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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 20-27

Profile of “Suspected Suicide Attempters” based on variations in intent


Department of Psychiatry, Hassan Institute of Medical Sciences, Hassan, Karnataka, India

Date of Submission24-Mar-2019
Date of Decision23-May-2019
Date of Acceptance04-Jun-2019
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Bharathi Gunjahalli
W/O Dr. Dhananjaya JR, Nirvikalpa, Beside Kaveri (Unnati) School, Shantinagar, Hassan - 573 202, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_20_19

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  Abstract 


Background: Suicide and attempted suicide are on a rise in India. Suicide attempt is an area which is well researched. However, there is a dearth of studies that focus on any other/absence of suicidal intent in “suspected suicidal attempters” (SSA). The present study aimed at identifying the presence or absence of intent in SSA to gain insight into the preventive methods. Methods: This study was based on cross-sectional baseline data of an ongoing prospective study of suicide attempters undertaken in General Hospital Psychiatry Unit. Convenient sampling was done; data were collected using semi-structured pro forma. Consenting medically stable SSA referred for psychiatric evaluation were included, and grouped based on variations in intent. Using SPSS software version 20.0, descriptive and inferential statistics were done. Results: Two hundred and forty-two participants were included in the study. Majority of participants (73.55%) with suicide intent were impulsive and 15.29% were planned. About 11.16% of participants had no intent (accidental incidents). Participants in accidental group were significantly older and more often diagnosed with alcohol use disorder (AUD) than the other two groups. Significantly, more number of agriculturists attempted impulsively/accidentally. Planned attempters significantly had less social support, higher suicide intent, and were more depressed. Conclusions: A tetrad of rural background, agriculturist, poisoning with pesticides, and AUD was seen in accidental and impulsive attempters, a noteworthy finding requiring imposing restrictions on the availability of alcohol and pesticides to prevent such occurrences. Accidental incidents as a group need further research and classification for its clinical and legal impact.

Keywords: Accidental, impulsive, no intent, planned, suicide attempt, suicide intent


How to cite this article:
Gunjahalli B, Punith M, Santosh S V. Profile of “Suspected Suicide Attempters” based on variations in intent. Ann Indian Psychiatry 2020;4:20-7

How to cite this URL:
Gunjahalli B, Punith M, Santosh S V. Profile of “Suspected Suicide Attempters” based on variations in intent. Ann Indian Psychiatry [serial online] 2020 [cited 2020 Oct 28];4:20-7. Available from: https://www.anip.co.in/text.asp?2020/4/1/20/262243




  Introduction Top


Suicide is a public health issue. Every year more than 100,000 people commit suicide. For each adult who dies of suicide, there are more than 20 others attempting suicide.[1],[2] Many demographic, social, and clinical factors pertaining to attempted suicides are identified.[3],[4],[5],[6],[7],[8] Suicide attempt and impulsivity are among the important risk factors for future suicide.[3],[4] Impulsive attempts are more frequent than planned attempts.[9] Studies show that mood disorders, anxiety disorders, and substance misuse predict suicide attempts in both developing and developed countries; however, a differential influence of these predictive factors are seen in developed and developing countries. In developing countries, substance misuse disorders are one of the predictive factors.[5] In addition, there is a changing trend in India from joint family to the nuclear family system.[10],[11] This dissolution of the joint family system to the nuclear family has led to decrease in social support, which has further contributed to increased risky behaviors.[3]

Even though “suicide” and “suicide attempt” is a well-researched area, there is a dearth of studies focusing the possibility that suspected suicidal attempts (SAT) are not always suicidal in nature. In India, patients who present with overdose/poisoning/hanging are registered as a medico-legal case.[12] On recovery, they are referred for psychiatric evaluation with the assumption that their attempt is “suicidal.” However, not all can be classified as suicidal. They may differ with respect to the intent. There may be the absence of any suicide intent. Identifying this aspect will help us understand SAT in a different perspective and facilitate: (1) in identifying the other possible causes for suspected suicide deaths/attempts to plan preventive measures. (2) To assess and classify cause of death in “suspected suicides,” as in such cases, the deceased cannot be evaluated for the intent.

In the present study, we aimed at identifying the presence or absence of intent in “SSA” and their profile based on the intent, to gain better insight into the preventive methods.


  Methods Top


This study was undertaken in the Department of Psychiatry, which is a General Hospital Psychiatry Unit attached to Government Medical College in South India. This study was based on the cross-sectional baseline data of an ongoing prospective study of suicide attempters. Patients with overdose/poisoning/hanging/other forms of possible self-injurious behavior who were referred from the other departments for psychiatric evaluation were included in the study. Ethical clearance was obtained from the Institutional Ethical Committee. The study was conducted over 3 months (February 2017–April 2017). Sampling was done using convenient sampling technique. Ethical clearance was obtained from the Institutional Ethical Committee.

A total of 261 patients were registered in the 3 months study. Among them, 19 patients did not consent for the study or reported alone. Hence, a total of 242 participants were included in the study. Written consent of the patient was obtained after explaining about the study, their consent was also taken to collect information about them from the relatives, whose consent was also obtained to get general information relevant to the study. In the case of minors, consent was taken from the parents or legal guardian. Data was collected using a semi-structured pro forma specially designed for the study. The inclusion criteria were as follows: (a) medically stable patients with overdose/poisoning/hanging/other forms of self-injurious behavior referred for psychiatric evaluation, (b) those accompanied by the reliable informant. Exclusion criteria: (a) those under police custody due to various reasons, (b) nonconsenting patients/informants.

Measures

The data collected using the semi-structured pro forma included sociodemographic information, mode of attempt, number of attempts, family history, and precipitant of the attempt. The location of attempt, i.e., whether the attempt was at home or outside, was recorded. The presence or absence of any stressor which precipitated the attempt, and if there were any stressors, the nature of the stressor was noted.

The Mini-International Neuropsychiatric Interview (MINI)[13] was used to make diagnostic and statistical manual (DSM)-IV psychiatric diagnosis. For the purpose of this study, the diagnosis of major depressive episode, dysthymia, manic episode, alcohol dependence/abuse (under one heading alcohol use disorders [AUD]) were considered during the analysis separately. The rest of the diagnosis, including any other physical illnesses, was clubbed under the category of “other” diagnoses. The diagnosis of adjustment disorder was made according to the DSM-IV diagnostic criteria [14] as there were participants who satisfied these criteria.

Suicide Intent Scale (SIS)[15] consists of 20 items, each scored from 1 to 3. For the purpose of scoring the severity, items 1–15 were considered, which gave a score range between 15 and 45. SIS total score was used to assess the severity of suicide intent of the participants. For the purpose of our study, participants with suicide intent, were divided based on the type of attempt (impulsive or planned) using the score on the 15th question of the SIS. The Score of 1 and 2 were considered as “impulsive,” Score 3 was considered as “planned” attempt. Participants were also categorized based on the severity of intent. As per the instructions in the SIS, score of 15–19 was scored as low intent, 20–28 as medium intent, and more than or equal to 29 as high intent.

The participants who denied any suicidal intent and claimed that it was accidental were thoroughly assessed for any suicide intent. Possibility of any event precipitating the incident was also assessed to find any suicide intent. Information was also obtained from the informants to confirm history. They were grouped under accidental group (AG) if the interviewer (trained psychiatrist – one of the three authors) was convinced that there was no suicide intent. Participants who claimed the incident as homicidal was grouped so, after ruling out psychotic disorder using MINI. Statistical analysis was performed using SPSS software version 20.0 (IBM SPSS Statisitcs for Windows, Version 20.0. Armonk, NY). Percentages were used for descriptive purpose. t-test, Chi-square test, and one-way ANOVA were used in the study to compare the groups. Logistic regression was used to predict the effect of independent variables on the dependent variable. Statistical significance (P) was set at a level of 0.05.


  Results Top


Age of the participants was between 13 and 75 years. The mean age was 31.66 years. Majority of the participants were from rural background (87.6%), from the nuclear family (64.9%), and were married (71.5%). Poisoning with pesticides was the most common mode (72.72%) of attempt in our study, and the majority of the attempts were at home (61.57%). There was no participant grouped under homicidal attempt. Hence, the participants were divided into impulsive suicide attempters (ISA), planned suicide attempters (PSA), and no intent/accidental group (AG) and analysis was based on the comparison of the three groups. Of the 242 participants, 178 (73.55%) were ISA, 37 (15.29%) were PSA, and 27 (11.16%) were grouped as accidental. For parameters which could not be considered for AG (suicide intent, precipitating factor), only ISA and PSA were compared.

Comparison of sociodemographic characteristics between the groups [Table 1]: The mean age of the participants in PSA was 30.05 years (standard deviation [SD] 9.03), ISA was 30.77 years (SD 11.28), and that in AG was 38.78 years (SD 15.55). There was a significant difference between the groups with respect to age groups, marital status, occupation, and family type. There was no significant difference between the groups with respect to gender, domicile, and educational status.
Table 1: Comparison of sociodemographic factors between the three groups

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Comparison of suicide attempt related factors

We found no significant difference between the three groups with respect to the mode of attempt, location of attempt, and family history of suicide attempt/suicide. A significant difference was observed with respect to number of attempts, with no attempts in AG and higher number (more than two attempts) in PSA [Table 2]. When the number of attempts were compared between PSA and ISA using independent sample t-test, there were significantly more number of attempts in the PSA group than the ISA group (t = 3.732, P < 0.001). There was a significant difference between the groups with respect to the severity of suicide intent [Table 3]. Seventy-three percent of PSA had high suicide intent.
Table 2: Comparison of attempt.related variables between the three groups

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Table 3: Comparison of SIS severity Scores between Impulsive Suicide Attempters & Planned Suicide Attempters

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Comparison of precipitants factor between the two groups

None of the participants in the AG had any precipitant. Hence, the ISA and PSA groups were considered for comparison. There was no statistically significant difference between the two groups with respect to the precipitating factor (χ2 = 5.37, P = 0.717). Interpersonal stress or conflict was observed in one-third of the patients in both groups, and half of them were related to their own or family member's (spouse or parent) alcohol-related problems [Figure 1].
Figure 1: Comparison of precipitating event in the two groups. ISA: Impulsive suicide attempters, PSA: Planned suicide attempters

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Comparison of psychiatric diagnoses

PSA was significantly more diagnosed with the major depressive disorder when compared to the other two groups (χ2 = 5, P = 0.02). There was a significant difference between the groups when adjustment disorder was considered, which was evidently absent in the AG as against the other two groups which had comparable figures. We found no significant difference between the groups with respect to other psychiatric diagnoses (dysthymia, bipolar disorder, and psychotic disorder) [Table 4].
Table 4: Comparison of diagnoses between the three groups

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Comparison of multiple psychiatric diagnoses

The three groups did not significantly differ when one or more psychiatric diagnoses were considered. There was no statistically significant difference in a mean number of diagnosis between three groups (P = 0.088), pairwise comparison using the Schefee post hoc test also did not show a significant difference between any pair.

Logistic regression model

Logistic regression was used to predict the probability of the type of attempt based on sociodemographic variables. Age, occupation, gender, domicile, education, and marital status entered on step 1 in the regression model showed no significance in predicting the type of attempt. [Table 5] shows logistic regression taking psychiatric diagnoses as independent variable to predict the probability of the type of suicide intent. It showed that major depressive disorder positively predicted the type of attempt (planned) (P = 0.001). AUD did not add significantly in predicting the type of attempt.
Table 5: Binomial logistic regression to predict the effect of psychiatric diagnoses (predictor variables) on type of suicide

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  Discussion Top


The aim of the current study was to identify the characteristics of patients with “SSA” referred for psychiatric evaluation based on the intent of the attempt. Majority of the participants were from rural background; the possible explanation is that India is predominantly made up of rural population,[16] and that they prefer being treated from government hospital when compared to the urban population who prefer private setup for their treatment. In this study, there was no participant grouped under homicidal attempt. Hence, the participants were divided into ISA, PSA, and AG and analysis was based on the comparison of the three groups. For parameters which could not be considered for AG (suicide intent, precipitating factor) only ISA and PSA were compared.

The current study has found that the number of ISA was higher than that of PSA, which is in agreement with previous authors [9] and contradicting others.[17],[18] The difference may be attributed to the time duration from the initial idea of suicide to actual attempt and the type of population/sample included in different studies.

In spite of careful assessment and collaborative history, we found about 11% of the participants had no suicide intent and were grouped as accidental. Earlier authors have observed a higher percentage of accidental incidents in female burns cases.[19] It is evident that those grouped as accidental incidents are heterogeneous consisting of (a) impulsive attempters, (b) planned attempters, (c) actual accidental cases, (d) homicidal incident, and (e) miscellaneous: not being aware of the incident due to or a consequence of psychiatric illness (dissociative state, influenced by hallucinations) or other physical condition (epilepsy). Failure to report their suicide intent could be due to the stigma attached to it and fear of legal actions (this is reduced after the enforcement of Mental healthcare Act, 2017 which has decriminalized suicide attempt and has encouraged psychological help).[20] Previous studies have not dealt with such accidental occurrences in depth. In a study by Gray et al.,[21] analysis of the causes of death in suspected suicides, have found 28.12% of accidental deaths, the study sample included suspected suicides using medical examiner database and information was obtained by structured interviews with the next of kin. Apart from including any drug overdose case where suicide was not certain, they have included suffocation cases where drugs and alcohol would have played a part in compromising an individual from self-preservation (e.g., positional asphyxia), recreational or vehicular inflicted fatal injuries as long as the injury was not clearly intentional and motor vehicle fatalities were included as accidental deaths. The study shows a lesser proportion of accidental incidents in comparison to the above-mentioned study possibly due to various reasons: First, in our study, participants were themselves assessed thoroughly regarding their intent after they were medically stable which would lead to a better result as compared to getting such information from the next of kin, who may not be aware of the deceased feelings at the time of death, this aspect is overcome in our study as the attempters are themselves evaluated. Second, our study included only medically stable cases referred for the psychiatric evaluation of “SSA,” which excluded cases with the fatal outcome, which was the main focus of the study, which is compared. Third, motor vehicle accident cases were not included in our sample as in such cases on survival, the intent is clear and hence, they are not referred for psychiatric evaluation.

In our study, the majority of participant in ISA and PSA were aged <40 years; AG was above the age of 40 years. There were significant more agriculturists in AG and ISA groups, which indicate that easy availability of pesticides, a common mode of attempt was one of the risks for persons with impulsive suicide attempt and in the accidental incident. Poisoning with pesticides as a common mode of attempt has been observed by other Indian authors.[11],[22] It was observed that the majority of the participants in AG, followed by ISA had poisoning as a common mode of attempt; however, there was no statistically significant difference between the groups.

We found no significant difference between the three groups with respect to the location of attempt and family history of suicide attempt/suicide. It is noteworthy that there were no precipitating factors or previous suicide attempts in participants of AG. In addition, participants in AG were not diagnosed with any psychiatric diagnosis except for AUD, which itself contributed to accidental incident directly or indirectly. This may indicate that the AG represented group with the actual accidental incident.

As there was the absence of precipitant factor in the AG, the ISA and PSA groups were considered for comparison. There was no significant difference between the two groups with respect to the precipitating factor. However, interpersonal stress or conflict was observed in one-third of the patients in both groups and half of them were related to their own or family member's (spouse or parent) alcohol-related problems. Interpersonal conflicts have been observed by other authors as one of the main precipitants.[10]

PSA was significantly more diagnosed with the major depressive disorder when compared to the other two groups. Study on completed suicides showed no difference with respect to depression between accidental deaths (in suspected suicides) and suicides.[19] However, considering the results of our study, assuming that absence of depression indicates that there is no risk of suicidal tendency, will probably miss on the group of patients who might impulsively attempt suicide, especially when faced with stressful life situation. There was a significant difference between the three groups with respect to AUD with more number of AUD (either dependence or abuse) in AG and ISA. This is a significant finding indicating that AUD, apart from being a risk for ISA [17] and an important reason to cause a conflict in the family, is also a reason for a person to accidentally poison or overdose themselves without any suicidal intention. There was significant difference between the groups when adjustment disorder was considered which was evidently absent in the AG as against the other two groups which had comparable figures. Adjustment disorder was one of the commonly diagnosed conditions in both groups, which indicated that persons' reaction to identifiable stressor was one of the important reasons for suicide attempt whether impulsive or planned. Mood disorder and adjustment disorder has been observed significantly more often in suicide attempters.[23]

Findings pertaining to the Indian context

When the entire study sample was considered, some interesting findings were observed which are worth discussing. First, pertaining to Indian sociocultural context the majority of the participants was from rural background and was less educated. Many of the participants were married, a finding common to other Indian studies.[24] One explanation for this is that in the background of rural culture, marriage is sustained in spite of any adversity or discord in the relationship. Hence, marriage does not act as a protective factor against suicide attempt or suicide.[25] Second, the triad of rural background, poisoning with pesticides as common mode of attempt/accidental instance and attempting at home can be seen as a reflection of the social situation in Indian (rural) setup, wherein easy availability of pesticides at homes (for agricultural purpose) is one of the important factors contributing to their misuse. Third, AUD was another common diagnosis found in all the three groups, significantly more in the impulsive and AGs. However, it did not add significantly in predicting the type of attempt. The occurrence of AUD in our study was much higher compared to the other studies.[9],[26] Community studies in the same town assessing the risk factors of hypertension have found alcohol use much lesser than the one found in our study.[27] The possible explanation would be the difference in sampling technique and diagnostic tools to identify the condition. Alcohol use, either directly leading to suicidal behavior/accidental overdose or poisoning or indirectly causing suicidal behavior in family members, is another important factor for suicide attempt (planned or impulsive) which is of concern. It is, however, important to note that alcohol-related problems either as the diagnosable condition was seen in all the three groups or that related to alcohol-related stressor in close family members who acted as a precipitant for the attempt in ISA and PSA alike. Alcohol use, therefore, has been both a distal and proximal risk factor for suicidal behavior.[28] This is very important when preventive measures are to be formulated and implemented.

In this study, data were collected by trained psychiatrists when the participants were medically stable and hence were more cooperative and comfortable for psychiatric interview and assessment. This removes the bias caused when the patient is interviewed in an emergency setup when there is a possibility of overrepresentation of psychological disturbance due to the emergency. However, there are some limitations which need to be mentioned. Our study being hospital based, selection bias is one of the limitations. The patients who were excluded from the study (did not consent for the study/medically unstable/had a fatal outcome) may have a different profile. Effects of stigma about suicide could have contributed to some of the participants attributing the incident as accidental. The ongoing prospective study will possibly clarify this aspect.


  Conclusions Top


Impulsive attempts are common form of suicide attempts. There is a possibility of accidental incidents in the suspected suicide attempters, especially so in those with AUD. A triad of higher suicide intent, lesser social support, and the presence of depressive disorder is a risk for planned attempts. A tetrad of rural background, agriculturist, poisoning with pesticides, and AUD was seen in accidental cases and impulsive attempters, a noteworthy finding which needs to be addressed by imposing restrictions on availability of pesticides and alcohol to prevent such occurrences. Occurrence of accidental incidents also has an impact on legal classification of deaths which are otherwise labeled as “suicidal” with its associated consequences for the family members (emotional and social).

Future directions

Accidental incidents as a group need further research and classification for its clinical and legal impact. Further comparison of suicides/suicide attempts/accidental incidents in regions where pesticides and alcohol are restricted and regions where such restriction are not imposed will give better insight. This will help in charting out preventing measures.

Acknowledgment

I would like to thank all the patients who consented for inclusion in the study.

Ethical statement

This study was approved by Institutional Ethics Committee with reference number IEC/HIMS/045/2016 obtained on 31st January 2017.

Declaration of Patient Consent

Patient consent statement was taken from each patient as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results / clinical information /image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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