Background: Several efforts have been made in the past to study psychosocial risk factors and clinical profile associated with attempted suicide, but only few have addressed the issues of youth in a conflict area Kashmir. Aims: To study psychosocial risk factors and clinical profile associated with attempted suicide in young adult and adolescent patients in conflict zone-Kashmir. Material and Method: It was a hospital-based study in which 200 young adults and adolescent patients who were admitted following unsuccessful suicide attempts to the emergency and referred to Department of Psychiatry, Govt. Medical College, Srinagar, Jammu and Kashmir, India. Selected patients were subjected to Mini International Neuropsychiatric interview (MINI) and International Personality Disorder Examination (IPDE) for evaluation of symptoms and diagnosis. Subjects of age less than 15 years and more than 34 years have been excluded. Results: Majority of the suicide attempters 65% were < 24 years of age with adolescent over represented in the sample (Mean = 21.24 ± 4.66), females were 58%, low socioeconomic status (86%), oral agents (most common method) was used by 84%, 64% had expressed suicidal or death wishes before act and 72% made an impulsive attempt. Eighty-two percent of the suicide attempters were suffering from some psychiatric illness at that time. Out of which 40% had mood disorder with predominance of major depressive disorder, 15% had personality disorders, and 9% had posttraumatic stress disorder. Conclusion: Knowledge of clinical phenomenology may assist in identification and early intervention of youth who are at high risk. Overall, findings indicate a strong and immediate relationship between suicide attempt and psychiatry morbidity.
Keywords: Attempted suicide, clinical phenomenology, psychosocial risk factors, young adult and adolescent patients
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Jan MM, Rather YH, Majeed N, Wani ZA, Dar MA, Margoob MA, Hussain A, Bhat TA. Psychosocial risk factors and clinical profile associated with attempted suicide in young adult and adolescent patients in conflict zone-Kashmir. Ann Trop Med Public Health 2017;10:154-9
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Jan MM, Rather YH, Majeed N, Wani ZA, Dar MA, Margoob MA, Hussain A, Bhat TA. Psychosocial risk factors and clinical profile associated with attempted suicide in young adult and adolescent patients in conflict zone-Kashmir. Ann Trop Med Public Health [serial online] 2017 [cited 2017 Jul 15];10:154-9. Available from: https://www.atmph.org/text.asp?2017/10/1/154/205561
Suicide is a serious public health problem. The World Health Organization, recognizing the growing problem of suicide worldwide, urged member nations to address the phenomenon. During the past decade, there have also seen dramatic and disturbing increases in report of suicide among youth.
In all countries, suicide is now one of the three leading causes of death among people aged 15-34 years. Until recently, the suicide rate was higher for the elderly, but now suicide predominates in younger people, both in absolute and relative terms, in a third of all countries.,,
In the last two decades, official figures of the suicide rate in India have increased from 7.9 to 10.3 per100,000. The actual number of suicides is understandably more than the reported official figures as nonreporting, underreporting, and misclassification are prevalent due to various sociocultural stigmas, religious sanctions, legal issues, and insufficient registration systems.
The real magnitude of suicide as a public health problem is not clear in the conflict zone Kashmir Valley. War damage the very fabric of society. Kashmir has been no exception and the ongoing conflict has had its toll on Kashmiri population. Nearly everybody has been affected by the violence. High levels of confrontation with violence have been reported in studies from Kashmir. People are frequently confronted with physical and psychological mistreatment. Torture, detention, threats, killings, and disappearances are common. The most frequent traumatic events encountered are firing and explosions (81%) and exposure to combat zones (74%). Exposure to violence has potential implications for mental health. Poverty, low education, social exclusion, gender disadvantage, conflict, and disasters are the major social determinants of mental disorders. Examination of the literature reveals a paucity of data on the impact of violence on mental health of population in Kashmir. In areas affected by chronic strife a larger chunk of population would be expected to experience mental health problems and such figures ought to apply to the people of Kashmir. There are high levels of psychological distress prevalent in the population.
There has been a qualitative and quantitative difference in the psychiatric morbidity as a direct result of the violence. A phenomenal increase in the number of people attending the psychiatric hospital is a direct reflection of that. There is a significant increase in the number of people being diagnosed with acute stress reaction, depressive disorders, anxiety disorders, and posttraumatic stress disorder (PTSD).,
The prevalence of PTSD is reported to be 15.9%. A predominantly Muslim society where death due to suicide has always been very low finds suicide as the second most common cause of unnatural deaths. One-third of the respondents contemplate suicide as per a survey done in four districts of the region. Most of the people who complete suicides are young males in the age group 25-34.
There have been an increase in the number of people who attempt suicide. The law makes attempted suicide a punishable offence and help is often not sought, which leads to underreporting. Kashmir, which is a predominantly Muslim society and Muslim suicide rates in whole India were lowest at 0.5/100,000 two decades back., But in the last two decades the scenario has changed, the prevalence of mental illness has increased dramatically in Kashmir. We have also noticed an increase in cases of suicidal behavior in young adult and adolescent patients reporting to our hospital although not reported.
In the above context, it was intended to study the risk factors associated with suicide attempts in young adult and adolescent patients reporting to our hospital, and of its first kind from this state which has seen decade long sociopolitical disturbance. The specific objectives of this study were to evaluate sociodemographic variables, clinical diagnosis, and the methods used during suicide attempts.
The study has been conducted in Department of Psychiatry, which belongs to a 1000 bedded tertiary care hospital associated to Govt. Medical College, Srinagar, Jammu and Kashmir, India. 200 consecutive young adults and adolescent patients following an unsuccessful suicide attempt were recruited for the study. They had reported to the Emergency Department and were referred to Psychiatry Department for further treatment. A suicide attempt is defined as a nonfatal self-directed potentially injurious behavior with any intent to die as a result of the behavior. It may or may not result in injury.
General description, demographic data, and circumstances of the attempt were recorded using the semi-structured interview schedule. Mini International Neuropsychiatric interview (MINI) was applied for evaluation of symptoms and diagnosis. MINI is a DSM-IV based diagnostic interview with high reliability and validity.
International personality disorder examination (IPDE) was applied to evaluate the personality disorders. IPDE is a semi structured clinical interview in accordance with both ICD-10 and DSM-IV criterion. That provides a means of arriving at the diagnosis of major categories of personality disorders.
An informed consent was taken from the participants and those who did not consent were excluded.
Patients less than 15 years and more than 34 years of age are excluded.
The study was approved by the department and institutional ethical committee and to maintain confidentiality of the study, the names of the participants were not recorded.
The original study protocol was approved by the ethical committee of medical college Srinagar and accepted by Kashmir University. Authors declare that the study confirms the regulations of the Declaration of Helsinki.
The data was tabulated and analyzed and the averages were calculated and subjected to descriptive as well as inferential statistics (chi-square) by using SPSS 20.0.
Out of 200 patients, 58% were females and 42% were males. Sixty-five percent of all suicide attempters were in the age group of 15-24 years while 35% in the age group of 25-34 years (Mean = 21.24 ± 4.66). Forty-six percent patients were single. Twenty-four percent of suicide attempters were from rural areas and 76% were from urban settings. Most of the suicide attempters were Muslims. Eighty-six percent subjects were from poor socioeconomic status [Table 1].
|Table 1: Shows sociodemographic variable study characteristics, subjected to chi-square test and significant values (P < 0.05)
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Eighty-two percent patients in our study were having some psychiatric illness at the time of suicide attempt. In this study there was predominance of mood disorders, which was present in 40% of our sample, with depressive disorder being most prominent. We found that 15% of cases were suffering from personality disorders. Eighteen percent of our cases were not having any psychiatric illness before the suicide attempt [Table 2].
|Table 2: Psychiatric status of patients before the suicidal attempt and the observations
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Self-poisoning was the most common method adopted for attempting suicide, 84% of the subjects used this method. Insecticides and pesticides were taken by 21% patients. Only 16% of patients resorted to physical methods like by burning (self-immolation) and jumping into river (drowning) [Table 3].
|Table 3: Methods adopted during suicidal attempt and the observations subjected to chi-square test and significant values (P < 0.05) marked by*
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Analysis of the material showed that females outnumbered the males in the present study, which is in agreement with the findings of Chandrasekaran et al.;, according to them suicide attempts are more common among females than males. Most of the suicide attempters were in the age group of 15-24 years. This is in accordance to WHO (2001) report according to that there have been dramatic and disturbing increases in suicide among youth (WHO report showed that age from 15 to 30 is at increased risk of suicide). Same results were also obtained in studies by Vijaykumar and Conwell.,
The majority of suicide attempters were from adolescence age group, as this age group mark the period of the life cycle when impulsive behavior and risk taking behavior are most common, and substance abuse and many mental illnesses emerge first. Other social and environmental factors such as increased academic pressure and competition for jobs are more in this age group.
It has been observed that most of the patients were single. Many studies in India have reported a higher percentage of unmarried patients in attempted suicide, Rao (1965) (66%); Sethi et al. (1978) (65.3%), Gupta and Singh (1981) (62%), and Ponnudurai (1986) (57%).
Most of the patients in our study were either illiterate or had a low education level when compared to findings reported by Lal and Sethi (1975) and Gupta and Singh (1981), the difference may be because most of the patients of our study belong to low socioeconomic group and were suffering of psychiatric illnesses which may have affected their school performance.
Housewives predominated in the attempted suicide group followed by semi-skilled laborers, unskilled laborers, and students. This is in agreement with the general perception that housewives have to face more household stresses than working class females which make them depressed and leading to suicidal attempts. While students accounted for the majority of suicide attempters in the study done by Rao and Chinnian (1972), surprisingly in our study there were only 8% students.
Fifty-four percent patients were from nuclear families, which are considered to be a nonprotective factor for attempted suicide in contrast to being in a joint family. In the study of Bansal 53% were from joint family, whereas the study of Ramdurg et al. showed that 41% belonged to nuclear family.
Most of the suicide attempters were from urban settings which is similar to other studies., The reason for urban preponderance may be because the present hospital, being located in the city, gets emergency patients predominantly from the city, and some surrounding villages.
Most of the suicide attempters were Muslims; this may be due to a large Muslim population in the study area. This is in contrast to earlier beliefs that suicide is very rare in Muslims.
Most of the subjects were from poor socioeconomic status. This finding is in agreement with the findings of the study of Nagendra et al. who found that most (83%) of the suicidal attempts were from the low socioeconomic groups. Most of the studies in different countries have reported that lower social class is an important risk factor for suicide and attempted suicide., In our study, self-poisoning was the most common method adopted for attempting suicide, which is also supported by the findings of other Indian and foreign studies., This may be due to the easy availability of insecticides and pesticides in most of the homes. Self-poisoning with sleeping pills which either have been prescribed by doctors or purchased from market without prescription, both trends highlight the fact that benzodiazepines can be easily purchased from a pharmacy in our society. Eight percent of the patients had a previous history of suicidal attempts. Bagadia et al. (1979) found 7% patients and Sethi et al. (1978) observed that 14.6% patients had previous suicide attempts.,
Identifying them is important because it has been reported that the adolescents often with past histories of suicide attempts are more vulnerable to suicide behavior.
Eighty-two percent patients in our study were having some psychiatric illness at the time of suicide attempt. This figure is much higher than the western reports may be because of the stressful environment in this part of the world (Kashmir Valley) due to longstanding sociopolitical disturbance and low intensity conflict like situation since last two decades. Although it is consistent with the other hospital studies done in other parts of our country.,,
In our study there was predominance of mood disorders, with depressive disorder being most prominent. This is in agreement with the findings of Indian as well as western studies.,,,,, According to Sainsbury(1953), approximately two-thirds of suicides are linked to depressive illness. Weismann (1974) reported depression to be most common diagnostic entity in suicide attempters (35%). In 2009, Qusaret al. found most common psychiatric diagnosis was major depressive disorder in attempted suicide.
In our study schizophrenia accounted only 4% cases. Rao in 1972 in his study reported 2.4% cases which is close to our study. Only 2% of our cases had adjustment disorders with depressive reaction. Four patients (2%) were suffering from obsessive compulsive disorder. Two percent cases were having substance dependency.
Using standardized tool that is IPDE we found that 15% of cases were suffering from personality disorders. Chandrashekaran et al. (2003) used the same tools and reported the prevalence of personality disorder only in 7% of patients; this could be due to the fact that they have included only first attempters which might exclude borderline patients.
Nine percent of our cases had PTSD. Various studies have found that PTSD is associated with increased risk of a subsequent suicide attempt. In our study prevalence PTSD is high compared to other studies done other parts of country, this can be explained by the fact that there is a higher rate of PTSD in this part of the world as reported by a series of studies of Margoob et al.,,
Substance abuse was less frequently reported in this study than elsewhere. The likely reason could be stigma and fear of getting identified and so denial, as patients want to conceal addiction from family.
Eighteen percent of our cases were not having any psychiatric illness before the suicide attempt. However, these cases were suffering from depressive mood at the time of suicide attempt, but they could not be fitted into any psychiatric disorder. This figure is quite less than the reports in the earlier studies of Badri Narayan (1977), Sethi et al. (1978), Gupta and Singh (1981), who did not find any psychiatric disorder in 34%, 45%, and 38% their cases, respectively, this difference is because of the growing concern of mental illnesses in Kashmir since two decades due to conflict.,,
There were limitations that should be taken into consideration in interpreting the results from this study. First, its a hospital-based study, sample size is small, the findings cannot be generalized to whole community. Second, in our study statistics used that is chi-square test as a univariate test, is not a strong method to show correlation of psychosocial risk factors and clinical profile with suicide attempters.
Ongoing conflict has had its toll on Kashmiri population. Nearly everybody has been affected by the violence. Exposure to violence has potential implications for mental health. There have been increases in the number of people who attempt suicide. So we should take steps to decrease suicide rate in society, especially in younger age groups who are at risk. As we have seen that most of the suicide attempters were having psychiatric comorbidity at the time of attempt to suicide, so measures should be taken to provide timely psychiatric services to these patients in the form of psychotherapy, pharmacotherapy, and adequate social support. Traditional ways of living in joint families are a protective factor as it provides more social support. In addition, public education and awareness should be generated in youth regarding mental illness to decrease stigma and encourage timely intervention. Government agencies should also strictly implement laws to restrict the easy availability of highly toxic pesticides and sedative drugs in the market.
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