|Year : 2018 | Volume
| Issue : 2 | Page : 125-134
Depression, suicidal risk, and its relation to coping in Indian school-going adolescents
M Manjula1, BN Roopesh1, Maraimma Philip2, Anupama Ravishankar2
1 Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Biostatistics, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Web Publication||14-Nov-2019|
Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Aims and Objectives: The study aimed at examining the prevalence of depression, suicidal risk in school going adolescents and to understand the stressors, coping methods used in relation to severity of depression and socio-demographic variables. Materials and Methods: Stratified Random sampling was used to select the 7 schools (8-10 grades) and 10 pre-university colleges (11 and 12 grades) from South Bangalore. Sample comprised of 1428 adolescents. Assessment tools used included Beck depression inventory, Checklist for stress, coping and suicidal behaviours, Suicidal probability scale, and Adolescent coping orientation to problems experienced inventory. Results: About 30% of the sample had moderate to severe depression, 3% reported suicidal behaviours and 0.7% had moderate to severe suicide risk. Older adolescents and girls had higher severity of depression. Suicidal risk was higher in males. Younger adolescents used more emotion focused coping strategies. Those with suicidal behaviours had higher scores on depression, hopelessness, suicidal ideation, and risk. Suicidal probability was predicted by scores on BDI, and methods of coping used. Conclusion: The study implicates need for preventive interventions in school setting in keeping with the sociodemographic and family factors and developmental needs of adolescents.
Keywords: Coping, school-going adolescents, severity of depression, suicidal behaviors, suicide probability
|How to cite this article:|
Manjula M, Roopesh B N, Philip M, Ravishankar A. Depression, suicidal risk, and its relation to coping in Indian school-going adolescents. J Mental Health Hum Behav 2018;23:125-34
|How to cite this URL:|
Manjula M, Roopesh B N, Philip M, Ravishankar A. Depression, suicidal risk, and its relation to coping in Indian school-going adolescents. J Mental Health Hum Behav [serial online] 2018 [cited 2020 Sep 23];23:125-34. Available from: http://www.jmhhb.org/text.asp?2018/23/2/125/270981
| Introduction|| |
Depression is a common mental health problem in adolescents across the globe., The prevalence of depression in a community sample of adolescents ranges between 18% and 40% across studies, which is largely due to methodological differences.,,, With respect to severity, 30%–37% of school-going adolescents had mild depression, 19%–20% moderate depression, and 1%–4% severe depression., Similarly, subclinical depression was reported in 18% of the school-going adolescents from Bengaluru, Karnataka, India (n = 800, 13–18 years). Female preponderance was reported across previous studies.,, Students from the public school, older adolescents, and those with academic difficulties had higher scores.,,
Depression and suicidality have a significant relationship, in that depression is one of the strongest and consistent predictors of suicidal ideation and attempts in adolescents. Risk of suicide in individuals with depression is 25 times more than the nondepressed.,, Suicide is a leading cause of death and shows the highest hazard at the ages of 15–19 years among young people in India. The prevalence levels of suicidal ideation (lifetime and last year) and suicide attempt (lifetime and last year) were 21.7%, 11.7%, 8%, and 3.5%, respectively. Another study reported 15% and 9% of suicidal ideation and attempts in young adults, respectively. Similarly, Borges et al. reported lifetime ideation, plan, and attempt in 11.5%, 3.9%, and 3.1% Mexican adolescent samples, respectively. A higher rate of suicidal ideation was reported in Pakistani college students (31.4%) and youth from Turkey (23%, suicidal ideation and 2.5%, suicidal attempts)., Across the studies, in a 12-month period, about 5.2%–8.4% of suicidal ideation and 2.5%–3.2% of suicidal attempts were reported., Severity of depression, hopelessness, suicidal ideation, death wish, female gender, age (older adolescence), externalizing behaviors, low self-esteem, and emotional self efficacy were found to significantly contribute to suicidal attempts.,,,,,, However, 60% of the depressive suicides had only mild-to-moderate severity, and the findings were inconsistent with respect to gender in India., High suicidal intentionality and lethality was associated with planning the attempt and efforts to conceal the same, whereas impulsive attempts with low intentionality and lethality were seen more in adolescents and young adults with emotionally unstable personality traits.
Stress and depression have a bidirectional relationship, and individuals with depression are often found to use strategies based on avoidance and denial. Similarly, emotion-focused coping is found to be associated with increased odds of depression and task-oriented coping and physical activity with a lower likelihood.,, Religious coping was common across anxiety and depression.
Most studies carried out on the prevalence of depression have used small sample sizes and do not consider equal representation of all age groups of adolescents (13–18 years). Coping methods used in depression are less studied. In the background of high prevalence of depression and suicide rates in the youth of India, it is imperative to study the prevalence of depression and suicidal risk and understand coping methods used in relation to severity of depression and demographic variables in order to plan community-based preventive interventions.
| Methods|| |
Stratified random sampling (public and private institutions and school and college youths) was used to include 7 schools (8–10 grades) and 10 preuniversity colleges (11 and 12 grades) out of 24 institutions approached from South Bangalore (zones: 1, 2, and 3; about 768 schools and colleges; 699 private and 69 public institutes). Those who could read and comprehend English or the local language Kannada were included in the study. About 2332 youths were contacted in the selected classrooms, and parental consent forms were sent through them. Of which, 61.23% of the parents gave written consent, 23.92% refused consent, and 14.85% did not return the consent forms. The final sample included 1428 youths. The sample distribution is shown in [Figure 1].
Sociodemographic details were collected using a datasheet developed for the study. Suicidal risk for the study included suicidal behaviors (any life-threatening thought or behaviors that suggest that the person intends either to harm or kill him/herself [World Health Organization 2001]) and suicidal risk as assessed by suicide probability scale. A checklist was developed, and content validity was established as there were no tools for assessing suicidal ideation and attempts in a comprehensive manner. It had two domains: (1) areas of stress and methods of coping and (2) suicidal ideas and behaviors. Because the scale was used with the community sample comprising many nonattempters, the items were organized starting with general information related to stress, causes, and methods of coping during stressful periods to suicidal ideas and attempts. The checklist included items to assess the suicidal ideation, intension, plans, method of attempts, reasons for attempts, weather it was shared with anybody, attitude toward help seeking, and sources considered for help.
Suicidal risk was assessed using suicide probability scale (SPS), a 36-item self-report measure, responded on a 4-point scale, designed as a screening instrument to assess suicidal risk in individuals aged 14 years and older. This is one of the first scales to have evidence of predictive validity for suicidal risk in adolescents. Items of the SPS assess four areas: hopelessness, suicidal ideation, negative self-evaluation, and hostility. There are three summary scores: a suicide probability score, a total weighted score, and a normalized T-score. A high internal reliability (Cronbach's alpha = 0.93) and test–retest reliability over a 3-week period (r = 0.92) were reported.
The Beck Depression Inventory (BDI)-II contains 21 items rated on a 4-point scale, designed for individuals aged 13 years and over. The scores range from 0 to 63; raw scores 0–13 indicates minimal depression, 14–19 mild depression, 20–28 moderate depression, and 29–63 severe depression. Coping was assessed using the Adolescent Coping Orientation for Problem Experiences (A-COPE) Inventory. It consists of 54 items rated on a 5-point Likert scale on the use of a specified coping behavior when they “face difficulties or feel tense.” It has 12 subscales. The Cronbach's alpha of A-COPE was high (α = 0.74), indicating a moderate-to-high level of internal consistency. The items are easy to understand and cover a range of coping methods.,
The study was approved by the NIMHANS Ethics Committee. The initial phase of the study included development and validation of the stress coping and suicidal behavior scale. All the tools were translated into Kannada using standard procedures. After getting the permission from the respective schools and colleges, the classes to be included in the study were randomly selected and all the students in the class were given parental consent forms. Parental consent and assent from students were obtained before administering the questionnaires. The questionnaires (English/Kannada) were administered in group format comprising 20–40 students. Before administration of tools, they were briefed about stress as part of student life and various methods of coping used by the youth. This also included introduction of depression and suicidal behaviors as part of stress experience to make them understand the terms used in the questionnaires and importance of identifying them. Each assessment session was followed by a debriefing session, in which participants' queries and doubts were clarified and any distress experienced was addressed. Indicators for the identification of psychological distress and need for help seeking and help facilitation were emphasized. The contact details of the researchers as well as other clinical psychologists in the city were provided. The average duration of each assessment session was about 2 h. The researcher was available in the campus for around 1 h in the library/any other place indicated by the school for the students to approach individually. Questions related to managing academic stress were the frequently asked domain and it was addressed. Appropriate referrals were made for those who sought help. Feedback about overall findings was provided to the school authorities, and confidentiality of the individual information was maintained.
The data were analyzed using the IBM SPSS Statistics for Windows, Version 22.0. (IBM Corp, Armonk, NY). Descriptive statistics such as mean, frequency, percentages, and standard deviation were used for the sociodemographic data as well data from stress, coping and suicidal behavior scale. The Mann–Whitney U-test was used for comparing the groups based on age, gender, and attempters and nonattempters on study variables as the variables were not normally distributed. The Kruskal–Wallis test was used to compare the categories of depression across variables. The correlations were calculated to find out the relationship between the variables, and stepwise linear regression analysis was used to find the predictors of suicide probability.
| Results|| |
The average age of the whole sample was 15.51 years and that of school samples was 14.22 years and college samples was 16.58 years. There was equal gender distribution (male = 50.6% and female = 49.4%) and distribution across private (48.5%) and government schools (51.5%). Majority of the participants belonged to nuclear families (88.2%), 97% of them were from intact families, and 89.8% were living with both parents. In the college samples, females were more (61.3%), belonged to nuclear (85.3%), intact families (95%), and had both parents (86.4%). The distribution among government and private institutions was 51.3 and 48.7%, respectively.
Academics and family emerged as major areas of stress both in school (34.5%) and college samples (56.6%). Specifically, unable to recollect in the examinations (20% – school and 39% – college) and difficulty in understanding subjects (9.4% – school and 7% – college) contributed to academic stress. About 19% and 16% of the school and college samples reported stress due to problems with friends; 8% and 5% reported problems with boyfriend/girlfriend.
The mean score on BDI for school sample was 14.18 and that of college sample was 15.73 with a significant difference between the two (Mann–Whitney U = 229079, P = 0.002). Similarly, females scored significantly higher (mean = 15.49) than males (14.44) (Mann–Whitney U = 233525, P = 0.021). There was no difference between the government and private and school and college samples. In the overall sample, with respect to severity of depression, 49.4% reported minimal depression, 20.8% mild depression, 20.5% moderate depression, and 9.1% severe depression (school sample: 20.5% mild, 18.8% moderate, and 7.2% severe depression and college sample: 21.1% mild, 22.0% moderate, and 10.9% severe depression).
About 3.9% of the overall sample reported suicidal ideation and 3% each reported frequent thoughts and of having involved in suicidal behaviors. Frequently used methods in the sample was cutting/scratching with a knife, medication overdose, and drowning. Most of these behaviors were shown within 6 months to 1 year before the study. Family problems, difficulty in academics, to punish self, and to get away from distressing feelings are frequently reported reasons. While 34/45 participants gave clues, 11/45 reported it as an impulsive act. About half of them shared with others after the attempt.
About 3.5% of participants had mild risk, whereas 0.7% had moderate-to-severe risk on SPS. Youths from government institutions had significantly higher scores on hopelessness (22.10 ± 6.44; 20.85 ± 7.08; Mann–Whitney U = 225496.0, P = 0.001). This finding needs to be taken with caution as the differences between the groups were marginal.
The school youth had significantly higher scores on emotion-focused coping strategies, whereas college samples used both problem-focused and emotion-focused strategies. Females had better coping with respect to developing own resources, solving problems, as well as obtaining social support.
Relationship between depression, suicidal risk, and coping
There was a positive correlation of BDI scores with suicide probability and the subscales of SPS (hopelessness, suicidal ideation, and hostility). BDI was negatively correlated with ventilating feelings, solving family problems, avoiding problems, seeking professional support, and being humorous.
Stepwise regression analysis to determine the influence of study variables on suicide probability shows that scores on BDI together with domains of coping could explain about 25% of the variation in probability scores (R2 = 0.252, 68.31, P = 0.001).
Comparison of attempters and nonattempters and severity categories on depression
Attempters scored higher on BDI, hopelessness, suicidal ideation, hostility, and suicide probability. They also had lower scores on ventilating feelings, developing self-reliance and optimism, social support, and relaxing.
Those with moderate-to-severe depression had higher hopelessness, suicidal ideation, hostility, suicide probability, and lower scores on ventilating feelings and solving family problems.
| Discussion|| |
The youth in the study reported academics and relationships to cause stress, which is in accordance with Indian studies carried out in high school students.,,,,, Relationships play a significant role in the life of youth, and stress due to relationship difficulties is commonly reported.,
Higher scores on depression in college sample and girls agree with the findings that severity of depression increases with age from middle adolescence to older adolescence, and girls are said to carry risk factors for depression even before early adolescence. The overall percentage of prevalence in the current study is consistent with the finding that about 18%–40% of the youth report depressive symptoms on self-report measures., Further, those scoring ≥22 might indicate probable caseness for depression and would require further clinical evaluation. However, in the background of significant overlap between depressive and anxiety symptoms (symptomatic and syndromal co-occurrence as well as somatic-vegetative construct of BDI), it is possible that many of them might also have anxiety-related problems. Thus, it needs further assessment to plan appropriate interventions.,
The percentage reporting suicidal ideation in the current study is less compared to the studies involving young adults (undergraduate students).,, However, the percentage of youth involving in suicidal behaviors is similar across the studies, which ranged from 2.5% to 3.5%, [Table 1]. The methods of attempt indicate that easy availability of means and medications at home or easy access to drugs over-the-counter in India might have influenced these behaviors.,,, The time duration of involving in suicidal behaviors indicates that these behaviors have started in the middle adolescence, which is in agreement with increase of suicidality during adolescence,,,, and that 45% of suicides in India involve 15–29 years old. The findings emphasize the need for addressing the issue of suicide from early adolescent years. Most of the adolescents gave clue about the suicidal behaviors hinting at their cry for help and also suggesting the role of the personality factors, often seen in adolescents and young adults. With regard to reasons, family- and academic-related problems top the list, which is well documented from other Indian studies, for example, family problems accounted for 23.7% of the suicides in India. Family problems such as single-parent families, abuse and neglect, and poor emotional support are implicated to have strong putative factors for suicidal risk., Not being happy with one self and having low self-esteem and consequently wanting to punish self for non-achievement were reported in other studies as well., The other reasons such as getting of anxiety, tension, loneliness, and negative thoughts seem to indicate presence of psychological problems; this is in agreement with the finding that 90% of the people who attempt suicide have some psychological problems., The intent to die was reported by two of them, when interpreted along with reasons listed out; it seems like many of them involved in nonsuicidal self-harm behaviors in the sample, indicating an intent to harm rather than kill oneself.
Majority sought help from family, friends, and a family doctor and did not consider professional help, which reflects on awareness and attitude toward mental health problems and help seeking. Also, the belief that psychological problems of the adolescents are manageable by themselves and do not require professional help adding to factors of stigma., Help seeking from professionals was more in Singh's study, which may be due to slightly older age group involved in her study, better knowledge about availability of help, and attitude toward help seeking.
The finding that <1% had moderate-to-severe risk when understood in the background of higher percentage of suicidal behaviours obtained on the checklist for suicidal behaviors might indicate that the actual risk is less than the behaviors recorded and there may be chances of recording nonsuicidal self-injurious behaviors resulting in a higher percentage in the checklist. However, it is worth addressing even 1% such that the distress of this population is reduced and productivity is increased.
Higher scores on hopelessness and hostility in college samples and negative self-evaluation in school samples [Table 2] may well be understood in the background that hopelessness, low self-esteem, and externalizing behaviors predicted suicidal risk,,, and that suicidal behaviors increase during older adolescence. Higher negative self-evaluation in the school samples may be a precursor for hopelessness and depression, contributing to future suicidal intent and attempts. Suicidal ideation and suicide probability were found to be significantly more in males compared to females. This may be explained in the context of changing family systems and cultural emphasis on the male stereotype. In support of this finding, completed suicides as well as suicidal attempts are reported more in males. With respect to socioeconomic status, youths from both private and government institutions belonged to lower middle class and reported of having similar family problems (based on the occupation/income reported by youths). Hence, there is a need to explore social factors contributing to suicidal risk in urban youth belonging to lower economic status.
|Table 2: Scores on suicide probability scale for school and college and male and female samples|
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The coping methods are well according to developmental changes, in which older adolescents are said to use more internal cognitive strategies and seek more social support. Better coping in females with respect to developing own resources, solving problems, and obtaining social support [Table 3] may also act as a protective factor against suicidal behaviors. The study sample reported many family factors contributing to stress (alcoholism in the parent/parents, marital discord, financial difficulties, and single-parent families); however, analysis of these in relation to stress and coping would have been possible if socioeconomic status and family factors were assessed objectively. In addition, there are no conclusive findings on the relationship between socioeconomic status and coping strategies.
|Table 3: Scores on adolescent coping orientation to problems experienced for school and college and male and female samples|
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It is well established that severity of depression, suicidal risk, hopelessness, and suicidal ideation are risk factors and predictors of suicide.,,,, Negative correlations of BDI with subscales of A-COPE [Table 4] indicate that as the depression increases, use of positive coping decreases and avoidance coping increases (including help seeking), which is found to have an exacerbating effect on stress and depression. Various individual and contextual factors are associated with help seeking in depression, among which severity, duration, and more number of episodes are related to help seeking. Thus, when the depression is less severe, youth may not perceive the need for help seeking. However, the correlation coefficients are small though statistically significant, which may be due to large sample size and sampling methods used. Thus, the results need to be interpreted with caution.
|Table 4: Correlations of Beck depression inventory across suicide probability scale and adolescent coping orientation to problems experienced scales|
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People with higher suicide probability scored higher on depression and these youths probably had need for developing more social support and make attempts to relax; however, they might find it difficult to avoid the problems and seek diversion, thus ending up focusing more on the stressors [Table 5]., The contribution of the identified variables in analysis for suicide probability is lower compared to the other studies, which might be because of the nature of the tool used for assessment or sample-related variables.
|Table 5: Stepwise regression analysis predicting suicide probability score|
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Attempters scored higher on BDI, hopelessness, suicidal ideation, hostility, and suicide probability is in accordance with the finding that severity of depression predicted suicidal attempts., The coping methods used by those who attempted indicate less attempts at active coping and more usage of emotion-focused coping, which is explained as a resultant of inflexible thinking that is reported to increase hopelessness and suicidality.,
Similar to earlier researches, those with moderate-to-severe depression had significantly higher scores on hopelessness, suicidal ideation, hostility, and suicide probability compared to other groups (post hoc test).,, Youths with moderate-to-severe depression also used more emotion-focused coping and reduced involvement in solving family problems, indicating more avoidant and behavioral disengagement strategies to cope with stress, which further increases depression. However, ventilating feelings seem to reduce with increase in severity of depression and in those with suicidal attempts [Table 6] and [Table 7]. This may probably indicate avoidance of experiencing emotions, which needs further exploration as there is no supporting literature for this.
|Table 7: Comparison of those with minimal, mild versus moderate and severe depression across the scales|
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Some limitations of the study are: the cooperation and involvement of all the institutions selected for the study was not same, which had an influence on the motivation and participation of the students, which would have influenced answering of questionnaires. This was also one of the factors limiting downstream engagement with some institutions for any further sessions. The study did not include youths from upper socioeconomic status due to difficulty in obtaining permission of the institutions as well as youth in community not pursuing education limiting the generalizability. Because of large sample size, small differences in the scores have emerged as statistically significant, which may not reflect the actual picture; thus, the results need to be treated with caution and the possibility of other confounding variables such as study design and scales used cannot be ruled out. Although the contact details of the mental health professionals were provided, we could not follow them up on having sought any help. The main strengths of the study are inclusion of large sample size representative of youths studying in public and private schools and colleges in an urban setting. Age range covered the whole adolescence phase. The study findings help in formulating preventive interventions addressing depression and coping with academic- and family-related stressors and relationship difficulties. Further, steps to address the psychosocial factors contributing to depression in youth belonging to lower socioeconomic status are also important.
| Conclusions|| |
Academic and family factors contribute to most of the stress experienced in youth. About 3.5% of the school-going youths are at mild risk and 0.7% at moderate-to-severe risk for suicide. Higher severity of depression, hopelessness, and suicidal ideation are associated with suicidal attempts. Late adolescence and gender seems to confer vulnerability to depression and suicidal risk. Emotion-focused and avoidant coping methods are used by youths with moderate-to-severe depression and those who involve in suicidal behaviors. The study implicates need for preventive interventions specifically addressing coping in youth with depression and suicidal behaviors keeping the sociodemographic factors in mind.
We thank all the participants and the institutions that gave permission to conduct the study.
Financial support and sponsorship
This work was supported by the Indian Council of Social Science Research (ICSSR), New Delhi, India (02/173/2011/SC/RP, ICSSR, NEW DELHI).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]