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Year : 2022  |  Volume : 31  |  Issue : 2  |  Page : 221-227  Table of Contents     

Assessment of lethality and its clinical correlates in suicide attempters with mood disorders

1 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
3 Department of Psychiatry, IHBAS, New Delhi, India

Date of Submission02-Dec-2021
Date of Acceptance15-Feb-2022
Date of Web Publication18-Aug-2022

Correspondence Address:
Dr. Raman Deep
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_251_21

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Background: Relatively limited literature is available on lethality assessment for suicide attempts in affective disorders from the Indian subcontinent. Aims: To assess the lethality and its clinical correlates in lifetime suicide attempters with mood disorders. Methods: A total of 100 lifetime suicide attempters, aged ≥18 years, with a DSM-5 diagnosis of bipolar disorder (BD) or major depressive disorder—recurrent (MDD-R) were recruited. Current euthymia was ascertained (Hamilton Depression Rating Scale (HAM-D) ≤7; Young Mania Rating Scale (YMRS) ≤4). Assessments were conducted using clinical pro forma, Risk–Rescue Rating Scale (RRRS), Columbia Suicide Severity Rating Scale (C-SSRS) and Barratt's Impulsiveness Scale (BIS). Results: Average age of the sample was 36.32 ± 11.76 years (48% males, 52% females). The mean duration of affective illness was 10.59 ± 8.32 years. Risk–rescue scores for lethality were significantly higher in males (vs females), bipolar disorder (vs unipolar), multiple attempters (vs single) and planned (vs unplanned) attempters. Risk–rescue score also showed a significant positive correlation with lifetime total and depressive episodes, and intensity of ideations, and a significant negative correlation with BIS—attention impulsiveness. Regression analysis [F (3,96) = 12.196, P < 0.001, adjusted R2 = 0.253] found that lifetime lithium prescription, intensity of suicidal ideations and attention impulsiveness explained 25.3% variance in lethality. Conclusion: Absence of lifetime lithium, higher intensity of suicidal ideations and lower attentional impulsiveness predicted higher lethality of suicide attempts. Lethality of suicide attempts was found to be associated with a multitude of clinical factors, notably male gender, bipolarity, multiple attempts, planned attempts and number of total and depressive episodes. Assessment of lethality and its correlates can help to plan strategies towards risk prevention in mood disorders.

Keywords: Lethality, mood disorders, suicide attempt

How to cite this article:
Chawla N, Deep R, Gupta S, Vishwakarma A, Sen MS. Assessment of lethality and its clinical correlates in suicide attempters with mood disorders. Ind Psychiatry J 2022;31:221-7

How to cite this URL:
Chawla N, Deep R, Gupta S, Vishwakarma A, Sen MS. Assessment of lethality and its clinical correlates in suicide attempters with mood disorders. Ind Psychiatry J [serial online] 2022 [cited 2023 Jan 28];31:221-7. Available from: https://www.industrialpsychiatry.org/text.asp?2022/31/2/221/353882

Suicide is a public health problem in most parts of the world, including Asia.[1] Suicide accounts for nearly 1.5% of global deaths and is a major contributor to mortality in patients with psychiatric disorders.[2],[3] A significant proportion of patients with severe mood disorders have suicidal ideations and behaviours.[4],[5] Lifetime risk of completed suicide in those diagnosed with mood disorders has been found to range between 4% and 14%.[6],[7],[8],[9] Risk factors such as male gender, past suicidality, family history of psychiatric disorder or suicide, and comorbid disorders such as anxiety and substance use disorders, among others, predict a higher likelihood of suicide attempts in patients with mood disorders.[4],[5],[10],[11]

There are some literature studies to indicate that individuals with mood disorders make more lethal attempts than other psychiatric diagnoses.[12],[13] A systematic review of 100 reports found that the attempts/suicide ratio is 3–6-fold lower (i.e. more lethal) in bipolar disorder (BD) compared to the general population.[12] Some authors have suggested that high lethality attempters might be a distinct phenotype within affective disorders.[14] Lethality is taken as an indicator for the probability of a suicide attempt to cause death.[15] Those with high-lethality suicide attempts appear to be clinically and behaviourally closer to those with completed suicide than those with low-lethality attempts and are eventually more likely to die by suicide. It is, thus, important to explore the parameters that may determine the 'lethality' of a suicide attempt.

Overall, there is limited literature on predictors of the lethality of suicide attempts in mood disorders.[12],[16],[17],[18],[19] Further, existing studies have not used a validated tool for lethality assessment. The few available studies on predictors of suicide lethality in mood disorders have used variable ways of defining and assessing lethality, such as deadliness of suicide methods as per their classifications, intent to kill self while engaging in life-threatening behaviour or degree of physical damage inflicted on oneself.[12],[15],[20],[21],[22] Lethality assessment in several existing studies was assessed on either a unidimensional tool,[21] or self-designed, non-validated questionnaires.[22],[23] There is also a need to take into account other factors such as those pertaining to rescuability or lethal intentionality, rather than sole reliance on actual medical harm from the attempt.

There is relatively less literature on suicide attempts in Asian populations, though such a need has been emphasized in the literature.[24],[25] Available Indian studies till date[13],[26],[27],[28],[29] have assessed factors associated with suicide attempts in general psychiatric samples; however, there was no particular focus on suicidality in samples with affective disorders.[25] No published study from India has described the correlates or predictors of the lethality of suicide attempts.

We aimed to explore the lethality and its clinical correlates among lifetime suicide attempters with a diagnosis of mood disorder seeking treatment at a tertiary care centre in India.

   Subjects and Methods Top

Ethical clearance was taken from the Institutional Ethics Committee before study initiation. It was a cross-sectional, observational study, conducted at the department of psychiatry of a tertiary care institute in India.

Study participants

All treatment-seeking individuals with mood disorders visiting the outpatient clinic were screened using pre-defined selection criteria. Participants were included only if they were aged 18 years or above, had a DSM-5[30] diagnosis of BD with lifetime depressive episode (≥ 1) or major depressive disorder—recurrent (MDD-R), had a history of suicide attempt/s, and were currently euthymic (Hamilton Depression Rating Score ≤ 7 and Young's Mania Rating Scale score ≤ 4).[31],[32] The 'suicide attempt' was operationally defined as per definition by O'Carroll and colleagues, i.e., 'a potentially self-injurious behaviour with a nonfatal outcome, for which there is evidence, either explicit or implicit, that the person intended at some (nonzero) level to kill himself/herself'.[33]

Exclusion criteria included active suicidality, ambiguous or uncertain suicidal attempts, presence of comorbid psychiatric illness, substance dependence (apart from tobacco) or any significant medical condition interfering with assessments.

Study assessments

After written informed consent, assessments were conducted in a single session lasting about an hour per participant. All participants were assessed using a demographic sheet and semi-structured clinical pro forma. They were further assessed using study instruments as follows: (i) Columbia Suicide Severity Rating Scale (C-SSRS), which is a valid and frequently used instrument to evaluate suicidal ideations and suicidal behaviour.[34] The internal consistency of the intensity subscale is high, with a Cronbach's alpha of 0.937. Lifetime version was used; (ii) Risk–Rescue Rating Scale (RRRS) which is a validated, quantitative method to assess the lethality of suicide attempts.[35] This instrument consists of items (scored from 1 to 3): five items describe risk factors (method used, impaired consciousness, toxicity, reversibility and treatment required) and five describe rescue factors (location, person initiating rescue, probability of discovery, accessibility to rescue and delay until discovery), yielding a risk–rescue score to indicate lethality, which involves subtraction of rescue score from risk score; (iii) Barratt's impulsiveness scale (BIS) is a 30-item self-report questionnaire which assesses general impulsiveness and assessment of attention, motor, self-control, cognitive complexity, perseverance, cognitive instability, attention impulsiveness [attention and cognitive instability], motor impulsiveness [motor and perseverance] and non-planning impulsiveness [self-control and cognitive complexity]. The items are scored on a four-point scale. Internal consistency of scale is satisfactory, with a Cronbach's alpha of 0.83.[36]

Statistical analysis

Statistical analysis was conducted using SPSS version 20. Descriptive analysis was used to describe the sample characteristics. Shapiro–Wilk test was used to assess normality. Mann–Whitney U test was used to compare RRRS scores between categorical variables, and Spearman's correlation for correlation between RRRS scores and other continuous variables.

Multivariate stepwise regression was conducted to derive the predictors of lethality, using the RRRS score as the dependent variable. Independent variables were chosen based on the level of significance (P < 0.05) found in comparative and correlational data with RRRS scores. A pair of variables (i.e. total number of episodes and total number of depressive episodes) showed a high correlation with each other (collinearity variance inflation factor (VIF) in regression model > 5), of which the variable with a higher spearman's statistic coefficient was retained (i.e. total number of episodes). Similarly, the average number of attempts was taken for the regression model, while the frequency of attempts (single/multiple) was omitted from the regression model. A two-tailed P value of less than 0.05 was considered significant.

   Results Top

A total of 100 patients were recruited as the study sample. The sociodemographic and clinical profile is presented in [Table 1]. The average age of the sample was 36.32 ± 11.76 years. More than half had made multiple attempts in their lifetime with the average number of attempts being 2.06 ± 1.39.
Table 1: Sociodemographic and clinical characteristics of the study sample (N=100)

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The most common method reported for the last attempt was ingestion (37%) followed by hanging (21%). Among a subset of frequent attempters (> 2 attempts), the most common method was oral ingestion (poisonous substance/medication overdose). Of the total, 59% experienced actual physical damage (40 minor, 16 moderate, 3 moderately severe) from their most lethal attempt. The mean score for C-SSRS intensity of lifetime suicidal ideation was 15.11 ± 5.22 for the sample, with a relatively higher score in ever lithium users (16.56 ± 4.52) versus lifetime non-users (14.43 ± 5.41) (U = 822.5; P = 0.049). [Table 2] presents the relationship of lethality (RRRS) scores to study variables.
Table 2: Relationship of risk–rescue score with clinical variables (n=100)

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Regression analysis was performed using the backward stepwise variable selection method. [Table 3] shows the best-fit model obtained from regression. Regression model was statistically significant [F (3,96) = 12.196, P < 0.001, adjusted R2 = 0.253], with lifetime lithium use, intensity of suicidal ideations and attention impulsiveness explaining 25.3% variance in risk–rescue scores.
Table 3: Predictors of lethality: regression analysisa*

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   Discussion Top

The paper adds to the limited literature on correlates and predictors of the lethality of suicide attempts in Indian patients with affective disorders.

The main findings from the study are that intensity of suicidal ideations, lifetime lithium prescription and attentional impulsivity were found to be significant predictors of lethal attempts on regression analysis. These predictors combined could explain 25% variability in lethality scores, pointing to multidimensional and complex nature of lethality of suicide attempts. Nonetheless, it is a significant model that contributed to one-fourth of variance in lethality scores.

The intensity of suicidal ideations was found to be the strongest predictor of lethality (β = 0.361). With every one-unit change in intensity of ideations, lethality scores changed by 0.361. Those with more intense ideations, in terms of frequency, number of hours of occurrence during the day, and stronger intentions to end their life, may directly impact the method and lethality of attempt. Although various authors have pointed out that the trajectory from ideations to attempts is not directly linear,[37],[38] a recent study by Law et al.[39] demonstrated that the intensity of suicidal ideations at the worst point had a greater likelihood of past suicide attempts.

Lithium therapy was a significant negative predictor for more lethal attempts (β = -0.187), with every one-unit increase in lifetime lithium therapy associated with a reduction in lethality scores by 0.187. Lithium is known to have anti-suicidal properties and exerts its effect by not only reducing relapses but also aggression and possibly impulsivity.[40]

A significant negative relationship was also seen with attention impulsiveness (β = -0.271), implying that there was a reduction in lethality score by 0.271 with every single unit rise in attention impulsiveness. This indicates that those with poorer attention may have less lethal attempts. This could be an extrapolation of poor planning secondary to poor attention. The evidence in this regard has, however, been equivocal as some studies showed aggressive impulsive traits may not predict suicide,[41] while others have reported that impulsivity is an important marker to predict suicide.[42] Apart from attention impulsiveness, no significant relation was seen with overall impulsiveness scores in our study sample.

Significant correlations of RRRS score were found with a number of episodes, number of depressive episodes and intensity of suicidal ideations. Lethality correlated negatively with attention impulsiveness. RRRS scores were significantly higher in males (vs females), BD (vs MDD-R), multiple attempters (vs single) and planned (vs unplanned) attempters. Findings are broadly consistent with the available literature in this regard.[12],[17],[20],[21],[22] Prior suicide attempt has been emphasized not only as a risk factor for further attempts but also as a more lethal risk factor for completed suicide.[43] Attempt of higher lethality by males is a well-established finding in the suicidality literature possibly owing to potential reasons such as choosing lethal methods, co-morbid substance use and higher intentions.[44]

The study holds various clinical implications. More intense ideations, absence of lifetime lithium use and less attention impulsiveness predicted attempts of higher lethality. It also emphasizes the importance of exploring various correlates which may help in early identification and preventing suicide attempts in future. The importance of lithium in reducing the lethality of suicide attempts has also been reiterated in our findings. There is a need for comprehensive evaluation of all attempters by qualified professionals. The determination of lethality of suicidal behaviour among patients with severe, recurrent mood disorder provides insights into differential risk for suicide death and may have implications for clinical management. If suicide risk factors are clearly and systematically explored, suicide may be prevented in patients with mood disorders by helping clinicians identify those at high risk.[5]

The strengths of the present study include the use of a stringent selection criterion to exclude those with unclear history of attempts, or those with para-suicidal attempts, and the use of valid and reliable instruments for assessment of lethality. A reasonably large sample size aided in strengthening the existing literature along with some new findings in the Indian population.

Findings must also be interpreted in the light of certain limitations. This was a cross-sectional study with non-random sampling from a tertiary care general hospital, limiting the generalizability of findings. Controlling the treatment parameters was out of the purview of this study. Moreover, since the attempt occurred in the past, the possibility of recall bias cannot be ruled out. Furthermore, suicide is a complex, multicausal phenomenon with an interplay of biological, psychological and sociocultural factors, and current study findings may not be able to answer all questions related to it. Future studies which can explore the suicidal behaviour prospectively over the course of treatment can better assess for predictors of high lethality and compare findings with other illnesses associated with high rates of suicide.

   Conclusion Top

Lethality of suicide attempts was found to be correlated with a multitude of clinical factors, notably male gender, bipolarity, multiple attempts, planned attempts and number of total as well as depressive episodes over a lifetime. The study also found that intensity of suicidal ideations, lifetime lithium therapy and attention impulsiveness significantly predict the lethality scores explaining one-fourth of the variance in lethality. It is essential to assess factors that can predict lethality in patients with severe mood disorders to plan strategies towards the prevention of suicide in this patient population.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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