|Year : 2015 | Volume
| Issue : 1 | Page : 64-69
Gender differences among suicide attempters attending a Crisis Intervention Clinic in South India
Vikas Menon, Shivanand Kattimani, Siddharth Sarkar, Avin Muthuramalingam
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||16-Jul-2015|
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives: Studying gender differences among suicide attempters is important for identifying gender-specific risk factors and for planning management and prevention. Our objective was to delineate gender differences among a well-defined group of suicide attempters. Materials and Methods: This record-based study was conducted among patients presenting to a Crisis Intervention Clinic in a Tertiary Care Hospital in South India. Information was gathered regarding sociodemographic and clinical characteristics. Hopelessness was measured using Beck Hopelessness Scale (BHS), and stress was evaluated using Presumptive Stressful Life Events Scale (PSLES). Results: The sample comprised of 162 males and 137 females. Males were significantly older and were more likely to be employed as compared to females. Alcohol use was significantly more in males and number of men who attempted suicide under intoxication was significantly higher. Females had a greater proportion of attempts with the use of plant poisons and medication overdose. There was no significant difference between two genders on BHS though differences were noted on types of stresses reported on PSLES. Conclusion: Gender-specific differences were noted with regard to substance use, mode of attempt and types of stressors experienced. Identifying these factors might help us to design targeted interventions to prevent further attempts.
Keywords: Attempted suicide, clinic, diagnosis, gender, stressor
|How to cite this article:|
Menon V, Kattimani S, Sarkar S, Muthuramalingam A. Gender differences among suicide attempters attending a Crisis Intervention Clinic in South India. Ind Psychiatry J 2015;24:64-9
Gender is one of the important sociodemographic factors that has been shown as a determinant of suicidal behavior. ,, One of the most robust findings in suicide literature across cultures and age groups is that more men die by suicide whereas more women attempt suicide , although this difference between genders is much narrower in developing countries like India.  Thus, suicidal behavior differs between genders as males appear to harbor a higher intent to die, and consequently use more violent and lethal means, while women, seemingly, attempt for motives other than death. ,,,, It has been argued that this so called "gender paradox" of suicidal behavior emanates from culturally rooted conceptions about gendered behaviors and may not reflect a true difference. , Indian and international studies confirm that men who attempt suicide are more likely to be unemployed, never married, have alcohol-related problems, and higher mean number of stressful life. ,,, A prior suicide attempt is among the best predictors of eventual death by suicide.  Hence, studying this high-risk group has significant preventive implications and identification of gender differences may play a notable role in this regard. 
Only a handful of studies in the region has focused on assessing gender differences in suicidal behavior. ,,, Many of them examined subgroups including medically serious suicide attempters or studied completed suicides. The changing sociodemographic profile such as increased participation of women in the workforce and gradually changing health delivery systems in the region call for a periodic re-evaluation of gender paradox in suicide attempters and making cross-cultural comparisons. Hence, this study was conducted to assess gender differences in characteristics among individuals who seek help for attempted suicide at a Tertiary Care Center in Southern India.
| Materials and methods|| |
The present record-based study was conducted at the Crisis Intervention Clinic (CIC) run by the Department of Psychiatry of a teaching cum tertiary care general hospital in Southern India. As part of hospital policy, all clients with attempted suicide undergoing treatment are referred to Psychiatry following medical management and prior to their discharge from the hospital. Such cases are assessed in the CIC by the resident doctors using a specially designed intake proforma under the supervision of faculty, and further management plans are drawn based upon the suicide risk. Information is gathered about demographic data, mode and circumstances leading to the attempt, and clinical aspects of history of suicide attempt and use of substances. In addition to the patient, information is also collected from the accompanying family member to ensure reliability and completeness of data. The presence of psychiatric diagnosis is ascertained as per International Classification of Diseases 10, clinical descriptions, and diagnostic guidelines.  For the purposes of the clinic, a suicide attempt is defined as "engagement in a potentially self-injurious behavior with at least some intent to die."  Additionally, the following instruments were used to complete the assessment:
For the present study, clinical charts of patients who were seen in CIC following suicide attempt over a 2 years period between July 1, 2011 and June 30, 2013 were reviewed. Information pertaining to the demographic variables, clinical characteristics, suicide-related measures, and scores on BHS and PSLES were retrieved from the records by one of the investigators (SK).
- Beck Hopelessness Scale (BHS) - This is a 20-item validated true-false scale that is used to measure the negative attitude and expectancies of the patients which reflects hopelessness. It has 9 items keyed false and 11 items keyed true. Each item is scored 0 or 1 and hence, total scores summing all the items can range from 0 to 20.  The scale has been previously used in studies from India 
- Presumptive Stressful Life Events Scale (PSLES) is scale to measure stressful life events that is developed and validated for Indian setting.  It is a 51-item scale of desirable and undesirable stressful events which is quantified with weighted scores. We used the scale, primarily, as a checklist to know how many number of stressful life events happened in the preceding 1 year prior to the current attempt.
Analysis of the data was conducted using Statistical Package for Social Sciences (SPSS) version 17.0 (SPSS Inc, Chicago). Descriptive statistics was used for denoting the demographic and clinical characteristics of males and females. Comparison between males and females were done using chi-square test c2 or Student's t-test depending upon whether the variable of interest was discrete or continuous. Fisher's exact test was used wherever applicable. Missing value imputation was not conducted as a part of the study. All analysis was carried out for two-tailed significance and the level of significance was set at P < 0.05.
| Results|| |
During the study period, 312 cases were registered in the clinic, of which suicidal intent could be established in 299 cases (95.8% of the sample) and were included in the present analysis. Of them, 162 were males (54.2% of the included sample) and 137 were females (45.8%). [Table 1] shows the different demographic and clinical variables across the two genders.
The clinical characteristics of the patients across the two genders are depicted in [Table 2]. Hopelessness measured by BHS was not significantly different between the two groups (t = 1.310, P = 0.192). Drug or alcohol use was more common among men (c2 = 93.274, P < 0.001) and significantly higher number of men attempted suicide under intoxication (c2 = 44.058, P < 0.001). The distribution of concurrent psychiatric diagnosis across the two genders is shown in [Figure 1]. Adjustment disorder was the most common psychiatric diagnosis in both the genders. Expectedly, substance use disorder was significantly more common in males (c2 = 21.206, P 0≤ 0.001).
The distribution of mode of attempt and reasons for attempt between genders is shown in [Table 3]. Pesticide use was the most favored mode by both males (70.4%) and females (56.9%). A higher proportion of males used pesticide for suicide attempt (c2 = 5.831, P = 0.016), while plant poisons and medications were more commonly used by females compared to males (c2 = 4.750, P = 0.029 and c2 = 5.967, P = 0.015). Interpersonal relationship issues were the most common reasons for the attempt in both the genders. There were no statistically significant differences between males and females in the reasons for the attempt.
|Table 3: Comparison of mode of attempt and reasons for attempt between genders |
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The stressful life events experienced by the individuals in the past 1 year was evaluated, and those that were significantly different between genders are shown in [Figure 2]. Family conflict was the most common stressful life event in both genders. Being unemployed (c2 = 4.519, P = 0.034) was significantly more in men. Appearing for examination or interview (c2 = 6.931, P = 0.008) and excessive use of alcohol or drugs by a family member (c2 = 7.017, P = 0.008) were perceived as significantly more common stressor among women.
| Discussion|| |
The present study suggests that differences are present between men and women suicide attempters with respect to concurrent diagnoses, mode of attempt and stressful life situations encountered. The demographics of our sample reveals two intriguing observations - that males outnumbered females and men who attempted suicide were significantly older than women. The latter is interesting because although previous studies have also alluded to this finding, , two recent studies that specifically evaluated gender differences among suicide attempters presenting to the emergency departments have suggested otherwise. , Males are known to make more lethal attempts  and consequently, may be overrepresented in samples drawn from Tertiary Care Centers such as ours. The present study suggests that men who attempt suicide were more likely to be employed as compared to women. This could be an indirect reflection of the social profile in the region, where men are the primary breadwinners. It could also indicate the causal role of job-related factors in leading an individual to contemplate and attempt suicide that this study was underpowered to confirm. Predictably, men were more likely to be alcohol users than women. This again may reflect substance use patterns in India where rates of substance use in men are considerably higher than that of women.  Attempted suicide under intoxication was also significantly more common among men. This is consistent with previous studies and could be one of the possible targets of intervention. ,
We observed that the hopelessness scores did not differ between male and female attempters. Hopelessness is one of the key constructs that is closely correlated with intent in suicide  and is believed to play an important intermediate role between a stressful event and subsequent suicidal behavior.  Considering its central role in suicide, it is surprising that very few studies have evaluated gender differences in hopelessness among suicide attempters and research has been largely inconclusive in this regard. Piccinelli and Wilkinson, in an elegant review on gender differences in depression, conclude that there is insufficient evidence to support the widely held notion that cognitive parameters such as hopelessness predispose women to mood disorders.  Adjustment disorder was the most common psychiatric disorder in both the genders. Local studies have suggested that adjustment disorders are encountered more frequently than mood disorders in the Indian setting. , Other studies, mostly from the West, suggest that depression may be the most common diagnosis among suicide attempters. , The diagnosis of adjustment disorder requires the presence of affective or conduct symptoms as a response to identifiable stressors. , Many individuals qualifying for such a diagnosis indicate that they were "distressed" by life events, but fall short of endorsing the full syndrome of depression. It is possible that symptoms consistent with depression might have been present, but time duration criteria of 2 weeks were not met in many circumstances. The propensity to attempt suicide is believed to increase in the early stages of recovery from depression as the patients feel more energetic and consequently, are able to translate their suicidal ideas or plans into action whereas previously they were too fatigued to do so.  The present study did not record the evolution and change of psychiatric diagnosis at follow-up and can only remark on the diagnosis at initial assessment.
As noted in previous studies from culturally similar settings, , self-poisoning using pesticide was the most common mode of attempt in both males and females. Additionally, plant poison and medication ingestion were more favored by females. Pesticide and plant poison in the form of yellow oleander (locally called "oduvanthalai") are commonly available in rural farming communities in the region. ,, Since more than 90% of our subjects hailed from rural areas, it is intuitive that access to such means was easy and contributed to the parity observed between genders though discordant findings have been noted elsewhere. ,, It has been pointed out that reducing availability to means could be impactful in reducing suicide attempts in the community. 
Interpersonal relationship reasons were most common reported cause for suicide attempt similar to other regional papers. , Family conflict was the most commonly reported stressful life event in both the genders and this is again in agreement with extant Indian literature.  Being unemployed was a significant stress experienced by men. Excessive use of alcohol or drugs by a family member and appearing for examination or interview was perceived as significant stressor among women. These gender dependent impact of psychosocial stressors on suicidal behavior noted in our study broadly concur with the conclusions drawn by Narishige et al. and Schrijvers et al. , These differences in the types and appraisals of stressors perceived by the two genders may be helpful while implementing customized counseling measures for suicide attempters.
The findings of the present study should be interpreted in the light of its strengths and limitations. The strength of the study lies in systematically assessing multiple characteristics pertaining to suicide in a set of patients identified with recent suicide attempts. Widely accepted standard nomenclature was used to define suicide attempt. We studied a larger sample as compared to two similar recent works. , The limitation of the study includes all the design limitations of a retrospective chart based study. Underreporting of symptoms may have occurred despite best efforts by the clinicians to collect as complete information as possible. No structured instrument was used to assess co-morbid clinical diagnosis and objective measures of lethality and intent were not utilized.
To conclude, it appears that gender differences among suicide attempters appear less pronounced in the Indian setting compared to the worldwide literature on the subject. Nevertheless, the present study does point to some important differences between male and female suicide attempters that may have implications for preventive work. Men were more likely to be substance abusers and attempt suicide under intoxication. The stressors experienced also differed between the two genders with work-related stressors commoner in men and excessive use of alcohol or drugs by another family member more frequently reported by females. This implies that suicide prevention strategies in men should focus on reducing comorbidities such as substance use that may also favorably impact the womenfolk. Reducing availability of means such as pesticide may reduce suicides in both genders and hence needs to be considered very seriously. Future studies should assess whether gender differences predict treatment outcomes in patients with suicide attempts. In this regard, a community-based sample may be more representative and may avoid referral biases and issues of gender related difficulty in access to treatment. Further research is also needed to throw light on gender differences in the interaction of risk factors for suicide that may better inform suicide prevention strategies.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]