A STUDY OF ATTEMPTED SUICIDE AMONG ADOLESCENTS

A STUDY OF ATTEMPTED SUICIDE AMONG ADOLESCENTS

Dr. G. MOHANROY 2. Dr. ASHARAF ALI 3 Dr. K.S. PILLAI

Abstract

Analysis of suicide attempts among cases referred to suicide prevention clinic at medical college Trivandrum was not done earlier. Suicide is a very important issue in Kerala and throughout the world. In United States guns are the leading method adopted by adolescents to end life. These cases are under reported also due to cultural and religious stigma attached to self destruction and to an unwillingness to recognize certain traumas such as some automobile accidents as self inflicted {world medical association statement on adolescent suicide adopted by world medical assembly Malta November 1991}. Kerala has the highest rate of suicide in India. The enigmas of so-called "family suicide" continue to haunt our minds every day. Not a single day pass without a report of a family suicide in newspapers among which adolescent suicide and attempted suicides are a major chunk. The Situation becomes still worse with the announcement of S. S. L. C results with the color photo of the rank holder in front page and a news about a suicide for a failure or low marks in the inner page. Still worse is the scenario of an adolescents committing or attempting suicide for not allowing watching him television taking him for a marriage or movie. The aim of the study was to find out gender wise, age wise, method wise, and primary axis I Diagnosis wise assessment of adolescents attempted suicide cases referred to Department of Psychiatry Medical College Trivandrum and to correlate it with the data available in literature.

Type of study : Descriptive study Method

The study was conducted by reviewing the cases that were referred to suicide prevention clinic of Government Medical College Trivandrum conducted on all Tuesdays. (Retrospective study) from 12-10-1999 to 31-07-2001 their age wise gender wise education wise method wise and primary axis I diagnosis was studied and data was analyzed using statistical method of percentage analysis.

Review of literature

Attempted suicide is a non-habitual act with a non-fatal outcome that is deliberately initiated and performed by the individual involved. It causes self-harm, or without intervention from others will do so. Beyond it, the act of self-harm is possibly carried out in expectation of such a non-fatal outcome and thus probably considered to communicate a wish to change social relations.

The suicide rate for adolescent represents approximately 12 percent of the total mortality in this age group. Lifetime prevalence rates of suicide attempts among adolescents are reported to range from 3.0 to 7.1 percent Male suicide rates in this age group are approximately 3 times higher in adolescent girls than among boys ¹. Protective factors for children and young adolescents may include less access to lethal means of suicide (Firearms) suicide risk, including substance use and depressive disorders, are more likely to be present in older adolescents than in children or younger adolescents ². In the United States firearms and hanging are the two most common methods of suicide in males. Female adolescents who complete suicide are more likely to take a lethal ingestion or jump from a height ³. Psychological autopsies of completed suicide cases show that a large number of cases had a diagnosable psychiatric disorder at the time of their death ⁴In US white males have highest suicide rate⁵ Even Broadcasting of movies depicting suicide may increase the suicide risk⁶ Implementation of gun safe storage laws in 12 states in United States didn't help much in decreasing suicide death under children below 15 ³. It is known that problems of many adolescence who were at high risk of suicide were not known to others and these students never received any treatment ⁷. Factors contributing to adolescent suicide are varied and include: depression, emotional isolation, loss of self esteem, excessive emotional stress, mental disorders, romantic fantasies, thrill seeking, drug and alcohol abuse, and the availability of firearms and other agents of self-destruction. Most often suicide is the result of several factors acting together, rather that they any one isolated factor. The lack of a consistent personal profile makes it difficult to identify those adolescents at risk for suicide ⁸. In the west there are a number of self-answering questionnaires for assessment of suicide risk among high school students⁷. Native communities are currently experiencing a high number of risk factors for suicide, including numerous social problems such as alcoholism and family breakdown. These risk factors seem to be symptoms of larger problem. Which is the erosion of the many institutions, which once transmitted the native culture from one generation to the nest. The task of identity formation in adolescent when explored showed that the Native adolescent find themselves in a situation where identity formation is difficult in both the majority white culture and their own culture. Though a number of consequences, this situation may be part of the reason for the higher numbers of suicide among Native adolescents ⁹. The risk factors for completed suicides appear to be Universal across cultures ¹⁰. Studies of adjustment disorders using structured diagnostic instruments have reported a fairly high level of co-morbidity. In a mixed group of children, adolescents and adults approximately 70 percent of patients with adjustment disorders had at least one additional axis I diagnosis. In the study of correlates of depressive disorder in children, 45percent of those with adjustment disorders with depressed mood had another diagnosis. Studies have consistently reported a significant association of adjustment disorders with suicidal behaviour; particularly in a adolescents and young adults ^{11
to 14}. Major depressive disorder is a known cause of suicide among elderly and adolescent ¹⁵. Organic mood disorder depressive can also be a factor for suicide. Conduct disorder is most vulnerable to another disorder late in life particularly in mood disorder ¹⁶. Mood disorders are not uncommon in persons with mental retardation. Learning problems, social skills deficits, and low self-esteem are often associated with development of mood disorders ¹⁶. Early onset schizophrenia because of the social educational disabilities it produces has a higher chance of suicide. Self-injuries are common in mental retardation ¹⁷. Past suicide attempt is associated with increased chances of subsequent attempts^4.

Objectives

The primary objective of the work was to find out the age wise gender wise method wise and primary axis I diagnosis wise distribution of attempted suicide cases, which were referred to suicide prevention clinic of government Medical College Trivandrum.

The secondary objective was to correlate the data that was obtained from the first study with available literature and others studies and to find out differences if any and to explain it in our socio cultural and legal perspectives.

Intervention

The cases were selected and anlyzed using statistical method the cases were analyzed according to age {below 14 years and above or equal to 14 years} sex {male or female} educational status {studied up to 5^th standard, above 5^th standard but below 10^th standard and above 10^th standard}. and method adopter for the act {drugs, poison, injury, kerosene/lotion, hanging and others which included I case of match stick and a case of coppersulphate and I case of Thinner} and primary axis I diagnosis which included adjustment disorder, acute stress reaction conduct disorder, organic mood disorder - depressive type, mental retardation, depressive disorders {adjustment disorder with depressed mood and a major depressive disorder} impulse control disorder and accidental poisoning.

Results
The results were analyzed using statistical methods of percentage calculation
Observation and results
100 cases were reviewed of which 38 were boys and 62 females (38% and 62% respectively) (table 1) there were 96 nuclear families and 4 joint famnilies (96% and 4% respectively) (table 2)
Table 1 : Gender wise distribution of cases
N=100	No	%
Boys	38	38
Girls	62	62
Table 2: Familystructure wise distributions of cases
N=100	No.	%
Nuclear family	96	96
Joint family	4	4
Educational status wise distribution of cases showed that there was only one illiterate a female 72 studies upto 10^th standard and 27 studied above that in tune with Kerala's high educational standards (Table 3)
Table 3: Educational status wise distributions of cases.
N= 100	No.	%
Illiterate	1	1
Upto 5^thstandard	0	0
Above 5^th standard below 10^th standard	72	72
above 10^th standard	27	27
Age wise distribution showed that 85 were above 14 years and 15 below 14 years (Table 4)
Table 4 : Age wise distribution of cases
N= 100	No.	%
11 to 14 years	15	15
15 to 18 years	85	85
35% of females attempted drugs compared to 13% of males more lethal methods were adopted by males compared to females. Hanging was more in males (10.5%) compared to 6.5% in females kerosene was almost equal 6.5% and 5.2 but slightly higher in females (Table5)
Table 5: Attempt wise distribution of cases
Table No.= 100
Mode	No.	%
Poisoning	55	55
Drugs	27	27
Hanging	8	8
Kerosene	6	6
Slash	1	1
Battery	1	1
Thinner	1	1
Matchsticks	1	1
Educational status wise and age wise distribution of male poisoning cases showed that older adolescents 76% attempted more with poison compared to younger ones 24% (Table 7) most of them had (76%) either completed 10^th standard or were studying above that studies in females showed a slightly higher percentage 83.33% in older adolescents more than 80% had completed 10th standard or were studying above that (table 8)
Table 7 : 25 Poisoning cases in male age wise and educational status wise distribution.
	No.	%
Number of cases	25	66
Age
Below 14 years	6	24
above 14 yrs below 18yrs	19	76
Educational status
Below 5^th Standard	0	0
Above 5^th Standard- below 10^th Standard	6	24
Above 10^th Standard	19	76
Table 8: 5 cases of drugs in male age wise and educational status wise distribution.
	No.	%
Number of cases	5	13.15
Age
Below 14 years	1	20
Above 14Yrs below 18yrs	4	80
Educational Status
Below 5^th Standard	0	0
Above 5^th Standard - Below 10^th Standard	1	20
Above 10^th Standard	4	80
Consumption of drugs also showed similar results (Table 9& 10)
Table 9: 30 Poisoning cases in female age wise and educational status wise distribution
	No.	%
Number of cases	30	48
Age
Below 14 years	5	16.67
Above 14yrs below 18yrs	19	83.33
Educational status
Below 5^th Standard (illiterate)	1	3.33
Above 5^th Standard - Below 10^th Standard	5	16.6
Above 10^th Standard	24	80
Table 10 : 22 Cases of drugs in female
	No.	%
Number of cases	22	35.5
Age
Below 14 yrs	2	9.1
Above 14yrs below 18yrs	20	90.9
Educational status
Below 5^th Standard	0	0
Above 5^th Standard - below 10^th Standard	8	36.36
Above 10^th Standard	14	63.64
Diagnosis wise 76% were adjustment disorders it is a well known fact that most of the suicide attempts in adolescents are due to adjustment problems 15% depressive illnesses 4% organic mood disorders 4% conduct disorders, impulse control and acute stress reaction 2% and Accidental, Mental retardation, Psychosis N O S and schizophrenia in 1% in 2 cases information was not adequate to reach a diagnosis. (Table 11)
Table 11. Primary axis diagnosis in 100 cases
Diagnosis	No.	%
Depressive illnesses Major depressive disorder/ Adjustment disorder with depressed mood	15	15
Organic mood disorder	4	4
Impulse control disorder/ intermittent Explosive disorder	2	2
Acute stress reaction	2	2
Accidental	1	1
Mental retardation	1	1
Psychosis N O S	1	1
Schizophrenia	1	1
Not diagnosed	2	2
Discussion
Suicide attempts are reported to occur approximately 3 times higher in adolescent girls than among boys in this study it was 1.63 times higher the explanation may be that girls were mostly brought to the clinic by their parents who were eager to find out whether there are some unknown causes for the attempt but boys were taken away by parents or they resisted a referral methods used were mostly poisoning and drugs (55% +27% = 82%) no guns related attempt was recorded (obvious as we don't have free gun laws) a number of patients had psychiatric diagnosis Adjustment disorders 67% Major depressive disorder/Adjustment disorder with depressed mood 15% Organic mood disorder 4% Conduct disorder 4% Impulsive control disorder 2% Accidental 1% Mental retardation 1% Psychosis N O S 1% Schizophrenia 1% Acute stress reaction 2% obviously correlating with the data in available literature there were 96 nuclear families (96%) compared to 4 joint families (4%) definitely children from nuclear families due to the lack of inherent cushioning effect on times of stress showed more suicidal risk. A Majority of cases (72%) studied up to 10^th Standard 27(27%) above that and 1(1%) was illiterate 85% of cases were in the age group of 14 to 18years were as 15% were in the 11 to 14 age group method wise 55% attempted poisoning and 27% consumed drugs hanging and drinking of kerosene were found in 8% and 6% respectively 66% of males attempted poisoning while 48% of females tried it showing the lethal nature of the act. 35% of females attempted drugs compared to 13%of males- (more females more soft methods) hanging was more in males (10.5%) compared to 6.5% in females- (harder method in male) kerosene was almost equal 6.5% and 5.2 but higher in females Educational status wise and age wise distribution of male poisoning cases showed that older adolescents 76% attempted more poisoning compared to younger ones.
It is an known fact that older adolescents opt for more lethal methods most of them (76%) either completed 10^th standard or were studying above that studies in females showed a slightly higher percentage 83.33% in older adolescents the data in par with male counter parts more than 80% had completed 10^th standard or were studying above that consumption of drugs also showed similar results.
Limitation of study
1. As this was a retrospective study cases results were mainly obtained from the register in the suicide prevention clinic
2. This was done on referred patients in a tertiary centre and hence cannot be translated to general settings.
3. No structured questionnaire was used.
Future directions
1. Adolescent suicides are increasing the physicians should be aware of this problem and to be ready intervene properly in view of emerging evolving issues especially depressive illnesses.
2. Family pathology should be looked for in all cases of adolescent attempted suicides and necessary measures should be taken.
3. As suicide attempt may increase the chance of further attempts these cases should be followed regularly preferably by psychiatrists.
4. Self-assessment questionnaires to be developed keeping in view socio cultural and other aspects in our community for our community.
Conclusion
This work highlights the importance of the issue of adolescence suicide it is as common here as in western settings. We need to know the importance of this issue and should be ready to accept it highlight it fight against it and if possible try our best to eliminate it or at least rein it.
References
1. Comprehensive Text Book of Psychiatry-Seventh edition. Page: 2742
2. Casat CD, Arana GD, Powel K: The DST in children and adolescents with major depressive disorder. Am J Psychiatry 140:503,1989.
3. Cummings P. Grosman DC, Revare F et al. State gun safe storage laws and child mortality due to fireams. JAMA 1997; 278: 1084-1086.
4. Gould MS Fisher P. Parides, et al. Psychosocial risk factors of child and adolescents completed suicide. Arch Cen Psychiatry1996; 53: 1155-1162
5. National centre for Health statistics. Vital statistics of the united State, Vol 2: Mortality (1964-1994). Hyattsville, MD: Public Health Service; 1995
6. Goauld Ms. Shaffer D the impact of suicide in television movies: evidence of imitation. N Engl J Med 1986; 315: 690-694
Shaffer D, Wilcox H, Lucas C, et al. The developement of a screening instrument for teens at risk for suicide poster presented at the 1996 meeting of the academy of child and adolescent Psychiatry; 1996 New York
8. World Medical Association Statement on Adolescent Suicide. Adopted by the 43nd World Medical Assembly Molta Nov. 1991
9. Paper submitted to the 8^th Canadian Association for suicide Prevention Conference-October, 1997, Thunder Bay, Ontario Karryl H. Quantz University of British Columbia.
10.Vijaya Kumar L, Rajkumar S. Are risk factors for suicide universal ? A case-control study in India. Acta psychiatrica Scandinavica 1999 Jun; 99 (6): 407-11
11.Bird HR. Canino G Rubio stipec M, Gould MD, Ribera J, Sesman M, Woodbury M, Gyertas-Goldman S, Pagan H Sanxhess-Lacay a Moscoso M: Estimates of the prevalence of childhood maladjustment in a community survey in Peorto Rico: The use of combined measures. Arch Gen psychiatry 45: 1220, 1998
12. Lewinsohn PM, Rhode P, Klein DB, Deekey J.R: Natural course of adolescent major depressive disorder: I continuity into young adulthood.J.Am Acad Child adolese psychiatry 38:56; 1999.
13.Newcorn JH Strain J: adjustment disorder in Children and adolescents J Am Acad Child adolese Psychiatry 33: 318,1992.
14. Runeson B : Mental disorder in youth suicide DSM-III - R axis I and II Acta psychatrica Scand 79:490,1989.
15. Angst J, Angst F, StassenHH: Suicide Risk in patients with major depressive disorder. J Clin Psychiatry 60:57,1999.
16. Gurguson DM, Lynsky MT Horwood L J: Origins of co mrobidity between conduct and affective disorders J Am Acad Child Adolese Psychiatry 35:451,1996
17. Fenstein C, reiss AL. Psychiatric Disorders in mentally retartded children and adolescents, Child adolese Psychiatry , Clin North Am 5:827,1996.
1. Dr. G. Mohan Roy Post Graduate Student, Medical College, Trivandrum
2. Dr. Ashraf Ali Asst. Professor, Dept. Of Psychiatry, Medical College , Trivandrum
3. Dr. K.S. Pillai, Prof. & Head, Dept. Of Psychiatry, Medical College, Trivandrum.