND SEXUAL ABUSE AMONG CASES AND CONTROLS
S.NO VARIABLE
CASES (N=53)
N
CONTROL (N=53)
n
PEARSON CHI - SQUARE
χ2
P value
1 PHYSICAL
ABUSE
PRESENT 30 17 6.460* 0.011
2 SEXUAL
ABUSE
PRESENT 2 0 2.038 0.153
*= p< 0.05, ** = p<0.01
0 5 10 15 20 25 30
PARENTS SIBLING FRIENDS SIGNIFICANT OTHERS
CONTROLS CASES
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From the above table statistically significant difference is found between the 2 groups with respect to physical abuse ,from this we infer that , there is significantly higher presence of physical abuse among adolescent suicide attempters , when compared to controls. From the above table we also infer that adolescent suicide attempters and controls do not differ significantly with regard to sexual abuse.
CHART 11 SHOWING THE PHYSICAL ABUSE AND SEXUAL ABUSE AMONG CASES AND CONTROLS
0 5 10 15 20 25 30 35
PHYSICAL ABUSE SEXUAL ABUSE
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TABLE 10 TABLE SHOWING THE PARENTAL DISCORD,PARENTAL SEPARATION,PARENTAL LOSS AMONG CASES AND CONTROLS
S.NO
VARIABLE
CASES (N=53)
n
CONTROL (N=53)
n
PEARSON CHI - SQUARE
χ2
P value
1 PARENTAL
DISCORD
PRESENT 23 12 5.161* 0.023
2 PARENTAL
SEPARATION
PRESENT 7 5 0.376 0.540
3 PARENTAL
LOSS
PRESENT 2 1 0.343 0.558
*= p< 0.05, ** = p<0.01
From the above table statistically significant difference is found between the 2 groups with respect to parental discord, from this we infer that , there is significantly higher presence of parental discord among adolescent suicide attempters , when compared to controls. From the above table we also infer that adolescent suicide attempters and controls do not differ with regard to parental separation and parental loss.
