|Year : 2014 | Volume
| Issue : 2 | Page : 69-73
Socio-demographic and clinical profile of patients with attempted suicide attending emergency services at the mental health institute in Northern India
Vijender Singh1, Dhanesh K Gupta2, Nimesh G Desai1, Ankur Srivastava3, Rashmi Chaudhry3, Anukriti Varma3, Somnath Sengupta2
1 Institute of Human Behaviour and Allied Sciences, Delhi, India
2 Institute of Mental Health, Woodbridge Hospital, Singapore, India
3 Ex -resident, Institute of Human Behavior and Allied Sciences, Delhi, India
|Date of Web Publication||20-Mar-2015|
Institute of Human Behaviour and Allied Sciences, Dilshad Garden, New Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Background: Attempted suicide is one of the major emergencies in psychiatry. Suicide attempts are considered to be the best predictors of an eventual completed suicide. Data of patients presenting with attempted suicide to the emergency settings at mental health institute settings is scanty in India. Aims: The study was carried out to assess the socio-demographic and clinical profile of the patients with suicidal attempt attending emergency services at a teaching Mental Health Institute in Northern India. Methods: Case records of all patients with attempted suicide attending emergency services at Institute of Human Behaviour and Allied Sciences (IHBAS) for one calendar year were reviewed. Socio-demographic and clinical details of the patients were retrieved on a Performa specifically designed for this study. Results: Of all the patients who attended emergency services during the study period, 56 patients had suicidal attempts. Majority of them were married (66%), males (57%), in the age group of 20-40 years (61%), were from nuclear families (80.4%) and had urban domicile (83.9%). Severe Mental Illnesses were found in about 70% of the cases with duration of illness more than 24 months in 39.2%. Thirty six (64.3%) patients had 1 suicide attempt while 18 (32.3%) had 2 or more attempts in preceding one month. In 70% - 80% of the cases, the lethality and intentionality of the index episode was found to be moderate to high. Most of the cases needed inpatient treatment. Conclusion: Assessment and management of patients presenting to emergency room with suicidal behavior is a key factor in preventing suicide. There is a pressing need to identify the socio-demographic and clinical factors affecting risk of suicide in a given case. Every case presenting with suicidal ideations or attempt should be evaluated in detail.
Keywords: Attempted suicide, clinical profile, emergency services, mental health institute, sociodemography
|How to cite this article:|
Singh V, Gupta DK, Desai NG, Srivastava A, Chaudhry R, Varma A, Sengupta S. Socio-demographic and clinical profile of patients with attempted suicide attending emergency services at the mental health institute in Northern India. J Mental Health Hum Behav 2014;19:69-73
|How to cite this URL:|
Singh V, Gupta DK, Desai NG, Srivastava A, Chaudhry R, Varma A, Sengupta S. Socio-demographic and clinical profile of patients with attempted suicide attending emergency services at the mental health institute in Northern India. J Mental Health Hum Behav [serial online] 2014 [cited 2019 Dec 11];19:69-73. Available from: http://www.jmhhb.org/text.asp?2014/19/2/69/153713
| Introduction|| |
Suicide presents as one of the serious social and public health problem. Its prevention is still a challenging task to the public health authorities and other health care providers. Worldwide, 100-300/million people commit suicide annually. India ranks 10 th with an overall suicide rate of 97.4/million with approximately 114/million in males and 80/million in females. , Suicide attempts are considered to be the best predictors of an eventually completed suicide. There has been an increase in the number of patients presenting with attempted suicide in the emergency settings in teaching general hospitals psychiatry in India and many researchers have reported about the profile of and the risk factors among patients with attempted suicide presenting in general hospital settings. ,,,, However, similar data from mental health institutes is scanty. It is worthwhile to explore whether the profile of patients with attempted suicide presenting at mental health institute settings differs from those presenting at general hospital psychiatry settings. Studies of these patients can provide useful information for understanding suicidal behaviors in patients presenting at mental health institute settings and can help in their better assessment and management, which will further help in developing suicide prevention strategies for these patients.
This study was conducted with an objective to describe the sociodemographic and clinical profile of suicide attempters attending the emergency services of a mental health institute in Northern India.
| Methodology|| |
The present study was carried out at Institute of Human Behavior and Allied Sciences (IHBAS), Delhi, a tertiary care teaching mental health institute in Northern India which was developed after transformation of erstwhile Hospital for Mental Diseases, Shahdara. At IHBAS, psychiatry emergency services are rendered round the clock by a qualified psychiatrist (Senior Resident) and a Junior Resident on duty with support of a consultant psychiatrist on call duty. Assessment findings are recorded on an emergency case record proforma and case record file. In routine practice, the assessment of patients involves (a) complete and comprehensive clinical assessment for risk of suicide and risk of harm to others, (b) assessment for evaluation of lethality and intentionality of a given attempt of suicide, (c) in order to make an objective assessment, a scale, that is, scale for Assessment of Risk of Suicide (SARS) developed by Faculty of Psychiatry at IHBAS, is used to find out the level of suicidal risk in a given case (a copy of the scale is enclosed herewith). Although majority of the patients are sent back after appropriate evaluation and management, the more serious patients having risk of harm to self or others (with suicidal attempt, disturbed, aggressive and violent behavior), or severe psychopathology are either kept in short observation facility available in emergency services, or are admitted to the psychiatry wards. These patients are seen by a consultant in the same evening or next day morning when the final decision regarding the diagnosis and further management is arrived at. For this study, case records of patients who attended emergency services during a period of one calendar year were reviewed. Out of the 10913 patients who attended emergency services during this period, 56 patients were found to present with attempted suicide. Data on sociodemographic details and clinical variables were retrieved from the case records of these patients and recorded in the structured proforma prepared for this study.
The data was analyzed using the SPSS (16.0) version (SPSS Inc, Chicago).  Descriptive statistical methods like mean, standard deviation (SD) and frequency distribution were used. For comparative statistics, Chi-square test was used, and a P < 0.05 was taken as statistically significant.
| Results|| |
Out of the 10913 patients who attended emergency services during the study period, 56 patients were found to have attempted suicide, indicating a prevalence of 0.51% for attempted suicide among those reporting to emergency room of a tertiary care mental health institute.
Of the 56 suicide attempters, 32 (57%) were males (male to female ratio 1.33). The mean age of the patients was 33.6 years (SD = 12.9), and the majority (61%) of the patients were in the age group of 20-40 years. Two-third (66%) of the patients were married. Majority of the patients belonged to nuclear families (80.4%), came from Delhi and adjoining towns (75%) and had an urban domicile (83.9%). Nineteen (34%) patients were government servants, and all of them were males while 14 (25%) of the patients were students and all of them were females, a finding that was statistically significant. Approximately half of the patients were unemployed during the preceding 1 year of the attempted suicide [Table 1].
Clinical profile and mental state at the time of presentation
Majority of the suicide attempters had severe mental illnesses (70%) [Table 2]. Suicidal ideas and suicidal intent were reported by 39.3% and 25% patients respectively at the time of their presentation to the emergency room. Other notable psychopathologies were delusion of persecution (34%) and auditory hallucinations of commanding type (20%) [Table 2].
Thirty-six (64.3%) of patients had 1 suicide attempt while 18 (32.3)% had 2 or more suicide attempts in preceding 1 month prior to the index attempt. For the index suicide attempt, 76% patients had moderate to high lethality, and 80% had moderate intentionality as was assessed clinically. Only one-third of the patients reached hospital within 24 h of the index suicidal attempt. Thirty-two (57.1%) of the patients were already registered with IHBAS. Poisoning was the most common (20%) mode of suicide attempt, followed by jumping from height (13%) [Table 3].
Based on the psychiatrist's clinical assessment, the suicide risk at the time of presentation to the emergency room was found to be moderate to high in 82.1% and low in 17.9 percent of the cases. Scores of the SARS were found to be moderate in 67.5% and low in 32.5% cases (n = 40). Most (95%) of these patients required hospitalization and a quarter of them required modified electroconvulsive therapy in addition to psychotropic medications.
| Discussion|| |
To the best of our knowledge, this is the first study on cases of attempted suicide presenting to emergency services in a mental health institute in India. Factors associated with attempted suicide may vary in patients presenting at different settings such as primary health care, General Hospital Psychiatry setting, and mental health institute setting. Many of these factors can play an important role in deciding the management of these patients both at macro level for the organization of emergency services in various settings, and at micro level for individualizing treatment plan for patients. Finding of the study can be useful in the planning of management of suicidal patients in the mental hospitals in India, which are currently in the process of modernization under National Mental Health Programme. 
The prevalence of 0.51% attempted suicide among treatment seekers at emergency services at the Mental Health Institute is lower when compared to General Hospitals Psychiatry Facility (5.36%).  It is likely that patients with suicidal attempts are more commonly taken to general hospitals either due to lesser stigma of general hospitals or for treatment of physical injuries associated with suicidal attempt. On the other hand, patients with other psychiatric emergencies such as aggressive and violent behavior or exacerbation of symptoms of their preexisting psychotic illnesses are more likely to be taken to the emergency room of a Mental Health Institute.
In this study, male suicide attempters outnumbered female attempters with a ratio of 1.33. Similar findings have also been reported by other studies also. ,,,,, This is in contrast to the female preponderance among suicide attempters reported in the International literature. , The possible reasons have been discussed by some of the researchers.  However in the absence of reliable community-based epidemiological studies, it may not be possible to comment whether the different gender presentation is due to actual differences in the incidence of attempted suicide or it is due to gender differences in bringing the suicide attempters to the hospitals. Some other recent studies have shown a female preponderance or equal gender distribution in suicide attempters. , Majority of the suicide attempters in this study were in the age group of 20-40 years, a finding similar to the other studies from India as well as internationally, suggesting that this most productive age group in the society has a high vulnerability to suicidal attempt. ,,,, Preponderance of female students in this sample of suicide attempters suggests that the young females or the female students who attempt suicide are more likely to be brought for the treatment in comparison to other females. However, this study could not investigate this aspect further.
More than three-fourth of suicide attempters in the study sample belonged to the nuclear family, a finding similar to the one reported in many studies. ,, There has been an increase in the number of nuclear families over the years in India. A higher level of stress is associated with living arrangements in the nuclear families due to urbanization, rapid changes in the lifestyles and waning support of families. The buffering effect of sharing the burden by all the members in joint families is lacking in nuclear families resulting in increased vulnerability of individuals to stress and psychiatric disorders, as well as to suicide attempts. However, this finding may partly be due to predominance of urban domicile of the study subjects as nuclear families are more common in urban areas.
There were some striking differences in clinical profile of patients in this study as compared to the ones reported in the studies carried out in general hospital psychiatry setting. All the patients had a psychiatric diagnosis and more than two-third had severe mental illnesses, in contrast to study on psychiatric referrals in general hospital settings wherein nearly half of the suicide attempters did not have any psychiatric diagnosis.  While it is true that people without psychiatric illnesses may also attempt suicide due to maladaptive coping with stress, the above finding in this study indicates that the suicide attempters seeking treatment at mental health institutes are more likely to have a psychiatric illness in comparison to those seeking treatment at general hospitals. Most of the patients in the current study were suffering from severe mental illnesses such as schizophrenia, bipolar illness and depressive disorder, a diagnostic profile very typical of patients seeking treatment at public sector psychiatric hospitals in India. This profile is quite different from the studies from general hospital psychiatry setting where adjustment disorders and affective disorders (common mental disorders) were the common diagnoses among suicide attempters who had a psychiatric diagnosis. ,
In the mental status examination of cases, half of the patients reported presence of death wishes or suicidal ideas and 25% of them reported suicidal intent at the time of presentation. While it is possible that a guilt feeling following a suicidal attempt may lead to absence of suicidal thoughts in many of the suicide attempters, the absence of suicidal ideas or intent in a significant proportion of the patients indicates the role of other kind of psychopathology in suicidal attempt and warrants that the risk of suicide should be considered even in those patients who do not actively report suicide-related cognitions. The cumulative factors like presence of other kind of psychopathology (delusion of persecution, auditory hallucinations commanding type), degree of stress and availability of the methods of suicide are very important and must be considered even when suicidal intent is absent. This may be more relevant in a mental health institute setting where majority of the suicide attempters are likely to have a severe mental illness, with the majority of them having psychotic symptoms.
Poisoning was the most common mode used for the suicide attempt in this study. It defies the common notion that the poisoning as a method of suicide was more common in rural areas. It is supported by many other studies. ,,, Availability of a particular method plays an important role in the method of choice, especially when the attempts are impulsive in nature.  Easy availability and lack of safety precautions of pharmaceuticals agents and pesticides in countries like India make them a preferred choice for suicidal attempt.
In the current study, there was a significant delay in seeking treatment after the index suicidal attempt, that is, 2/3 of cases reached hospital after a delay of more than 24 h after the suicidal attempt [Table 3]. The delay in seeking treatment by the patients in this study is even more puzzling due to the fact that nearly two third of the patients had made one prior attempt and one-third of the patients had made two prior attempts in the month preceding the index suicidal attempt. The possible reasons behind the delay in seeking treatment could be (1) avoiding early contact with the government hospital due to perceived medico-legal complications, (2) Medical complications of the suicidal attempt for which patients might have been taken to a medical center before a psychiatric consultation, (3) Lack of perceived urgency to seek treatment or need to visit a psychiatrist in such a situation. The possibility that many of the patients and families might not have realized the seriousness of suicidal attempt becomes significant in view of the finding in this study that the three fourth of index suicidal attempts had moderate to high lethality and 80% of the attempts were associated with moderate intentionality. This emphasizes the need of educating people regarding suicidal behavior as a public health measure for suicide prevention.
An intriguing finding in the study was that more than half of the suicide attempters had received treatment at IHBAS at some point of time before their index suicidal attempt. Although it is not uncommon that patients on treatment have suicidal ideas or may make a suicidal attempt during various phases of illness, this warrants further investigation to understand the factors, which could be responsible for suicide attempt in a patient who is already on treatment. Plausible reasons could be either a recent change in psychopathology not detected in the most recent follow-up or patient having irregular follow-up. A higher degree of caution and vigil for development of suicidal behavior is required in all such patients.
The findings of this study should be seen in the background of certain limitations of this study. The study used the method of retrospective chart analysis due to which many of the important factors could not be studied. This study could not answer questions like the reasons for delay in seeking treatment after suicide attempt; reasons for suicidal attempt in the patients who were already on treatment at IHBAS, and details of treatment before seeking treatment at emergency services at IHBAS. Also, there is a possibility of misclassification of the cases of deliberate self-harm as suicidal attempt, as the former one could be a nonsuicidal behavior also.
| Conclusions|| |
Suicidal attempts still remain an important psychiatric emergency. With the ongoing process of modernization of public mental hospitals in India under its National Mental Health Programme, an increasing number of suicide attempters are likely to seek help in the emergency services of these hospitals. Some of the findings in this study highlight specific characteristics of suicide attempters presenting to a Mental Health Institute. These findings can be useful in improving management of these patients. Further studies need to be carried out to help planning of suicide prevention strategies in patients seeking treatment at public psychiatric hospitals in India and other developing countries.
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[Table 1], [Table 2], [Table 3]