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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 36-42

Study on suicidal intent and its relationship with psychiatric morbidity in cases of deliberate self-harm


1 Consultant Psychiatrist, Department of Psychiatry, GTB Hospital, Mumbai, Maharashtra, India
2 Assistant Professor, Department of Psychiatry, DVVPF's Medical College, Ahmednagar, Maharashtra, India
3 Associate Professor, Department of Psychiatry, Ashwini Rural Medical College, Hospital and Research Centre, Solapur, Maharashtra, India
4 Ex Professor and HOD, Department of Psychiatry, B J Government Medicao College and Sasson General Hospital, Pune, Maharashtra, India

Date of Submission08-Dec-2020
Date of Acceptance01-Mar-2021
Date of Web Publication20-Apr-2021

Correspondence Address:
Dr. Nitin D Bhoge
Department of Psychiatry, Ashwini Rural Medical College, Hospital and Research Centre, Kumbhari, Solapur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_65_20

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  Abstract 


Background: Mental disorders are among the strongest predictors of suicide attempts. However, little is known regarding which disorders that is uniquely associated with suicidal behavior because of high levels of psychiatric co-morbidity. The present study was planned to undertake on suicidal intent in such deliberate self-harm patients.
Aims: The aim is to determine the suicidal intent and to assess the relationship with psychiatric morbidity in patients of deliberate self-harm
Settings: Patients of deliberate self-harm.
Design: Cross-sectional study.
Materials and Methods: The sample consisted of 50 patients of deliberate self-harm admitted during study period of 6 months in appropriate in-patient unit for observation and necessary intervention, who fulfils inclusion criteria. A semi structured pro forma was used for collection of socio-demographic data, case history and Beck's Suicide intent scale was used which is designed to assess the severity of intention to die associated with an episode of deliberate self-harm.
Statistical Analysis Used: Descriptive statistics such as mean, standard deviation, and percentage was used to present the data. To assess the relationship between the suicidal intent and psychiatric morbidity, Chi-square test was used. A P < 0.05 were considered significant. Data analysis was performed using software SPSS v20.0.
Results: Self poisoning (80%) was found to be the most common method employed in deliberate self-harm. 74% of the deliberate self-harm attempts were impulsive in nature. Altercation with the spouse (30%) was the most common precipitating factor. Psychiatric morbidity was found to be associated with suicidal intent (P = 0.0068).
Conclusions: In conclusion, even with low intent to harm self we have to be careful while examining the patients of psychiatric morbidity. They are at risk of attempting harm to self. We cannot ignore the patients just on the basis of low intent to harm self.

Keywords: Beck's suicide intent scale, deliberate self harm, psychiatric morbidity, self-poisoning, suicidal intent


How to cite this article:
Pawar SS, Tagad PK, Bhoge ND, Pawar AV. Study on suicidal intent and its relationship with psychiatric morbidity in cases of deliberate self-harm. Arch Ment Health 2021;22:36-42

How to cite this URL:
Pawar SS, Tagad PK, Bhoge ND, Pawar AV. Study on suicidal intent and its relationship with psychiatric morbidity in cases of deliberate self-harm. Arch Ment Health [serial online] 2021 [cited 2021 Nov 28];22:36-42. Available from: https://www.amhonline.org/text.asp?2021/22/1/36/314187




  Introduction Top


As per the Oxford dictionary, the term suicide is Latin in origin, in which “sui” means oneself, and “cide” means killing. It is a major public health problem and has claimed lives of an estimated 815,000 people worldwide in the year 2000.[1] Centers for Disease Control in 2010 reported that, in the year 2007 more than 34,000 suicides occurred in the U. S., while the report published by the National Crime Record Bureau in 2010 (NCRB) states that more than one lakh (134,000) lives were lost due to suicide in India. The rates of suicide are higher in males as compared to the females in both the U. S.(4:1) and India (65:35). It is one of the top ten leading causes of death in all age groups.[2],[3]

There are two types of suicidal behaviors– fatal and nonfatal. Nonfatal suicidal behaviors include suicidal ideation, suicidal plan, and suicidal attempt.[4] The fatal suicidal behaviors are the ones that end in death called as completed suicide. Attempted suicide is both, one of the strongest predictor of completed suicide and an important indicator of extreme emotional distress.[5] A study of attempted suicide shows that, attempted suicide is 30–100 times more common than completed suicide.[6] It is estimated that in India, the incidence of nonfatal suicidal attempts is 250/100,000 persons per year.[7]

Easy availability of pesticides, psychosocial stressors, such as conflict with spouse, other family member, failed love affairs, and economic distress are significant risk factors for the increasing rate of suicides all over.[7],[8]

In study of dysfunctional families, found poor communication skills in the family members and inter-personal problems within the families are important risk factors to be associated with deliberate self-harm.[9] After the attempt, many significant others worry or fear about the attempt, or that the self-harming behavior will be repeated. The fear is accompanied with the feeling of being burdened. Some feel a sense of overwhelming responsibility to prevent further attempts. Other reactions to the attempt are feelings of helplessness, anger, irritability, hostility, shame, and guilt amongst the family members.

Need of the study

The findings of the West, to some extent were replicated in the Indian studies. Substance use disorders and adjustment disorder in males, and depression and adjustment disorder in females, were most common psychiatric diagnosis. Looking toward the scenario, this problem is serious while the resources to deal with the problem are very few. It becomes imperative under the circumstances that service should be guided by knowledge about the person it should reach. The present study was planned to conduct on suicidal intent in deliberate self-harm patients. This study can also help involving professionals from other medical faculties, so that we can work in liaison with each other towards managing this global crisis.

Objectives

  • To determine the suicidal intent in patients of deliberate self-harm
  • To assess the relationship between the suicidal intent and psychiatric morbidity in cases of deliberate self-harm.



  Materials and Methods Top


The present study was conducted over a period of 6 months in a general hospital which also serves as a teaching institution. Patients were recruited from in-patient units of Medicine, Surgery and Burns wards where the patients of deliberate self-harm were admitted with self-poisoning, self-injury, self-immolation, etc. The sample consists of 50 patients of deliberate self-harm admitted in appropriate in-patient unit for observation and necessary intervention. Institutional ethical clearance was obtained prior to begin of the study. Informed consent was obtained from each patient.

Selection criteria

Males and females aged between 20 and 40 years, accompanied by good attendant who was well informed about the patient and those who were able to participate and did not require any urgent medical or surgical management were included Patients who were not accompanied by a good informant and who were medically unstable and not able to participate for the interview were excluded.

Case history

A semi structured proforma was used for collection of socio-demographic data and case history. The suicide intent scale was developed by Beck et al. at the University of Pennsylvania for use in patients who attempt suicide but survive.[10] This scale is a 15 item questionnaire designed to assess the severity of suicide intention associated with an episode of deliberate self-harm. The diagnosis of psychiatric disorder was made by the ICD-10 criteria.[11]

Statistical analysis

Descriptive statistics such as mean, standard deviation, and percentage was used to present the data. To assess the relationship between the suicidal intent and psychiatric morbidity, Chi-square test was used. A P < 0.05 were considered significant. Data analysis was performed using software SPSS v20.0 IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, N.Y., USA).


  Results Top


Average age of our study population was 29.12 years. Majority of patients belongs to age group 20–24 years (32%) and 30–34 years (32%) followed by 25–29 (22%).

Out of the 50 patients of deliberate self-harm, 68% were male and 32% were female [Table 1].
Table 1: Basic characteristics of deliberate self-harm

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In our study, self-poisoning (80%) was found to be the most common method employed in deliberate self-harm. Out of these 60% were by insecticide consumption and 20% were by tablet consumption. Self-immolation was used by 12% of the patients, with a few patients engaging in self-injury (6%), and hanging (2%) [Table 2].
Table 2: Method of deliberate self-harm

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Seventy-four percent of the deliberate self-harm attempts were impulsive in nature, while the rest 26% had previously planned their act [Table 3].
Table 3: Nature of attempt

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Altercation with the spouse (30%) was the most common precipitating factor for deliberate self harm. Out of these, 30% were altercation with the spouse and 18% were altercation with significant other family member [Table 4].
Table 4: Precipitating factor

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In our study, 48% of the patients of deliberate self harm had medium intent, while 28% and 24% had low and high suicidal intention, respectively [Table 5].
Table 5: Suicidal intent in patients of deliberate self-harm

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There was significant association was found between psychiatric morbidity and suicidal intent (P = 0.0068) [Table 6].
Table 6: Relationship between suicidal intent and psychiatric morbidity

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  Discussion Top


In this study, we examined subjects once their general condition was stabilized. By this time, subjects might have gone through introspective period, which reduced the strength of intent reported to the examiner. It is possible only subjects who has low lethality attempt were admitted to wards and the high lethality died and we could not interview with them. These are some of reasons which can explain the negative correctional between intent and psychiatric morbidity.

Basic characteristics

Average age of our study population was 29.12 years, and that for males was 26.67 years and for females was 26.43 years. These findings were comparable to the findings of the Western and Indian studies. In these studies, suicidal behavior was more frequent among the younger individuals. The mean age of the sample population was found to be 29–30 years, for both sexes. The age of the youngest and oldest patient has been different because these studies have included all deliberate self-harm attempters irrespective of their age.[12],[13]

In our study population, the number of males (68%) was more than that of females (32%). This finding is similar to the findings of sex distribution in various Indian studies where out of 35 patients there were 19 males and 16 females.[14] In another study, there were 55.81% males and 44.19% females among the deliberate self-harm attempters.[15]

Method of attempt

In our study, self-poisoning (80%) was found to be the most common method employed in deliberate self-harm. Self-immolation was used by 12% of the patients, with a few patients engaging in self-injury (6%), and hanging (2%).

Most of the other Indian studies also reported self-poisoning by insecticide consumption as the most common method employed by deliberate self-harmers. Easy availability of the poisonous compounds and carelessness of people in handling them is the probable cause for this finding. The rest of the patients had used other means of deliberate self-harm like, consumption of other poisonous and inedible substances, drowning and hanging. In a study, it was found that deliberate self-harm by consumption of corrosives was the most common method (30%), flowed by use of insecticides (22%), and psychotropic medications (7%). There is unrestricted availability of corrosive compounds in the Indian households for domestic purposes.[16]

The Western studies have reported drug overdose to be the most common method employed for deliberate self-harm. Psychotropic drugs were more commonly used by the older patients, while analgesics and over-the-counter medications were used more commonly by the younger patients. This reflects the type of medications prescribed and available to different age groups.[17] Women more frequently took an overdose while men had a higher rate of self-injury with sharp objects and tended to employ more “hard” (violent) methods.[8] Some studies carried out in the adolescent age group suggest that both girls and boys are using self-cutting as the most common method of deliberate self-harm.[18] Hanging, burning, drowning, jumping from heights are the more lethal and violent means of deliberate self-harm. The persons engaging in such acts usually suffer from some psychopathology and have high intention to die. Because of the high lethality of these acts, most of them end in death.[19],[20] Therefore, these methods as means of deliberate self-harm are far less common than the other methods.

Nature of the act

In this study, we found that 74% of the patients had impulsively attempted the act, while the rest

26% had previously planned their act. Impulsivity is an important component in patients of deliberate self-harm, who do not wish to die. Impulsivity is associated with non-lethal methods of deliberate self-harm, while the wish to die is related to planning.[21] Most of the patients in our study, who had attempted the deliberate self-harm impulsively, had done so within few minutes of the precipitant event. They had not given much of a thought to the outcome of their attempt. Out of the total number of patients whose act was impulsive (n = 32), most of them (n = 33) had low to medium suicidal intent. The intention behind their act was either to manipulate the situation, escape from the situation, or make someone else feels guilty.

In a study, it was observed that 24% of the survivors of near fatal deliberate self harm attempt spent <5 min between the decision to attempt deliberate self harm and the actual attempt. These patients tended to be less likely to have considered another method of deliberate self harm, perceived a greater likelihood of discovery, and a lower expectation of death. Researchers have noted a tendency for impulsive suicide attempts to be immediately preceded by interpersonal conflicts and have suggested that impulsive suicide attempts might be a response to these conflicts rather than an actual desire to die. Planned suicide attempts often result from chronic mental health problems such as depression. They are likely to be more lethal and are associated with a higher suicidal intent.[22]

The relation between impulsive behavior and deliberate self-harm attempt can be thought of as having two dimensions. A self-harm attempt may be impulsive or not, or the attempter may have impulsive traits or not. There are no studies simultaneously measuring attempt impulsivity and attempter impulsivity. In our study, we studied the attempt impulsivity. Using the two items on Beck's Suicide Intent Scale, active preparation for the attempt (item 6) and degree of premedication (item15), impulsivity of the attempt can be operationalized. Impulsivity may also be evaluated by the length of the interval between the decision to attempt suicide and the actual attempt.[23] Planning appears to be an opposite dimension of impulsivity. Planned suicide involves a more subjective element drawn from the desired outcome and perceived lethality of the act of self-harm.[24] Impulsive behavior differs from corresponding premeditated behavior by having an inappropriately short threshold for response, lack of reflection, lack of modulation, and lack of potential gain, leading potentially to dissociation between an action and its intent.[21]

Precipitating factors leading to the act

The most common precipitant to the act of deliberate self-harm in our study was altercation with the family members (48%). Of these, 30% were altercation with the spouse and 18% were altercation with significant other family member. The reasons for altercations varied from financial problems, substance use in the spouse, failure in examinations (in the student population), and interpersonal problems within the family members. 24% patients had financial problems which had lead them to engage in deliberate self-harm. Other precipitating factors were presence of major psychopathology. In case of a person having schizophrenia, distress due to auditory hallucinations and delusions were the precipitating factors for deliberate self-harm. Patients having severe depression had pessimistic thoughts about the future and persistent ideas of hopelessness, which served as the factors responsible for deliberate self-harm (10%). Others reasons (18%) were broken love affair, loss of spouse, or other familial problems.

In another study, it was found that, disharmony with the persons with whom they resided (51%), worries about work or employment (5%), financial problems (5%), physical pain or mental illness (4%) were the precipitating reasons leading to the attempt. Other less common factors were crime, housing and drinking problems, bereavement and gambling.[17] Other precipitants found in a small proportion of attempters were infertility, impotency, political disputes, and recent changes in living conditions or jobs.[25] The commonly cited factors preceding the act are quarrel and consequent scolding by significant others, broken love affair[7] and marital maladjustment (in females), and unemployment (in males).[6],[15]

Suicidal intent in deliberate self-harm

We assessed the suicidal intent in the patients with the help of Beck's Suicide Intent Scale, which classified the patients into those having low, medium, and high suicidal intent. In our study, 48% of the patients had medium intent, while 28% and 24% had low and high suicidal intention respectively.

Deliberate self-harm often seems to have such mixed intentions, death being just one of them.[26] Suicide intention refers to the intensity of wish for death at the time of the deliberate self-harm attempt.[27]

In a study, at the time of deliberate self-harm, 46% male and 34% female attempters wanted to die. However, a day after the attempt, only a few were found to be regretful that they had not killed themselves (17% males and 11% females). It suggests that in patients with high suicidal intention, a failed deliberate self-harm attempt does not necessarily mark a significant personal threshold that “changes everything” for the person. Many of these patients have persistence of the suicidal intent even after they have been rescued. They are the ones in whom the chances of repetition of deliberate self-harm attempt are higher.[8],[17] A significant correlation was also found between suicidal intent and deliberate self-harm, and more so between when it was associated with hopelessness. Hopeless about the future is one of the most significant factors which can predict deliberate self-harm in an individual.[28]

Relationship between suicidal intent and psychiatric morbidity

A significant association was found between psychiatric morbidity and suicidal intent. However other studies have stated that psychiatric morbidity was associated with high suicidal intent. High suicidal intent was significantly correlated with psychiatric disorder, especially in those suffering from major depressive disorder.[29] It was also found to be significantly correlated with hopelessness.[30]

Those with high intent are more likely to succeed in completing the suicide, which can be one of the reasons for this result. As we have examined only survivors in this study. Also we have omitted patients having serious medical status as interview was not possible. We need population based study of all the suicides both completed and failed to assess exact role of suicidal intent and psychiatric morbidity.

The reason for this difference is that the most common psychiatric morbidity in our study was substance use disorders and adjustment disorder. The patients with substance use disorders had consumed alcohol just prior to the attempt. Alcohol dependence itself and recent negative life events are related to self-harming behavior. Both may lead to problems in adjusting to a stressful situation, ultimately resulting in deliberate self-harm.[31] Acute use of alcohol prior to the act impairs the judgment and is associated with impulsive self-harm. They are not aware about what they are doing and have a low intention to die at the time of the attempt.[32]

As compared to females, males are more likely to have higher intention to die at the time of the attempt.[17] Intention to die also varies with the age. In comparison to the young, older patients have a higher intention to die. This finding is consistent with the relatively high risk of suicide in older adults.[20] Among the younger population, especially the adolescents, “wanting to get relief from a terrible situation” and “wanting to die” are the most commonly reported intentions. This suggests that the adolescents have an ambivalent attitude towards the act of deliberate self-harm. The ambivalent attitude only reflects the feelings of extreme anxiety that the individual experiences when he is in an impossible situation.[18] High suicide intent was also found in those who repeated their self-harming behavior.[33]

Suicidal intent was significantly correlated with psychiatric disorder, especially in those suffering from major depressive disorder.[29] Intent is significantly correlated with hopelessness.[30] High suicidal intent carried the risk of repetition of acts of deliberate self-harm and ultimately death due to suicide.[20]

Those without co-morbid psychiatric illness were more likely to attempt deliberate self-harm to “make others feel guilty,” “to escape an unbearable situation,” “to ask for help,” “to change someone's mind,” “because of loss of control.”[27],[30]

The findings of the West were replicated in the Indian studies. Suicidal intent was found to high in males and in older age group of people.[34] A significant correlation was also found between suicidal intent and deliberate self-harm, and more so between hopelessness and deliberate self-harm.[28] Patients with comorbid psychiatric illness had a higher intention to die. This suicidal intent was persistent up to many days following the attempt, as opposed to those without psychiatric illness who regretted having attempted deliberate self-harm. Persistence of intention to die is risk factor for repetition of deliberate self-harm.[35] It was also found that the patients who had intention to die had planned their act way ahead and had taken precautions against discovery in order to avoid being rescued.[36]

The cognitive and attitudinal phenomena of hopelessness are the important target symptoms in treating suicidal individuals.[28] Therefore, in terms of prevention and intervention, it is the intention behind the deliberate self-harm episode, and not the situation per se (e.g., interpersonal crisis), that is of importance and requires modification.[8]

Strengths and limitations of the study

We studied the intention to die, which is important in predicting the seriousness of the attempt and future risk of repetition of deliberate self-harm. Thus necessary steps can be taken to prevent further catastrophe. Further studies recommended on large scale population. We need further studies to assess the intent at the time of attempt or immediately after the attempt. This can be done by examining the patient in causality or emergency department to avoid the delay of interview. This could be one more reason behind the significant finding to low intent of self-harm attempt and psychiatric morbidity along with high incidence of substance abuse as diagnosis of psychiatric morbidity. Furthermore, we have not included the subjects who have completed the suicide or whose condition was serious to have interview.

Implications

Modifying the inter-personal communications within the family might help in alleviating such feelings as well as in prevention of further self-harm episodes. Further systematic review type of studies may be carried out for further evidences. The present study added to the current scenario by adding findings of relationship of intent deliberate harm with psychiatric morbidities. Early assessment and intervention can help in diagnosis and management of psychiatric morbidity as well as in prevention of repetition of the act.

Controversies raised by this study: The present study was made an effort to establish relation of deliberate self-harm episodes with any psychiatric morbidity, therefore no controversies raised by this study.

Future research directions

Further studies are to be done into the factors and pathologies leading to intention to self-harm. Furthermore, we need to understand the psychological factors contributing towards the deliberate self-harm. Not only the end point of self-harm but the onset of such intent and factors responsible for this thought process needs further studies.


  Conclusion Top


Our study has shown that the intent to self-harm is low in patients with psychiatric morbidity more commonly so in patients with substance abuse. We can conclude that even with low intent to harm self we have to be careful while examining the patients of psychiatric morbidity. They are at risk of attempting harm to self. We cannot ignore the patients just on the basis of low intent to harm self.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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