|Year : 2016 | Volume
| Issue : 4 | Page : 260-267
Risk factors of suicide among patients admitted with suicide attempt in Tata main hospital, Jamshedpur
Manoj Kumar Sahoo1, Harshita Biswas2, Sanjay Kumar Agarwal3
1 Associate Specialist, Department of Psychiatry, Tata Main Hospital, Jamshedpur, Jharkhand, India
2 Clinical Psychologist, Department of Psychiatry, Tata Main Hospital, Jamshedpur, Jharkhand, India
3 Senior Consultant, Department of Psychiatry, Tata Main Hospital, Jamshedpur, Jharkhand, India
|Date of Web Publication||15-Dec-2016|
Manoj Kumar Sahoo
Department of Psychiatry, Tata Main Hospital, Jamshedpur, Jharkhand
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: More than one lakh lives are lost every year due to suicide in India. In the last three decades (from 1975 to 2005), the suicide rate has increased by 43%. Jamshedpur is an Industrial town, which is rapidly growing and having population with mixed cultural background. Recently, there has been increasing trend in a number of suicide attempt across various age groups; there are around 300 cases of suicide attempt admitted to Tata Main Hospital each year. Objective: To study the risk factors associated with suicide attempts. Methods: The study was carried out in the Tata Main Hospital, Jamshedpur. Over a period of 6 months, we gathered data of 101 suicide attempters referred from medical, surgical departments and casualties and taken up for the study. Data were collected on specific pro forma was prepared to collect various others risk factors. Results: More number of female patients compared to male, younger age, lower-middle income group, urban background, school educated, and unemployed were more represented in this study. In 70% of patients, psychiatric disorder was found, but few among them had prior treatment. Increased family conflicts, marital problems, financial difficulties, and perceived humiliations are some of the risk factors. Conclusion: The early identification and treatment of vulnerable populations with risk factors for suicide across the lifespan will help in planning and implementing strategies for prevention.
Keywords: Risk factors, suicidal intent, suicide
|How to cite this article:|
Sahoo MK, Biswas H, Agarwal SK. Risk factors of suicide among patients admitted with suicide attempt in Tata main hospital, Jamshedpur. Indian J Public Health 2016;60:260-7
|How to cite this URL:|
Sahoo MK, Biswas H, Agarwal SK. Risk factors of suicide among patients admitted with suicide attempt in Tata main hospital, Jamshedpur. Indian J Public Health [serial online] 2016 [cited 2017 Sep 23];60:260-7. Available from: http://www.ijph.in/text.asp?2016/60/4/260/195853
| Introduction|| |
More than one lakh lives are lost every year due to suicide in India. In the last three decades (from 1975 to 2005), the number of suicides per one lakh population (suicide rate) has increased by 43%. However, the male-female ratio has been stable at around 1.4–1. There is a wide variation in suicide rates within the country. The Southern states of Kerala, Karnataka, Andhra Pradesh, and Tamil Nadu have a suicide rate of >15, whereas in the Northern States of Punjab, Uttar Pradesh, Bihar, and Jammu and Kashmir, the suicide rate is <3. This variable pattern has been stable for the last 20 years. Higher literacy, a better reporting system, lower external aggression, higher socioeconomic status, and higher expectations are the possible explanations for the higher suicide rates in the southern states. Majority of the suicides (37.8%) in India are by those below the age of 30 years. The fact that 71% of suicides in India are by persons below the age of 44 years imposes a huge social, emotional, and economic burden on society.
The actual number of suicides is understandably more than the reported official figures such as nonreporting, underreporting, and misclassification are prevalent due to various sociocultural stigmas, religious sanctions, legal issues, and insufficient registration systems. It has been suggested that the annual suicide rate could be 6–9 times the official rate. There has been less work in systematic profiling of risk factors in developing countries compared to the developed counterparts. Variations in suicide risk factors in different cultures and periods are known; and it is acknowledged that more research is required, especially from developing nations.
Tata Main Hospital is situated in the urban city of Jamshedpur; it is a 914-bedded multispecialty hospital. Jamshedpur is an Industrial town, which is rapidly growing and having population with mixed cultural background from Jharkhand, West Bengal, Bihar, Orissa, and other part of countries. Recently, there has been increasing trend in a number of suicide attempts across various age groups, particularly young adults in Jamshedpur.
Over the years, according to the National Crime Records Bureau, in Jamshedpur, the risk factors for suicide found were suspected/illicit relation, failure in examination professional/career problem, and fall in social reputation. To the best of our knowledge, there are no studies that have been reported from industrial townships and from the state of Jharkhand. Thus, the specific objectives of this study were to study the risk factors associated with suicide attempts in a sample from Jamshedpur and to reflect on the possible prevention methods.
| Materials and Methods|| |
The study was carried out in the Tata Main Hospital, Jamshedpur. “Any act of self-damage inflicted with self-destructive intentions, however vague and ambiguous” was taken as a suicide attempt, for the purpose of the study. The study design was hospital-based cross-sectional study and sampling technique used was purposive sampling. Over a period of 6 months (August 2013–January 2014), data of suicide attempters were gathered referred from medical, surgical departments and casualties and took them up for the study. All the suicide attempters admitted to the hospital were referred for psychiatric evaluation considering medicolegal issues. In addition, the departments were informed about the study to ensure prompt referral. Patients whose injuries were considered to be accidental in origin with no suggestion of self-harm intention were excluded after detailed interview by the psychiatrist. The patients were interviewed once they gained physical stability after resuscitation and a period of observation in the medical or surgical unit. Close family members of each patient were interviewed with the patients' consent for additional information. No specific data collection pro forma was designed for the family members. The family members were interviewed to corroborate the information given by the patient regarding the risk factors. Patients were selected on the criterion of attempted suicide. The study was explained to selected individuals, and those who fulfilled the criterion and agreed to participate were included in the study.
The study protocol was approved by the Institutional Ethics Committee. Informed consent was collected from the participants and confidentiality was assured. A semi-structured pro forma was used for recording the sociodemographic profile, methods, and situations around the suicide attempt, intent, method, and clinical profile of the patient. Psychiatric diagnoses were made according to diagnostic criteria for research of International Classification of Diseases-10 Classification of Mental and Behavioral Disorders  by the researchers.
Suicidal ideation was assessed through interview with patient and rated as low, medium, and high according to the frequency of suicidal ideation. Suicide intent was studied by applying Pear's suicide intent scale; the scores indicate the severity of the intent of the suicide. It is divided into three parts; low, medium, and high intent. 0–3 indicates low intent; 4–10 indicates medium intent, and score >10 indicates high intent.
The psychosocial risk factors and personality factors (PFs) were assessed using a form called Suicide Risk Assessment Guide. The form has been published in the book, Suicide Risk Assessment - a Manual for Health Professionals.
Descriptive statistics were used to compute the mean standard deviation and frequency. Chi-square test was used to test the variable for significance followed by regression analysis to compare the significance among 3 age groups.
| Results|| |
The results include the sociodemographic profile of the suicide attempters, where n = 101, the sociodemographic profile of attempters is given in [Table 1]. The clinical characteristics are presented in [Table 2]. There was no refusal for participation in the study by the attempters and their family. The sample consisted of 42 males and 59 females. The remaining variables of family, psychosocial factors, and PFs are presented in [Table 3].
|Table 1: Sociodemographic profile of suicide attempters admitted in Tata main Hospital, Jamshedpur|
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|Table 2: Descriptive statistics for the clinical variables across all age groups|
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|Table 3: The descriptive statistics for family factors, psychosocial factors, and personality factors across all the age groups|
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Attempters were categorized as up to 19 years, 20–40 years, and 41–65 years. To compare the three groups, Chi-square test and regression analysis were used. The results show attempters mostly were found in the age group of 20–40 years. There were more female attempters compared to males, mostly of Hindu religion and significantly high number of attempters were single (P < 0.05). There was a significant difference in the educational groups (P < 0.05) that persons with fewer years of education, that persons with fewer years of education were more compared to others educational groups. Among the three groups, a significant number of matriculate and under matriculation people belonged to the age group of 20–40 years. The variable occupation was found to be statistically significant (P < 0.05) where 50.5% were students, followed by housewives, semi-skilled, professional, and unemployed individuals. Most of the attempters (43.6%) had a family income greater than Rs. 20,000 belonged to nuclear type of family (60.4%) and hailed from an urban locality (79%).
Clinical characteristics of the sample include the suicidal intent, suicidal ideation, suicidal plan, methods of suicide, and psychiatric diagnosis.
The mean suicidal intent was 10.9, with a standard deviation of 7.5, indicating mostly the suicide intent ranged from high to medium intent in attempters. The variable suicidal plan was found to be significant (P < 0.05), especially among the age group up to 19 years. Nearly 68.3% of the suicide attempts were committed after a precipitating factor triggered the event. The most common methods of suicide found were consumption of phenyl, other forms of cleaners, consumption and overdose of medication lying at home such as iron capsules, and pain medication contributing to 36.6% of cases. Followed by benzodiazepines consumed by 25.7%, pesticides (21.8%), and the least common method being cutting and slashes with amounted to 4%. Presence of psychiatric diagnosis was present in 70% of the cases, and 30.7% of the patients were found to have depression followed by adjustment disorder and the least common diagnosis being anxiety disorder.
In this sample of suicide attempters, 31% had family risk factors such as history of suicide in family members and 10% had family conflict out which 1% was subjected to domestic violence. A significant percentage of suicide attempters 79% were found to have psychosocial risk factors and 49% have personality risk factors. The psychosocial risk factors which contributed the highest were perceived humiliation, marital/relationship problems, financial difficulties, and interpersonal issues. The PFs which were commonly seen were poor affective control, impulsivity, and poor coping skills.
| Discussion|| |
Risk factors observed to be associated with the suicide in this study were consistent with those reported commonly in literature. However, there were variations and the results suggested locally relevant issues that can contribute to prevention strategies.
Sociodemographic risk factors
Age and gender
A preponderance of younger age groups is frequently noted in suicide attempts. Similar to the earlier studies, in this study, 61% of attempters belonged to the age group between 20 and 40 years followed by 19 years and below. Majority of the suicides in these age groups denote that the most productive age groups of being at risk and thus imposing a huge social, emotional, and economic burden on society. The study showed more female attempters compared to their male counterparts. Globally, attempted suicide is more common in women and completed suicide is more common in men. Men commonly use more lethal modes and plan the act more meticulously to avoid detection. In contrast, women commonly use less lethal modes and are more impulsive, less well planned, and more likely to be found and rescued. Although some Indian studies have found a higher incidence of suicide in men than in women, others have found the contrary. The reasons for greater female suicide completion in India may be sociocultural. The common practice of arranged marriages in India results in social and family pressure for the woman to stay married even in an abusive relationship; this may increase the risk of suicide in women.
According to literature, marriage is generally protective against suicide; this empirical regularity is referred to as the “coefficient of preservation” based on Durkheim's 1897 seminal monograph Le Suicide. Persons living alone are at particular risk. However, in Indian studies, it is common to find a higher proportion of attempters being married. In the present study, married attempters constituted around 43% and single constituted to be 52.5%. In the current study, the sample predominantly comprised younger population and students. Being single, divorced or separated, or widowed has been found to be risk factors in many Western studies although it may not be predictive in developing countries.
Education and occupation
Level of educational attainment is a surrogate marker of intelligence though drawing conclusions on this premise is problematic when education is not universally available. The National Crime Record Bureau (NCRB) data reveal that 25.3% of suicide victims were educated up to primary level, 23.7% had a middle-school education, 21.4% were illiterate, and 3.1% were graduates or postgraduates. Index study results showed that lower level of education such as 42% matriculation and 30% below matriculation were significantly more compared to other educational groups. Thus, displaying similar results with the earlier studies that stated, low intelligence results in a 2–3-fold increased risk of suicide. Possible explanations are that persons with low intelligence are less able to compete for jobs and therefore acquire lower income and social status. They may also be less efficient in coping with stress. There is a fairly strong association between unemployment rates and suicide, but the nature of this association is complex. The study showed more number of attempters were students (46%) compared to other group of skilled or semi-skilled professional, this results are similar to few earlier studies by Rao, where similar results were observed.
There have been not many studies that have assimilated the data for suicide plan. In the current study, it was seen that suicidal plan was present in 23% of the subjects. In a study by Kar, in which the suicidal intent was studied showed, a little over one-third of the attempters reported unequivocal intent to die. It was evident that the ones who were more determined to die, had planned their attempts, and the planned attempt was also significantly associated with persons with psychiatric illness.
In India, during 2012, the means adopted for committing suicide varied from the easily available means such as consumption of poison, jumping into the well, etc., to more painful means such as self-inflicted injuries, hanging, and shooting. The most common modes of suicide were consumption of a poison (32.3%), hanging (33.2%), self-immolation (8.8%), and drowning (5.9%) are jumping from buildings accounted for 1.3%. This pattern is recapitulated in the NCRB 2013 report. Studies show that consumption of pesticides, such as the readily available agricultural pesticides in rural areas, is the most common means of suicide and attempted suicide in India  and in rural areas of low-income countries. In the present study though we have not found the pattern to be similar as the sample consisted more of urban population, so phenyl consumption and general medication lying at home were found to be the common method. The difference between countries in methods employed for suicide may reflect differences in socioeconomic factors, availability of lethal means, and firearms legislation, rather than differences in the nature of the behavior, per se common methods used in developed countries include firearms, car exhaust asphyxiation, and poisoning, whereas in developing countries, pesticide poisoning, hanging, and self-immolation lead the list.
Studies in India show varying results with rates of psychiatric disorders, few studies ranging from 9.5% to 24.9%. Mood disorders, particularly depressive disorders, were the most common diagnosis followed by alcohol abuse. Neurotic, stress-related, and somatoform disorders were diagnosed in 14.5%. In the index study, the percent of psychiatric diagnosis which was around 70% where depressive disorders were the most common followed by adjustment disorder and least common being substance abuse and anxiety disorder. Mental disorders (particularly depression and alcohol use disorders) are a major risk factor for suicide in Europe and North America; however, in Asian countries, impulsiveness plays an important role. It is often reported that rates of psychiatric disorders are higher among suicide completers in developed countries relative to developing countries though under-diagnosis in developing countries is a possible explanation.
The relationship of suicide to negative life events, stress, object loss, and negative interaction needs to be understood in the framework of a model of vulnerability, support, coping, and problem-solving. Indian society, being sociocentric, lays importance on interpersonal relationships. It is, therefore, unsurprising that marital conflict is the most common cause of suicide among women, whereas interpersonal conflict is the most common cause among men. In our study also similar findings have been observed as most of precipitating events were conflicts in relationships, either with spouse, parents, or love interest. Few studies reflected other suicide trigger that includes physical illness, bankruptcy, illicit relationships, and drug intoxication. An interesting finding, rarely seen in the West, is the high rate of suicide associated with sexual abuse and illegitimate pregnancy. This may be a reflection of cultural taboos related to sexuality in India.
The study results showed some psychosocial factors contribute to the suicidal attempts such as perceived humiliation, marital and relationship issues, and financial issues. As already discussed in the earlier segment, the precipitating factors commonly seen are interpersonal conflict, marital conflict, and some studies even showed the presence of difficulties such as bankruptcy. Thus, the results are in synchronization with the earlier studies where these have been pointed out as the common psychosocial concerns in developing countries like India. In India, the top 10 causes or correlates of suicide in 2013 were family problems (24%), illness (19.6%), unemployment (1.6%), love affairs (3.3%), drug abuse/addiction (3.4%), failure in examination (1.8%), bankruptcy or sudden change in economic status (2.0%), poverty (1.4%), and dowry dispute (1.7%). Many of the remaining causes, namely, suspected/illicit relation, cancellation/nonsettlement of marriage, not having children (barrenness/impotency), death of a dear one, dowry dispute, divorce, ideological causes/hero worship, illegitimate pregnancy, physical abuse (rape, incest, etc.), poverty, professional/career problem  reflect the unique social structure of our society, and the social pressures that individuals face.
Fergusson et al. found that two dimensions of personality – neuroticism and novelty seeking were significantly correlated with suicidal ideation and suicide attempt. Other traits such as low self-esteem, perfectionism, external locus of control, impulsivity, and aggression have been suggested in literature. However, the available research for any specific trait is relatively sparse and often equivocal. Multiple suicide attempts of low intentionality and lethality are typically associated with maladaptive coping and impulsivity in personality disorders. The rate of personality disorders among those who attempt suicide in India ranges from 7% to 50% in various studies. In a 16-PF study of personality, attempters were found to lack ego strength, lack frustration tolerance, be emotionally less stable, and be impulsive. The association of impulsivity and marital discord among self-immolators has been frequently reported in Indian and other Asian studies. The current study also revealed that the most common PFs are maladaptive coping style, poor affective control, and impulsivity.
The study findings reflect the profile of suicide attempters attending tertiary level hospitals and may not be generalized to all suicide attempters in the general population. There may be a recall bias for family and past histories. The sample size can be considered small. No structured scale or tool was used to assess personality risk factors.
| Conclusion|| |
Psychosocial and clinical risk factors associated with suicide attempts in Jamshedpur resembled those described in literature, but with a few variations. The early identification and treatment of vulnerable populations with risk factors for suicide across the lifespan will help in planning and implementing strategies for prevention. The identification of such individuals requires a multidisciplinary approach with active participation from teachers, school authorities, health professionals, and the legal system. The findings of this exploratory study also identify areas for further focused research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]