|Year : 2018 | Volume
| Issue : 1 | Page : 80-86
Study on risk factors in adolescents admitted with deliberate self-harm in Tata main hospital, Jamshedpur
Manoj Kumar Sahoo, Harshita Biswas, Sanjay Kumar Agarwal
Department of Psychiatry, Tata Main Hospital, Jamshedpur, Jharkhand, India
|Date of Web Publication||15-Oct-2018|
Dr. Manoj Kumar Sahoo
Department of Psychiatry, Tata Main Hospital, Jamshedpur, Jharkhand
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Suicide ranks as the second cause of death worldwide among 15–19 years olds, with at least one lakh adolescents dying by suicide every year. Therefore, research on understanding the dynamics of suicide attempts in adolescents can be used as a means of suicide prevention. Objective: The objective of this study is to understand the psychological, social, and personality factors contributing to deliberate self-harm/suicide attempt in patients of adolescent age group admitted to Tata Main Hospital, Jamshedpur. Materials and Methods: This study was carried out at Tata Main Hospital Jamshedpur. Consecutive suicide attempters up to the age of 19 years referred from medical or surgical wards over a period of 1 year are taken up for study. Data were collected on socio-demographic sheet and specific pro forma to collect various risk factors contributing to this behavior specifically designed for this study. Data were analyzed using descriptive statistics and Chi-square test. Results: Majority of the suicide attempters were females of younger age, lower-middle income status, urban background, and students. Two-third (68%) of the attempter had at least one psychiatric diagnosis. Nearly 75% of the suicide attempts were committed after a precipitating factor. The risk factors associated with suicide attempts in included increased family conflicts, peer-interpersonal problems, perceived humiliations and personality traits. 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: Adolescent, prevention, self-harm, suicide
|How to cite this article:|
Sahoo MK, Biswas H, Agarwal SK. Study on risk factors in adolescents admitted with deliberate self-harm in Tata main hospital, Jamshedpur. Ind Psychiatry J 2018;27:80-6
Adolescence is a life period during which a young person often feels confused, insecure, unhappy, and burdened by different expectations and demands. It is not uncommon that these unpleasant feelings become expressed through suicidal ideas or suicidal behavior., In most countries, suicide is second or third-leading cause of death in youth. Suicide rate in adolescence is quite high, but differs over time and from country to country.
According to the World Health Organization, 2003 almost 1 million people die from suicide every year. Attempted suicides are about 20 times. Rates among young people have been increasing to such an extent that they are now the group at highest risk in one-third of the countries. Suicide ranks as the second cause of cause of death worldwide among 15–19 year olds, with at least one lakh adolescents dying by suicide every year. The National Crime Records Bureau (India), reports that in 2011, more than one lakh (135,585) persons committed suicide. Around 2.24% of the victims were children up to 14 years whereas 35.4% suicide victims were youths in age group of 15–29 years showing that the suicidal behavior increases markedly during adolescence.
There are various models explaining adolescent suicide attempts. They suggest that young people who attempt suicide possess certain cognitive, behavior, and emotional characteristics which may increase the risk of recurring suicide behavior., More specifically, factors commonly linked to adolescent suicide attempts are: family history of suicide behaviors, family organization and structure, family conflicts,,, poor control of own impulses, previous suicide attempts, psychiatric disorders,, depression, anxiety,, low self-esteem, feeling of helplessness, poor problem-solving skills,, various forms of social withdrawal, and substance abuse.,
Adolescents who attempt a suicide and fail may injure themselves seriously enough to require medical attention. The trauma which follows an unsuccessful attempt may be physically disfiguring or result in long-term disability. The mental health consequences of attempts are equally significant, and there are fewer rehabilitative resources available in our settings. Subsequent to an attempt, the associated stigma or physical scarring may affect school attendance. Those who fail to return and complete school are less likely to find employment as adults. Parents, often faced with few treatment options, may be forced to reduce meaningful economic activity to reintegrate their adolescent into the family and community. Among poor households, this means being driven deeper into poverty. Despite this, research on correlates for suicidal expression among adolescents remains a neglected public health priority. It is apparent that the body of knowledge and empirically based data on this subject has been increased. However, there are a growing number of reports of suicide attempts in youth, indicating that this phenomenon has not been fully understood, and that we cannot be content with the extent of our knowledge about it. Considering that between a quarter to a third of all suicide victims have previously attempted suicide, it is beyond any doubt that research on and understanding of the dynamics of suicide attempts in adolescents can be used as a means of suicide prevention.
| Materials and Methods|| |
The study was carried out in 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 study. The study design was hospital-based cross-sectional study and sampling technique used was purposive sampling. Over a period of 1 year, 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 which lead to the event (precipitating factors), intent, method, and clinical profile of the patient. The data for precipitating factor was collected by interviewing the patients and the informants and looking for any incidents/factors before the event that lead to the suicide attempt. No structured questionnaire was used to assess about the precipitating factors, it was based only on the detailed interview. The precipitating factors data were analyzed on qualitative basis. The psychiatric diagnoses were made according to the diagnostic criteria for research of International Classification of Diseases10 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 Pierce'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.
| Results|| |
The results include the sociodemographic profile of the suicide attempters, where n = 100, the mean age of suicide attempters was 16.8 ± 1.3. The sociodemographic profile of attempters is given in [Table 1]. The clinical characteristics are summarized in [Table 2]. The remaining variables of family, psychosocial factors, and PFs are summarized in [Table 3]. There was no refusal for participation in the study by the attempters and their family. The sample consisted of 39 males and 61 females. Attempters were categorized as up to below 14, 14–16, and 17–19 years. To compare the three groups, Chi-square test was used.
The results show attempters mostly were found in the age group of 14–16 years. There were more female attempters compared to males, mostly of Hindu religion and significantly high number of attempters was students (P< 0.05). Among the three groups, statistically significant number of attempters were matriculated and under matriculation (P< 0.05). Most of the attempters had a family income >Rs. 20,000 belonged to nuclear type of family and hailed from an urban locality.
Clinical characteristics of the sample include the suicidal intent, suicidal ideation, suicidal plan, methods of suicide, and psychiatric diagnosis. The mean suicidal intent was 2.11, with a standard deviation of 7.5, indicating mostly the suicide intent ranged from medium-to-low intent in attempters. Especially among the age group up to 19 years. Nearly 75% of the suicide attempts were committed after a precipitating factor triggered the event. The common reasons were academic failures, romantic relationships, and conflict with parents. 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 33% of cases. Followed by pesticides (27%) and benzodiazepines consumed by 18% the least common method being cutting and slashes with amounted to 5%. Presence of psychiatric diagnosis was present in 68% of the cases, and 25% of the patients were found to have depression followed by adjustment disorder 11% 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. A significant percentage of suicide attempters 76% were found to have psychosocial risk factors and 55% have personality risk factors. The psychosocial risk factors which contributed the highest were interpersonal problems, perceived humiliation, and violence at home The PFs which were commonly seen were poor affective control and impulsivity.
| 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.
There is a shift in the predominance of the number of suicides from the elderly to the younger people worldwide. The mean age of cases was found to be 16.8 ± 1.3. Which is like earlier Indian studies. However, it is observed that such a higher rate is by no means consistently exclusive for the youth only, for in the report published by the National Crime Records Bureau, 34.4% of all suicides were between 15 and 29 years. A study by Kumar et al. had reported that the mean age of the sample as 17.58 ± 1.26 when 74 adolescent suicide attempters were studied. This increase in rate in later adolescence may be due to greater psychopathology, more cognitive ability to plan and act, more autonomy, and less supervision. Majority attempters were females, nearly, all studies on adolescent suicide attempts have reported more representation of females ,,, Although in the traditional Indian culture, women enjoy a more protected role, the changing expectations, and workforce participation, the female sex also experience a concurrent rise in role conflicts and psychosocial stressors. The hostile environment in families, preexisting personality problems, and mental illness could precipitate suicidal behavior.
In this study, the majority attempters were students, studying in schools. Similar findings showed that suicide of students has risen from 5.5% of all cases from 2010 to 6.2% in 2013. However, earlier studies have reported that suicide attempts in youth were linked to educational disadvantage. An Indian study identified 41.9% of adolescent suicide attempters to be from lower socioeconomic status and 58.1% to be unemployed. Socioeconomic factors and unemployment in the etiology of suicide have been recognized as important. It is not suggested that unemployment causes suicide per se, but creates a feeling of hopelessness, which adds further stress to the economically and psychologically vulnerable. The present sample is taken from an industrial hospital where the maximum sample population is ward of employees thus having all the facilities. So that could be one of the reasons for more number of student populations in the age group, as the hospital caters majorly for the employees
In this study, 67% of cases belonged to nuclear families. Earlier studies have also reported higher representation of nuclear family setting among adolescent suicide attempters. This overrepresentation could also be due to the disintegration of the joint family system within the society which has led to change in family environment and added burden on the family members.
Method of suicide
In our study, the most common methods of suicide found were consumption of phenyl, other forms of cleaners (33%) of cases, followed by pesticides (27%). Studies conducted earlier in different parts of India have reported poisoning by insecticides as the most common method followed by drug overdosage. Our results were comparable to these earlier studies where similar findings were found., The reason for this variation in findings can be attributed to the fact that the data has been collected from an urban setting where usage and possessing of insecticides at home is not as common as in rural settings. Still, this cause amounts to the second most common cause in our study. Usage of organophosphorus compounds as insecticides/pesticides and easy availability are the contributing factors for its rampant use in suicide attempts. Areas where vegetable poisons such as odollum and nerium are commonly available provide an easy source for the attempters. The World Health Organization has suggested restricting access to pesticides as a means to reduce suicide attempts. Practice of over-the-counter issue of drugs should also be curtailed.
Adolescent suicide attempters, in general, are a heterogeneous group though the majority of their attempts were impulsive, a cry for help to reduce personal distress. The intent of their act is often found to be low unless associated with severe psychopathology such as depressive disorder which was found to be true in our study also.
In our study population, 68% of cases had a psychiatric disorder; most as depressive disorder followed by adjustment disorders. High rates of psychiatric comorbidity (80%) among adolescent suicide attempters had been observed by earlier researchers.,, A study by Kumar et al. reported that 65% of the sample (n = 74) had diagnosable psychiatric disorder. The results obtained in this study were comparable to the above study when psychiatric morbidity was considered. These findings point to the possibility that psychiatric disorders and psychological disturbances are important risk factors for attempted suicide. This is of importance to the professional caregivers who provide services to these people so that they can be identified early and necessary interventions can be done before it precipitates an attempt.
Precipitating life events
In our study, 75% of patients had a precipitating event before the attempt. It has been seen in various studies that the number of stressful life events before the attempt was found to be an important risk factor associated with adolescent suicide attempts. The events that preceded an attempt were mostly undesirable events (failure in examination, break up with friend, family conflict, illness or death of family member, excessive alcohol, or drug usage by family member); Majority of the attempters reported interpersonal problems as the main precipitating factor for attempt.
As a significant sample consists of students, so in this category, the importance of parent's support and their availability for ensuring the adolescent capacity to prevail over various stresses in life might contribute to becoming a significant stressor. In addition, the parents' over expectations for their academic achievements and criticisms on their underperformance could be contributing factors for suicidal behavior. Humiliations meted out in schools could also be among other factors.
Paykel et al. had observed that the patients who attempt suicide show as much as four times an incidence of an upsetting life event in the preceding month compared to the general population. Elevated levels of undesirable events and exit events in the previous year were observed by Adams et al. The impact of stress is tempered by the mitigating effect of primary (in the family), secondary (among friends, relatives, and neighbors) and tertiary (at social service organizations, religious, and charitable services) factors. However, when the person is faced with the issues in the context of interpersonal and family breakdowns, the stressed adolescent who is already in an age of emotional turmoil due to physiological and psychological changes stands in a high-risk position. Therefore, it is imperative that this section of the population needs more psychological and social support especially during periods of stress.
Personality risk factors
The present study shows 30% of personality traits as risk factor for suicide. Past few years, various studies show the relationship of personality traits with suicide behavior has been increasing. According to Brezo et al. (2006), personality traits are linked to suicide behavior because traits contribute to a diathesis for suicide behavior. In the diathesis model, the pathological behavior is seen as the product of internal characteristics and external events. Internal characteristics constitute a vulnerability that can, in conjunction with precipitating external events, create a window of opportunity for the emergence of pathological behavior. Personality traits reflect a propensity or disposition toward those cognitions, emotions, and behaviors which are consistent with the trait. Since situations are also important, traits do not determine behavior, but instead, influence its baseline probability. The connection between personality traits and any actual, concrete behavior is therefore indirect and probabilistic.
Limitations of this study are that it is a hospital-based study and sample includes a selection bias as only those medically stable were included as cases. 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|| |
The outcome of this study has implications in both clinical and public health approaches to the reduction in rates of adolescent suicide attempts. It helps a professional to identify high-risk cases and intervene before the crisis occurs. Promising prevention strategies include school-based skills training for students, screening for at-risk youths, education of primary care physicians, media education, and lethal means restriction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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