|Year : 2017 | Volume
| Issue : 1 | Page : 34-39
Self-reported suicidality behavior and attitudes toward suicide among medical and paramedical students
Ashish H Patel1, Ritambhara Y Mehta1, Nilanjan Chandra1, Pradhyuman Chaudhary1, Ravi H Shah2
1 Department of Psychiatry, Government Medical College, Surat, Gujarat, India
2 Consultant Psychiatrist, Surat, Gujarat, India
|Date of Web Publication||19-Jun-2017|
Ashish H Patel
B-302 Satkar Residency, Near Global Gajera School, T.P 10, Pal, Surat - 395 009, Gujarat
Source of Support: None, Conflict of Interest: None
Aims and Objectives: The aim of this study was to evaluate knowledge and attitudes toward suicide and suicidality behavior among medical and paramedical students. Materials and Methods: A cross-sectional study was conducted in a medical college of western India where undergraduate medical (238), physiotherapy (25), and nursing (137) students were enrolled. After taking informed consent, detailed assessment of knowledge, attitude towards suicide using Suicide Opinion Questionnaire and suicidality behavior using mini-international neuropsychiatric interview were done. Data were analyzed using appropriate statistical tests. Results: Ninety-three percent students agreed “people who are at risk can't be easily identified.” Eighty percent students believed “potentially anyone can be a suicide victim.” Acceptability of suicide was highest in nursing students; B.P.T students had highest knowledge regarding suicide. None had active suicidal ideation or planning. Only at a thought level, one-third of total population reported feeling of hopelessness sometime in their life. Sixteen percent, nearly double females (n = 299) thought sometimes in their life that “it would be better off dead” compared to 8% males (n = 101). Among three groups, nursing students showed highest suicidality behavior. Conclusions: Attitudes toward suicide and suicidality behavior differ among the groups with significant gender differences. Although acceptability is the highest among nursing students, the group is at higher risk with higher suicidal ideation. Students believe, “people who are at risk can't be easily identified;” hence, further exploration, awareness, and interventions are suggested.
Keywords: Attitude, knowledge, medical and paramedical students, suicidality behavior
|How to cite this article:|
Patel AH, Mehta RY, Chandra N, Chaudhary P, Shah RH. Self-reported suicidality behavior and attitudes toward suicide among medical and paramedical students. Ann Indian Psychiatry 2017;1:34-9
|How to cite this URL:|
Patel AH, Mehta RY, Chandra N, Chaudhary P, Shah RH. Self-reported suicidality behavior and attitudes toward suicide among medical and paramedical students. Ann Indian Psychiatry [serial online] 2017 [cited 2019 Mar 18];1:34-9. Available from: http://www.anip.co.in/text.asp?2017/1/1/34/208336
| Introduction|| |
Suicide can be defined as intentional self-inflicted death, a complex human behavior as well as multifaceted health problem. Globally, one million people die from suicide annually. Approximately, 500 adolescents complete suicide each year. In the world, suicide mortality rate is 1.6/100,000; whereas in India, it is 10.3/100,000. India alone contributes to more than 10% of suicides in the world and out of that, over 71% of suicides are below the age of 44 years. This imposes a huge social, emotional, and economic burden on the society. These official statistics are considered to be an underestimate of the true incidence of suicidal behavior as they are underreported due to the public stigma and cultural taboos associated with suicide.
Adolescent suicide has become an issue of increasing concern over the past 25 years. Epidemiological studies have demonstrated a significant rise in suicidal behavior among adolescents to the extent that suicide is presently the second leading cause of death for the 15–19 year of age and the third leading cause of death among adolescent of 15–24 years of age in the world.,, Suicide attempts are even more prevalent than completions, with estimates ranging between 50 and 200 attempts for every actual suicide., In middle and low-income countries, reliable figures on suicide rates are lacking and there are few studies on suicidal attitude and knowledge among college students.
There are many myths and facts related to suicide. Suicidal behaviors are common and problematic among young populations. As both medical as well as paramedical individuals are included in the management of suicidal patients, medical and paramedical personnel's attitudes toward suicide play a key role in the management of suicide. Every completed suicide is a potentially preventable death if warning signs and symptoms are identified early and managed with the help of individual and support system. Sometimes, simply talking to a sympathetic, nonjudgmental listener is enough to prevent the person from attempting suicide. In India, several studies are done on prevalence of suicide, but few focusing on knowledge and attitudes toward suicide. This study attempts a holistic approach to evaluate knowledge and attitudes toward suicide and suicidality behavior among medical and paramedical students.
| Materials and Methods|| |
A cross-sectional study using quantitative and qualitative questionnaire was conducted in a medical college of western India where undergraduate medical (1st, 2nd, 3rd year), physiotherapy and nursing students of campus colleges were enrolled in the study. All the participants were unmarried. After approval from the Institute's Ethics Committee and respective authorities of colleges, entire batches of students were assessed simultaneously in a lecture hall during routine nonclinical, paraclinical, and clinical lecture sessions of 2 h of each batch. Students who were present during lectures were enrolled. “Participant information sheets” were given and informed consent forms were duly filled by participants before the study. Anonymity was explained.
A detailed assessment of knowledge and attitudes toward suicide and suicidality behavior was undertaken using two different questionnaires. For assessing attitude and knowledge, structured questionnaire, Suicide Opinion Questionnaire (SOQ) and for suicidality behavior, Module C Mini International Neuropsychiatric Interview  were used. Questions were asked aloud with interpretations, examples, and explanations whenever demanded by students. The data collection was followed by an interactive session on suicide prevention and awareness.
Consenting participants could know the results of their own assessment if they requested for the same. Detailed evaluation of the problem and requisite follow-up visits were provided from the Department of Psychiatry depending on the need and willingness of the participant. All participants were offered therapeutic help (maintaining their confidentiality) by the Department of Psychiatry consultants if their suicidality behavior was found problematic on the tool and if they were willing to take the help. Two students approached afterward and were counseled accordingly. Because all the students were not interviewed and assessed individually, the results were discussed as only propensity for suicidality and not as an established diagnosis of any disorder. Data were tabulated and analyzed using appropriate statistical methods. Responses were expressed in proportions.
Suicide Opinion Questionnaire
It is a 111-item questionnaire from which relevant 51 questions related to students were selected after focused group discussion among four psychiatrists. The removed items were mainly tapping marriage or old age-related items. SOQ is a five-point Likert scale ranging from strongly disagree (0) to strongly agree (4). Fifty-one questions were further divided into five domains.
- Acceptability domain (eight statements) taps whether people accept suicide in terminally ill, disabled, or think that suicide is a normal act or personal act, should not be interfered with
- Perceived factual knowledge domain (17 statements) taps suicide characteristics of rate, prevalence, influencing factors (protective or leading to suicide), relationship with mental illness
- Social disintegration domain (five statements) taps asociality, loneliness, helplessness as a factor for suicide
- Personal defect domain (14 statements) taps suicide is because of some defect in personality or maladaptive coping pattern
- Emotional perturbation domain (seven statements) taps emotional instability or impulsivity as reasons of suicide.
Mini International Neuropsychiatric Interview-6
It has various modules from which Module C which taps suicidality behavior was used. Module C consists of 18 questions where initial questions explore hopelessness and passive death wishes while further questions explore more severe and intense suicidal behavior.
| Results|| |
Total 400 students participated in this cross-sectional study, among them 238, 137, and 25 students were from medical, nursing, and physiotherapy colleges, respectively. Seven students refused to take part as they were refusing to get involved in a topic regarding suicide (all were medical students). Age of samples ranged from 18 to 23 years with mean of 20.2 ± 2.6 years. Out of 400, 101 (39.2%) were males and 299 (60.8%) were females [Table 1].
Attitudes towards suicide
Out of 51 questions of SOQ, the polarized statements in which more than 50% students agreed are shown in [Table 2] while others' questions had neutral responses. Sixty percent students agreed that “many suicide notes reveal substantial anger toward world.” Sixty-four percent students agreed that “people who threaten to commit suicide rarely do so.” Sixty-three percent students agreed that “large percentage of suicide victim's note is of unreturned love.” Almost three-fourth of the students, i.e., 77% agreed that “people are not acting rationally at the time of suicide.” Sixty-five percent students agreed that “external factors like lack of money are major factor for suicide. Almost two-third students believed that most suicides are due to loneliness. Half of the students had uncertain attitude whether “suicide attempt results in death.” Eighty-seven percent students agreed that “most suicide attempters fail in their attempt and should undergo therapy.” Almost all students agreed that “people who are at risk can't be easily identified.” Eighty percent students believed that “potentially anyone can be a suicide victim” [Table 2].
Gender differences in attitudes toward suicide
Males and females did not differ much in attitudes toward suicide. There were significant gender differences in only 9 statements out of 51 statements of SOQ seen on independent t-test. Only in two statements more females agreed than males that “suicide is an impulsive and evil act which should not be condoned.” On the other hand, males strongly believed that “many suicide notes reveal loneliness, substantial anger towards the world; suicide attempters have a weak personality structure, usually seeking sympathy from others, attempters are atheists; suicide attempt is a “cry for help” and majority of suicide attempts result in death” [Table 3].
Correlation between five Suicide Opinion Questionnaire subscales
The Pearson correlation regarding the association between the five SOQ subscale scores revealed that the subscale “personal defect” and “social disintegration” had a statistically significant positive linear relationship with moderate strength of association. The subscale “personal defect” and “acceptability” had a statistically significant negative linear relationship with mild strength of association. The acceptability of suicide was low in students who believed that suicide attempters were more socially disintegrated and had personal defect [Table 4].
|Table 4: Correlation between five Suicide Opinion Questionnaire subscales|
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Differences among student groups toward five Suicide Opinion Questionnaire subscales
Although nursing students thought that social disintegration and personal defect were least contributors for suicide, their acceptability were highest among the three. Nursing students had higher knowledge regarding suicide than M.B.B.S. B.P.T students had highest knowledge and they were more agreeable that social disintegration, personal defect, and emotional perturbation lead to suicide but showed least acceptability toward suicide. In comparison to B.P.T students, acceptability toward suicide was higher in M.B.B.S students, but they thought emotional perturbation was the least contributor for suicide [Table 5], Post hoc ANOVA test used].
|Table 5: Differences among student groups toward five Suicide Opinion Questionnaire subscales|
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Gender differences in suicidality behavior
None had active suicidal ideation or planning. Only at a thought level, one-third of total population reported feeling of hopelessness sometime in their life. Sixteen percent, nearly double females (n = 299) thought sometimes in their life that “it would be better off dead” compared to 8% males (n = 101) [Table 6].
Suicidality behavior among various groups
Among three groups, nursing students showed highest suicidality behavior intended to hurt themselves in any accident either actively or passively, thought about killing themselves. More M.B.B.S students felt hopelessness and had mental images of harming themselves with at least a slight intent to die in comparison to other groups [Table 7].
| Discussion|| |
The study of college students done by Bernard and Bernard suggested that depression, isolation, and anger are the feelings most often expressed by 75% of suicides attempters. In this study, approximately two-third students agreed that most suicides were due to loneliness and anger toward the world [Table 2].
Cross-cultural comparisons on attitudes toward suicide have demonstrated overall permissiveness and the view that suicidal acts are a private or joint matter; gender differences have also been seen in the moderator role in the relationship between hopelessness, depressive symptoms, and levels of individual's suicidal ideation., In our study also, there were significant gender differences in attitudes toward suicide in 9 statements [Table 3].
Previous many research works on attitudes toward suicide were done on psychologists. Domino et al. studied medical students and found that they tended to characterize suicides more as a mental illness outcome, whereas psychology students identified suicide as a personal right/choice. The antipodal findings from one study suggested that Japanese medical students agreed with the choice of voluntary death under specific circumstances (for example, “suicide is an acceptable means to end an incurable illness”). In this study, acceptability of suicide was the highest among nursing students [Table 5].
Differences were noted in the prevalence of suicide ideation and behavior among middle school students between genders and grades in China. Similarly, in our study, there were differences among gender as well as groups in suicidality behavior [Table 6] and [Table 7].
Domino et al. studied that psychology students had a higher prevalence of suicidal thoughts and previous suicide attempts compared to medical students. In our study, comparatively nursing students showed highest suicidality behavior corroborating the facts that paramedical students had more suicidal tendency and behavior. Culp et al. surveyed a sample of high school students and found 6% had attempted suicide, while 33% had reported some degree of suicide ideation. Similar results have been obtained by Eskin  indicating that suicidal behavior is indeed highly prevalent within the adolescent population. Study among college students in Turkey reported suicidal ideation to be 11.4%, which is similar to the study from India and the latter highlighted the relationship between social discrimination and suicidal behavior. In this study, none had attempted suicide, but 57 (14%, n = 400) students thought that “it would be better off dead” sometimes in their life [Table 7].
Two different scales were used to assess attitude and behavior toward suicide and correlation between five SOQ subscales was assessed.
It was a cross-sectional study and the sample size was small. Out of 111 items of SOQ, only 51 items were taken and used in the structured questionnaire. Students were surveyed simultaneously in a group setting, individual interviews were not taken.
| Conclusions|| |
Attitudes toward suicide and suicidality behavior differ among the groups with significant gender differences that of higher suicidal ideation in females. Although acceptability is the highest among nursing students, the group is at higher risk with higher suicidal ideation. Students believe, “people who are at risk can't be easily identified;” hence, further exploration, awareness and interventions are suggested.
Implications of the study
Suicidality behavior is a highly complex biopsychosocially governed behavior. Medical, nursing, and physiotherapy professionals deal with chronically ill, depressed, and suicidal patients. Nursing students despite being more knowledgeable about suicide, also were more accepting, and reported higher levels of suicidal behavior. Acceptability justifies a behavioral pattern and therefore could have an association with higher suicidal behavior. These findings suggest that emotional understanding of a subject is equally if not more important compared to knowledge about the subject. It is, therefore, important to incorporate not only knowledge but also attitudes and acceptability about suicide in students and patients in medical and paramedical training through case discussions and informal forum.
The author is thankful to Dr. Naresh Chauhan, Assistant Professor, Department of Preventive and Social Medicine, Government Medical College, Surat, for statistical analysis of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaplan HL, Sadock BJ. Synopsis of Psychiatry. 8th
ed., Ch. 3. New York: Lippincott Williams and Wilkins; 1998. p. 864-72.
Cantor C. Suicide prevention and schools. Aust J Guid Couns 1995;5:81-5.
Vijayakumar L. Indian research on suicide. Indian J Psychiatry 2010;52 Suppl 1:S291-6.
Berman AL, Jobes DA. Suicide prevention in adolescents (age 12-18). Suicide Life Threat Behav 1995;25:143-54.
Centers for Disease Control and Prevention (CDC). Suicide among children, adolescents, and young adults – United States, 1980-1992. MMWR Morb Mortal Wkly Rep 1995;44:289-91.
Commonwealth Department of Health and Family Services. Adolescent Suicide in Australia: A Background Monograph. Canberra, Australia: Australian Government Public Services; 1997.
Orbach I, Bar-Joseph H. The impact of a suicide prevention program for adolescents on suicidal tendencies, hopelessness, ego identity, and coping. Suicide Life Threat Behav 1993;23:120-9.
Steele A, McLennan J. Suicidal and counter-suicidal thinking. Aust Psychol 1995;30:149-52.
Domino G, Moore D, Westlake L, Gibson L. Attitudes toward suicide: A factor analytic approach. J Clin Psychol 1982;38:257-62.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al.
The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33.
Bernard JL, Bernard ML. Factors related to suicidal behaviour among college students and the impact of institutional response. J Coll Stud Pers 1982;2:409-13.
Domino G, Takahashi Y. Attitudes toward suicide in Japanese and American medical students. Suicide Life Threat Behav 1991;21:345-59.
Gibb BE, Andover MS, Beach SR. Suicidal ideation and attitudes toward suicide. Suicide Life Threat Behav 2006;36:12-8.
Chang WW, Yao YS, Yuan H, Chen BF, Liang YL, Chen Y, et al.
Prevalence of suicide ideation among middle school students in China: A systematic analysis of studies between 2000 and 2012. Zhonghua Liu Xing Bing Xue Za Zhi 2013;34:515-9.
Domino G, Lin J, Chang O. Attitudes toward suicide and conservativism. A comparison of Chinese and United States samples. Omega J Death Dying 1995;31:237-52.
Culp AM, Clyman MM, Culp RE. Adolescent depressed mood, reports of suicide attempts, and asking for help. Adolescence 1995;30:827-37.
Eskin M. Opinions about and reactions to suicide, and the social acceptance of a suicidal classmate among Turkish high school students. Int J Soc Psychiatry 1992;38:280-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]