|Year : 2013 | Volume
| Issue : 2 | Page : 118-124
Racial differences in suicidal ideation among school going adolescents
Santosh Kumar1, Vidhata Dixit1, Suprakash Chaudhury2, DK Kenswar3
1 Department of Psychiatry, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
2 Department of Psychiatry, Pravara Institute of Medical Sciences (Deemed University), Rural Medical College, Pravaras Rural Hospital, Loni, Maharashtra, India
3 Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry and Allied Sciences, Kanke, Ranchi, Jharkhand, India
|Date of Web Publication||21-May-2014|
Department of Psychiatry, Pravara Institute of Medical Sciences (Deemed University), Rural Medical College, Pravaras Rural Hospital, Loni, Ahmednagar - 413 736, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Young adults are at increased risk for suicidal behavior and there is growing concern about racial differences in suicidal ideation, especially in the younger population. Aim: The aim of this study is to assess suicidal ideation in school going tribal and nontribal adolescents and to study its relationships with psychological well-being, depression, and anxiety. Materials and Methods: A total of 259 students of Classes X, XI, and XII of three Schools of Ranchi, who fulfilled inclusion and exclusion criteria, were screened for suicidal ideation by Suicidal Ideation Questionnaire (SIQ) and psychological well-being by General Health Questionnaire-12 (GHQ-12). The level of anxiety and depression was assessed by Hospital Anxiety Depression Scale (HADS). Results: Overall 33.2% of the adolescents had suicidal ideation out of which 34.2% were tribal-students and 32.8% nontribal-students with no significant intergroup difference. Psychological discomfort (GHQ-12 Score ≥3) was noticed in 59.1% of adolescents, but no racial difference was found. However, the mean HADS depression score was significantly higher in tribal adolescents, more so in tribal boys than nontribal adolescents or boys, respectively. There was a significant positive correlation of SIQ total score in all the adolescents with GHQ-12 total score, HADS total score, HADS anxiety score, and HADS depression score. Conclusion: There were no racial differences in suicidal ideation and psychological discomfort among tribal and nontribal adolescents. Tribal adolescents, and more specifically tribal boys, had more depression than their nontribal counterparts. Suicidal ideation was positively correlated with psychological discomfort, anxiety, and depression.
Keywords: Adolescents, anxiety, depression, psychological discomfort, race, suicidal ideation
|How to cite this article:|
Kumar S, Dixit V, Chaudhury S, Kenswar D K. Racial differences in suicidal ideation among school going adolescents. Ind Psychiatry J 2013;22:118-24
Suicidal ideation refers to a myriad of cognition specific to death, self-destructive behavior, related actions and activities. Adolescents today face tremendous life pressures that put them at risk for myriad self-destructive behaviors, and suicide is the most devastating consequence of their inability to cope. Completed suicides are only part of the picture. Other forms of suicidal ideation and behaviors are much more common. Suicidal ideation has been viewed as an initial stage on a continuum of suicidality and a primary marker for future suicidal behavior. , Studies have consistently documented that woman , and young adults ,,,,, are at increased risk for suicidal behavior.
Ethnic and racial differences in suicidal ideation and attempts are growing concern in the context of globalization and modernization. Suicide attempts were highest among American Indian/Alaska Native (AI/AN) females, followed by Latinas, AI/AN males, and Asian American/Pacific Islander females; suicide attempts are lowest among African American and white adolescent males.  A particularly high rate of suicide in Native Americans of United States points towards the existence of a higher suicidal risk among indigenous people in different parts of the world. This may be related to erosion of traditional cultural values, increased alcoholism, criminality, and unemployment.  In a recent national study in United States, an increased rate of suicide and nonfatal suicidal behaviors were shown to be higher among blacks, particularly among the youngsters.  This was in contrast to earlier two large national epidemiological studies which had suggested that Blacks were at lower risk for suicide attempt than non-Hispanic whites.  Suicide rates for Māori youth (28/100,000) are higher than those for non-Māori youth (12/100,000). 
Although youth suicide rates have declined slightly since 1992, it is still the third leading cause of death among 10-24 years old following automobile accidents and homicide.  Equally concerning, suicide rates among certain subpopulations, such as black males, White females, Asian youth, AI youth, and sexual minority youth have all increased.  Within a typical high school classroom, it is likely that three students (one boy and two girls) have attempted suicide in the past year. For every three students who attempt suicide, only one receives medical attention. The other two get up and go to school the next day. 
Much of the research on factors considered to be related to adolescents' suicidal behaviors has focused on variables such as depression and hopelessness. There is limited research exploring differences across racial groups in cognitive variables associated with depression (e.g. attributional style, negative cognitive errors, and the cognitive triad of depressive thoughts about self, the world, and the future).  The majority of this research has focused on differences in the mean level of these variables endorsed by different racial or ethnic groups. However, until date, this research is inconclusive with some studies finding no ethnic differences,  others finding Caucasians demonstrating more biases  and one study finding that African Americans report greater biases. 
The extent of adolescent suicidal behavior demands a need for examining potential processes and factors that may affect or exacerbate adolescent suicidal cognitions. Such research is important for increasing our understanding of these behavior and developing appropriate intervention procedures. India has the second largest adolescent population in the world and has tremendous racial and cultural diversity. Recently, few studies have focused on the assessment of suicidal ideation and its correlates in Indian adolescents  and have found similar results, as per reports given in the western literature, in terms of prevalence, gender difference, and psychological correlates of suicidal ideation in this population. However, the racial difference in suicidal ideation in Indian adolescent has not been highlighted previously. This study was intended with this perspective to find out any such difference along with its correlates in school going adolescents. Schools of Ranchi were selected to collect the sample in view of easy availability of two groups of sample, that is, tribal and nontribal adolescents.
| Materials and methods|| |
This study was carried out at the Departments of Psychiatry and Clinical Psychology, Ranchi Institute of Neuropsychiatry and Allied Sciences. The project proposal was approved by the Institutional Ethical Committee.
The study sample consisted of 259 school going adolescents from X to XII standards. They were selected through stratified random sampling method from three different private as well as Government Schools of Ranchi, Jharkhand, India.
It was a school-based cross-sectional analytical study using simple screening instruments for detecting racial differences in suicidal ideation, psychological well-being as well as depression and anxiety in school going adolescents of both genders.
- Adolescents of both genders studying in X, XI, and XII standards
- Overtly healthy
- Understanding English and Hindi languages.
- Any medical or psychiatric condition requiring medication at present
- Any past history of diagnosed mental illness.
This was a self-prepared semi structured performa, especially designed for this study. It contained information about sociodemographic characteristics such as age, sex, race, standard (education), living pattern, domicile, and socioeconomic status.
Suicidal ideation questionnaire
The Suicidal Ideation Questionnaire (SIQ) is a 30-item self-report questionnaire that is used to screen for frequency of suicidal ideation in adolescents. The item response format of the SIQ ranges from 0 (I never had this thought) to 6 (almost every day). A total score (range = 0-180) is computed to derive severity of suicidal ideation score; higher score indicate greater frequency of suicidal ideation. The psychometric properties of SIQ have been supported in several clinical and nonclinical adolescent samples. For the total SIQ score, the recommended raw cut-off score indicative of the potential for suicidal risk is 41. 
General health questionnaire-12
This is a very popular screening tool to assess psychological well-being in the general population. Although originally designed to be used in adult populations General Health Questionnaire (GHQ), it has been used with adolescents too. Among the four versions of GHQ, the GHQ-12 is the shortest version and commonly used one. It has a sensitivity of 89% and specificity of 80%. It has reasonable test-retest reliability as well as both content and construct validity. It is used to identify the severity of psychological distress experienced by an individual within the past few weeks. Each item on the scale has four responses from "better than usual" to "much less than usual." The scores were summed up by adding all the items on the scale ranging from 0 to 12. A cut-off score of 3 is usually taken to determine respondents' level of psychological well-being. 
Hospital anxiety depression scale
This scale is a self-assessment instrument for detecting anxiety and depression in vulnerable population. There are 14 items (7 for anxiety and 7 for depression). Each item is rated on four points (0-3) rating scale. A score of more than 10 indicates definite presence of anxiety or depression. Hospital Anxiety Depression Scale (HADS) has been found to a valid screening tool to assess depression and anxiety both in somatic, psychiatric, and primary care patients and in the general population. ,
After obtaining written permission from the principals of three schools for conducting the study, the parents of the students were informed about the aim and objectives of the study in the parent teacher meeting and their informed consents was obtained. Thereafter, the students were explained about the study project in the presence of school staffs. Those who agreed for the study as well as fulfilled the inclusion and exclusion criteria were included and the data were collected in leisure periods of school. The students were instructed not to write their names to maintain the confidentiality. The sociodemographic details were collected in self-prepared semistructured performa. After explaining the instructions, the students of three classes separately were given response sheets of SIQ, GHQ-12 and HADS to fill them up in English or Hindi languages. All data were collected anonymously, and participants were assured of the confidentiality of their responses and the voluntary nature of their participation.
Analysis of data
The data obtained was analyzed using the Statistical Package for Social Sciences version 16.0 (IBM) with parametric and nonparametric tests being used as applicable.
| Results|| |
Sociodemographic characteristics of all the students in the study are shown in [Table 1]. Nontribal boys were significantly more in number than tribal boys and tribal girls were more in number than nontribal girls. The majority of tribal-students belonged to rural background, while the majority of nontribal-students to urban background. Similarly, significantly more number of tribal-students belonged to low socioeconomic status than nontribal-students (27.8% vs. 7.8%) while more number of nontribal-students to middle socioeconomic status than tribal-students (92.2% vs. 72.2%). Statistically no significant difference was observed in two groups in relation to age (range: 13-17), standard (class) of education, and living pattern.
[Table 2] shows that overall 33.2% of the adolescents had suicidal ideation (as defined in this study as SIQ total score being >41) out of which 34.2% were students from tribal background and 32.8% students from nontribal background. However, there was no significant difference in term of suicidal ideation between two groups. Further, overall 59.1% of the adolescents had psychological discomfort (as defined in this study as GHQ-12 total score being ≥3) out of which 65.8% were students from tribal background and 56.1% students from nontribal background. However, there was no significant difference in term of psychological discomfort between two groups. Psychological discomfort was present in 69.4% of girls where a statistical trend (χ2 = 3.798, df = 1, P = 0.056) of more psychological discomfort was noticed in girls from tribal background (80%) than girls from nontribal background (62.7%).
|Table 2: Racial differences in suicidal ideation (SIQ total score: >41), psychological discomfort (GHQ‑12 total score: ≥3), and levels of anxiety (HADS‑anxiety subscale score: >10) and depression (HADS‑depression subscale score: >10) in all school going adolescents|
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[Table 3] shows that HADS depression score was significantly higher in school going students, especially boys from tribal background compared to students from nontribal background. However, no significant difference was found on SIQ, GHQ-12, HADS total, and anxiety scores in the two groups.
|Table 3: SIQ total score, psychological discomfort (GHQ‑12 total score), HADS total score, HADS anxiety subscale score and HADS‑depression subscale score in tribal and nontribal school going adolescents|
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[Table 4] shows that there was a significant positive correlation of suicidal ideation in all adolescents from a tribal background with GHQ-12 total score (r = 0.469, P < 0.001), HADS total score (r = 0.553, P < 0.001), HADS anxiety score (r = 0.574, P < 0.001), and HADS depression score (r = 0.379, P < 0.01). However, the correlation is moderate, the R2 being 0.22 meaning only 22% of the variation in GHQ-12 can be explained by the SIQ. Similarly, for other HADS scores also the correlations are moderate.
|Table 4: Correlation of suicidal ideation (SIQ total score) with GHQ‑12 total score and HADS scores (total score, anxiety score and depression score) in all tribal adolescents (n=79)|
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[Table 5] shows that there was a significant positive correlation of suicidal ideation in all adolescents from nontribal background with GHQ-12 total score (r = 0.465, P < 0.001), HADS total score (r = 0.487, P < 0.001), HADS anxiety score (r = 0.525, P < 0.001), and HADS depression score (r = 0.317, P < 0.001). However, the correlations are moderate.
|Table 5: Correlation of suicidal ideation (SIQ total score) with GHQ‑12 total score and HADS scores (total score, anxiety score and depression score) in all nontribal adolescents (n=180)|
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| Discussion|| |
One of the major findings of the study is that about 33% of school going adolescents had suicidal ideation. This finding is in accordance with some earlier reports from both India , and abroad ,,, that young adults are at increased risk for suicidal behavior. However, our study could not find any significant racial difference in suicidal ideation in these students. To the best of our knowledge, we did not find any Indian data over the issue, but some studies from abroad are worth mentioning. National studies in the United States and New Zealand have found that suicidal ideation and suicidal behavior to be significantly more among young tribal population than the Whites. ,
In view of the significant gender differences in suicidal ideation in previous studies of both abroad ,, and India,  this study had as one of its objectives to seek any racial difference in both male and female students separately. It was noted here that while 43% of female adolescents had suicidal ideation, only 27% of male adolescents had suicidal ideation. However, there was no significant racial difference in suicidal ideation in either male adolescents or female adolescents separately.
Overall, about 59% of all students had psychological discomfort (as measured on GHQ) and such percentage was comparable in students of both races. However, the level of depression (as measured on HADS) was significantly more in tribal adolescents than nontribal adolescents. Recently, an Indian study found psychological distress (as measured on GHQ) to be present in around 15% of adolescents of a public school in India. They have also found that depression was present in around 20% those adolescents.  In comparison to the above study, it appears that more number of students in our study had psychological discomfort. In other countries, the research examining racial/ethnic differences in adolescent psychopathology has yielded inconsistent findings about differences in the prevalence of symptoms of depression, anxiety, eating disorders, and aggression. Some studies document significant group differences , while others have reported no differences in symptoms across groups. 
Like suicidal ideation, racial differences in psychological discomfort and levels of anxiety and depression were analyzed in both male and female students separately. Overall, a significant racial difference was found only in the level of depression. The tribal boys had more level of depression than nontribal boys. As of now, it has been widely emphasized that suicidal ideation and its correlates such as distress, depression, etc., are more common in females. However, according to official statistics, in many countries, there are differences in the rate and expression of men and women's suicidal behavior.  In our study, a finding of significant racial difference in only male adolescents may signify that young boys are more prone to be affected by racial issues.
Further, a finding of a positive relationship found between suicidal ideation and psychological discomfort as well as levels of depression and anxiety in both tribal and nontribal adolescents indicates many issues in hand in the current context. In a similar study on school going adolescents, it was pointed out that even moderate levels of depressive symptomatology can be associated with suicidal ideation in the young population.  In the psychiatric literature, some factors such as erosion of traditional cultural values, increased alcoholism, criminality, unemployment, etc., have been highly emphasized to be responsible for making the native population at risk of psychological disturbances.  In our study, it was found that a significantly more number of tribal-students belonged to lower socioeconomic status than nontribal-students. Low socioeconomic status has consistently been found to be associated with higher rates of depression and other psychiatric disorders in epidemiologic studies. , This may be one of the reasons for more depressive symptomatology in tribal boys. However, a gender matched study is expected to discuss this issue because such matching was not done in our study.
Overall, in a background of a significant number of adolescents having suicidal ideation as well as its correlates like depression and psychological discomfort, a finding of racial difference in depression or any of psychological construct in a small part of the country implies a lot. Of course, there is a need to search the same comprehensively in tribal natives at different parts of India where cultural and racial diversity is present. This study provides an initial step in developing reliable estimates of racial differences in suicidal ideation and its correlates in small part of India. While this study has limitations, it provides information that may be critical for suicide intervention and prevention programs directed toward tribal population at an earlier stage. Though suicide risk is important to examine in school samples, an investigation that broadly examines a representative community sample would be ideal and more generalizable.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]