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Psychiatric Morbidity among Patients of Suicide

Background: The word suicide is derived from the Latin word “self murder.” It is the human act of self intentioned cessation, self inflicting, committed out of acute anguish, tunneled logic and constricted thinking. Aims: To find psychiatric morbidity among patients of suicide. Materials & Methods: The present cross-sectional study conducted on 118 patients of suicide who were admitted in the hospital and were seeking psychiatric consultation through liaison. Various parameters like their sociodemographic characteristics, mode of suicide and precipitating factors were noted in a preformed proforma after a detailed interview. Psychiatric diagnosis was made according to ICD-10 after assesing the patient with MINI ((Mini International Neuropsychiatric Instrument). Results: Maximum i.e. 52.5% patients were in the age group 15-30 years, Females were 65.3%, 56.8% patients were of rural background. Majority of the patients were Hindus (64.4%), married (61.9%), educated (77.1%), unemployed (70.3%) and were of low socioeconomic status (48.3%). Total of 52.5% were having family conflict as the precipitating factors. Poisoning was the most common way of suicide accounting for 61.9% suicidal attempts. Psychiatric morbidity was present in 60.2% patients of which depression was the most common diagnosis and was present in 28% patients of suicide. Conclusion: From present study, suicide appears to be a major public health problem which can be prevented. Persons who had attempted suicide and their family members should be followed up in order to prevent future attempts. Strict laws for storing potentially poisonous drugs and chemicals would help in reducing suicidal attempts by restricting access.


Introduction
Suicide is the primary psychiatric emergency. It is a fatal, destructive and preventable act that represents the person's wish to die 1 and is performed by the person in the knowledge or expectations of its fatal outcome. 2 It is the human act of self intentioned cessation, self inflicting, committed out of acute anguish, tunneled logic and constricted thinking. 3 The word suicide is derived from the Latin word "self murder." There is a range from thinking about suicide and acting it out. Some peoples may have only ideas of suicide, some peoples makes plans from days to years before acting it and some may commit suicide instantaneously on impulse. 1 Financial difficulties, family problems, defamation, low frustration tolerance, unemployment, harassment, psychosocial problems, diseases, problems in education system, failure in exams, weakening protective values of social institutions like family, increased use of alcohol and drugs are among the stressors which ultimately leads to death. 2 Globally, an estimated 700,000 people take out their own lives annually. As per WHO, an attempt at the suicide is made every 3rd second with a success of 1 suicide per minute. Annually 700,000 peoples commit suicide worldwide which is more than people killed by the armed conflict. 4 In India in every 5 minutes a person kills himself whereas 7 attempts suicide forming about 100000 suicidal deaths occur annually. 3 Suicide rates are rising in both developed and developing countries more quickly. 2 It is the 11 th leading cause of death in the United States whereas in India it is among the top ten. 4 There has been increase in cases of psychological disorders along with suicide and suicide attempters. Hence the present study was conducted to find psychiatric morbidity among patients of suicide.

Methodology
The present cross-sectional study was carried out at government medical college Jammu and its associated hospitals. All the patients of suicide who were admitted in the hospital and were seeking psychiatric consultation through liaison were included in the study whereas patients of homicidal or accidental poisoning were excluded from the study. A total of 118 patients were selected for the study and their sociodemographic characteristics, mode of suicide and precipitating factors were noted in a preformed proforma after a detailed interview. Psychiatric diagnosis was made according to ICD-10 after assessing the patient with MINI ((Mini International Neuropsychiatric Instrument). 4

Statistical analysis
Analysis of data was done using statistical software MS Excel / SPSS version 17.0 for windows. Data presented as percentage (%) as discussed appropriate for quantitative and qualitative variables Table 1 shows that 52.5% patients were in the age group 15-30 years, 33.1% were between 31-45 years and only 14.4% were above 45 years of age. There were 65.3% females and only 34.7% males. 56.8% patients were of rural background and 43.2% with urban background. Majority of the patients were Hindus (64.4%), married (61.9%), educated (77.1%), unemployed (70.3%) and were of low socioeconomic status (48.3%). Table 2 shows that 52.5% were having family conflict as the precipitating factors whereas marital dyshormony was present among 38.1% patients. Other precipitating factors included were financial crisis (27.1%), love affair (11.8%), exam failures (10.2%) and others (22.9%). Table 2 also depicts that poisoning was the most common way of suicide accounting for 61.9% suicidal attempts. Medicines such as benzodiazepines were used by 23.1% patients whereas 14.4% patients used other methods like hanging and burning. Table 3 shows that the psychiatric morbidity was present 60.2% patients. Depression was the most common diagnosis and was present in 28% patients of suicide which were followed by adjustment disorder (11%), anxiety disorders (5.9%), psychotic disorders (5.1%), substance use disorders (5.9%) and other psychiatric disorders (4.2%).

Discussion
The rise in attempting suicide especially among the young people's is a major concern all over the world.
In Indian history there were many examples of committing suicide most famous of which were Rajput women's committing suicide to save their dignity when it was in danger and the mass suicide by self-immolation was called johaf. 5 Compared to complete suicides, attempted suicides were more common. It seems the patients who were attempting suicides were suffering from various psychiatric disorders. 6 Hence the present study was conducted to find psychiatric morbidity among patients of suicide.
In the present study majority i.e. 52.5% patients attempting suicide were in the age group 16-30 years followed by 33.1% in 31-45 years and 14.4% in above 45 years. In recent times suicide rates are rising more quickly in adolescents and young peoples than all other age groups, both in developing and developed countries which may be due to the stressors and triggering factors like emotional issues, exam failures, peer pressure, substance abuse, financial difficulties, high parental expectations, family conflicts etc. 3 4 Other studies had found similar results. 5,8,9,10 In the present study 65.3% suicide attempters were females and 34.7% were males. In India women are more non-assertive, docile and submissive, and with the building of these traits their psyche results in difficulties to deal with their negative feelings adequately. Being married, hostile family environment, difficult and uncooperative husband, loss of husband sympathies and dowry demands by inlaws are the most common stresses in women resulting in suicide as the only choice of way out from psychological pain, anguish and suffering. 11 Moreover depressive episodes occurs more commonly in female than males resulting in more suicidal ideation and thus more suicidal rates among females 12 which may further be precipitated by factors like financial difficulties, family problems, harassment, defamations, unemployment, domestic violence etc. 2 The finding is in agreement with Purushothaman P et al who found that 65% of suicide attempters were females. 7 Similarly Qusar MMAS and Shoib S et al had also observed that 59.1% and 55.5% patients which attempt suicide were females. 2,4 Similar results were also found by other studies. 5,8,9,10 In the present study 56.8% suicide attempters were from rural background and 43.2% were from urban back ground. Compared to urban areas, rural areas had low literacy rates and higher unemployment rates. More over most peoples in rural areas were of low socioeconomic status. 13 All these factors have been repeatedly cited as significant risk factors predicting suicide. 10 Our finding is in accordance with Kumar SPN had also found 60% of the suicide committers were from rural areas. 10 Similarly some studies had found majority of the patients attempting suicides were from rural areas 4,11 whereas other studies had found the opposite. 7,9 In the present study 64.4% were Hindus whereas 26.3% were Muslims and only 7.3% patients belong to other religion. As per census 2011, religion wise India is dominated by Hindus followed Muslims and then by the peoples of other religion 13 13 In the present study about 61.9% suicidal patients were married. In India there several reasons for suicide being more common among the married than unmarried people. Marriage in India is a social obligation which is usually performed by elders irrespective of the individuals preparedness. In India mentally ill are likely to get married sooner than mentally health as marriage is considered be part of the treatment for mental illness resulting in several adjustment problems among the married mentally ill persons. Divorce being socially unacceptable, hence suicide provides the only way to escape from the stressful situation. 10 Purushothaman P and Kumar SPN et al in their respective studies had found that about 60% subjects with suicidal attempt were married. 7,10 Similar findings were also noted in other studies 9,11 whereas shoib et al had found no marital difference among suicide committers. 4 58.5% patients in this study were from joint families whereas 41.5% were from nuclear families. Suicidal ideation occur more frequently in persons living in joint family than persons who were living alone and high suicidal rates in joint families are the effects of their disintegration due to rapid industrializations and urbanizations. 15 Similarly Shoib S et al had also founds 42.78% suicidal patients were from joint family, 36.3% were from nuclear family and 20.89% were from ex nuclear family. 4 However Kumar SPN and Purushothaman P et al had found more suicide attempters from nuclear family. 7,10 In the present study 77.1% patients who attempted suicide were educated and only 22.9% were uneducated. This could be explained by the fact that India is growing faster in the last few decades and there are increasing trends of education among younger generation as more and more adolescents are attending schools and colleges 13 which were reflected in our study. Shoib S et al had found higher suicidal rates among illiterates 4 whereas Ram et al and Purushothaman P et al had found suicidal attempts more in literates. 7,8 In the present study 70.3 % suicide attempters were unemployed and 29.7% were employed. Unemployment results in financial crisis and if prolonged person may find suicide as the only way to escape way from the situation. Moreover unemployment is the risk factor associated with depression 12 which itself is associated with more suicidal tendencies and suicidal rates. 9 Our study is in accordance with Purushothaman P et al and Kumar SPN who found higher suicidal rates among unemployed peoples. 7,10 However Shoib S et al and Ram et al had found that employed peoples attempts more suicides than unemployed. 4,9 In the present study, the majority i.e. 48.3% patients were from lower socioeconomic status followed by 41.5% in the middle and 10.2% in the upper socioeconomic status. The reason for this could be that the lower socioeconomic status may be more associated with domestic violence, poverty and unemployment all being risk factors for depression 12 which itself causes higher suicidal rates. 9 Our finding is in accordance with other Indian studies which had showed higher rates of suicides among peoples of lower socioeconomic status. 4,7,9,10 Family conflicts (52.5%) and marital dyshormony (38.1%) were the leading precipitating factors associated with suicide which is consistent with study done by Shoib et al. 4 In

Conclusion
Suicide appears to be a major public health problem which can be prevented. Persons who had attempted suicide and their family members should be followed up in order to prevent future attempts. In order to improve coping skills, health education, problem solving techniques and life skill training and problem-solving techniques may be regularly taught at schools. Strict laws for storing potentially poisonous drugs and chemicals would help in reducing suicidal attempts by restricting access.