A preliminary study of suicide attempters presented at Liaquat University Hospital, Hyderabad
Objective: To identify the association of gender, age, and level of education; on mode of suicidal attempt and presence of guilt; among survivors of suicidal attempt.
Design: Cross-sectional study.
Place & duration of study: The study was carried out in Liaquat University Hospital Hyderabad, from July to December 2008.
Subjects & Method: All 82 referred cases, that were referred for evaluation after recovering from suicidal attempt at Liaquat University Hospital Hyderabad, were screened for psychiatric disorder by administering General Health Questionnaire. Required psycho-social variables and diagnoses were recorded on a semi-structured proforma.
Results: A total of 82 cases with 58(70.73%) males and 24(29.26%) females, with a male: female ratio of 2: 1, were evaluated in this study. All were within 40 years of age, mostly less than 30. 50(61%) were singles and 32(39%), married. Males selected more violent method (drowning & hanging) while self poisoning was the most common method used by females. Family problems seem to be the most common precipitants leading to suicidal attempt (28 cases), both in males and females. Previously diagnosed psychiatric disorders were present among one third of patients. Majority of patients (80%) did not have guilt about their act mainly males and the people belonging to younger age group (less than 30).
Conclusion: This is a preliminary study on the topic. Suicide still is an under-reported and under researched area in Pakistan. Two major areas need special attention in our scenario; one, Family conflicts and in-appropriately treated psychiatric disorders are found to be the main precipitants; and the other one is absence of guilt over suicidal attempt, particularly among younger population.
Key words: Suicide Attempters, Deliberate Self Harm, Family, Psychiatric Disorder, Guilt, Psycho-social
A number of psycho-social risk factors have been studied to be associated with suicide, including marital disruption, un-employment, lower socio-economic status, living alone, a recent migration, early parental deprivation, family history of suicidal behavior, psycho-pathology, poor physical health and stressful life events1,2,3,4. In their study Larsson et al found that the frequency of life time suicide attempts could be predicted by level of suicidal ideation and presence of family member or a friend, who had attempted (or committed) suicide5. Besides above factors emotionally unstable personality disorder and substance dependence are found to be the major risk factors of suicide6. In a study of risk factors of suicide, conducted in the mega city of Karachi, found psychiatric disorders (especially Depression), marital status (being married), unemployment, and negative and stressful life events, to be the major predictors of suicide7.
Suicide is a major risk factor for life as one million people world wide die by suicide each year8. According to W.H.O9 report only a few number of suicide are from countries outside western world, especially from Muslim countries, particularly Indonesia, Pakistan and Bangladesh10. The lesser number of suicides from Pakistan may be due to dearth of reported local data on this issue as suicidal behavior is an understudied subject in Pakistan. A variety of social, legal, and religious factors, make reporting and data collection on suicide and nonfatal suicidal behaviors, difficult11, 12.
As the determining factors may not be fully elucidated in cases of completed suicide so to study the problem, a cross-sectional analysis was carried out to find out different psycho-social factors among survivors of suicide attempters, belonging to the interior catchment of Sindh province, in a hope of viewing a better view of the state of affairs, particularly of Hyderabad city and its suburbs.
SUBJECT AND METHODS
This is a cross sectional observational psychosocial analysis of survivors of attempted suicide. Patients had been referred for psychiatric evaluation, on recovering; at the time of discharge from medical or emergency wards. Each patient was interviewed either within the hospital on recovery, or during their first follow- up (within one week), in the out-patient department, after being discharged from Liaquat University Hospital, and hospitals affiliated with Liaquat University of Medical and Health Sciences from July 2008 to December 2008. Psychiatric interviews were conducted, and psychiatric case-ness was identified using General Health Questionnaire13. Later on, identified cases were diagnosed, on the basis of I.C.D-1014.
Data regarding specified socio-demographic characteristics, reasons for suicidal behavior, methods used, presence or absence of guilt, and outcome were noted on a special data collection form. Data was analyzed using the SPSS-15 version.
Total 82 cases (58 males and 24 females, a male: female ratio of 2: 1) were evaluated in this study. First time suicidal acts accounted for 58 cases (71%), while 8 women (33%) and 16 men (28%) had a past history of more then one suicidal acts, before the study period. Table 1 gives the socio-demographic and personal characteristics of the study’s sample.
Methods Used. Methods used in the suicidal act are listed in Table 2. The result of this study shows that different methods of suicidal attempt were adopted by each gender. Males selected more violent method (drowning & hanging) while self-poisoning was the most common method used by females. Multiple attempts were more in males then females and each time different method was used to attempt suicide.
Stressors for the suicidal act: Back-ground psychosocial stressors are listed in Table 3. Family problems seem to be the most common precipitants leading to suicidal attempt both in males and females. Previously diagnosed psychiatric disorders were present among one third of patients. More man (41%) than women (16%) had psychiatric disorder as apparent precipitant of suicidal attempt. The psychiatric conditions leading to suicidal attempt include, depression, schizophrenia and drug dependence.
Presence of guilt: To find out the perception of suicide attempters their guilt about act was assessed. In this study majority of patients (80%) don’t present with guilt about their act. The feeling of guilt was more marked in females (n=8, 33.3%) then males (n=8, 13.8%). The absence of guilt is more common (90%) among young patients (i.e. before the age of 30 year) then older patients (50%)
This paper entails the findings of first ever, although small scale study, on suicide attempters, at a tertiary care university hospital of interior of Sindh province of Pakistan. The key findings are discussed below in the light of similar earlier studies. In our sample, majority of the attempters are males (more than two third). This finding is not in line with the similar study on suicide attempters, conducted by Nojomi et al in Iran15; where, about 60% of attempters were females. Although completed suicide is four times more common among males; but suicide attempt is four times more common among females16.Our sample shows a different pattern. This variation may be due to deliberate concealing of suicide attempt by females or due to milder degree of method of suicide not requiring medical attention of sufficient degree to reach a tertiary care hospital. This paradox needs to be explored in future studies.
In the population, studied, most suicide attempters are in younger age group( 29 or younger). This finding is comparable to the one, pointed out in the study by Shahid and Hyder17, on the patients with deliberate self harm. In our data, most attempters are single, but most males are single and most females suicide attempters are married. This again follows the same pattern as was pointed out by Shahid and Hyder17 in their study for deliberate self harm. All the females are house wives, in the current sample; as in the case with study under comparison17.
Most attempters fall in the category of up to primary level education, which is not case in the study of Nojomi15, where most cases are high school graduates. Pattern of method of attempt, in our sample population, is strikingly comparable to the previous studies e.g. the one carried out by Skogman et al18. Commonest reported cause of attempt is interpersonal and family conflicts. This is also in support of the finding in the study by Shahid and Hyder17.
Most common psycho-pathology found among the sample population was Depression followed by Drug Dependence and Schizophrenia, all of them account for about 35% of the total sample. Thus the current study points towards at least three out of five major risk factors, identified in the study of Cheng et al6. 80.5% of attempters do not have feelings of guilt about the act, most of them males and young population. This is a noticeable finding and requires careful focus in the studies to come and social measures to combat such a trend.
Suicide still is the under-reported and under-researched area in Pakistan. Certain areas need special attention in our scenario. Common man is very sensitive to family conflicts, be it male or a female, particularly in our catchment of study. In-appropriately treated psychiatric disorders are found to be among main precipitants. This, points towards the extreme needs of better mental health care facilities in the catchment. The absence of guilt over suicidal attempt, particularly among younger population, is seemingly a dangerous trend, and require further focus of not only, psychiatric researches, but also on parenting strategies and prevention of psycho-social stressors, to which our youth is exposed.
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