|Ahead of print
|A cross-sectional study of frequency, type, and lethality of deliberate self-harm in bipolar affective disorder patients presenting to tertiary care center
Fakirappa Basavaraj Ganiger1, Somashekhar Bijjal2, AT Safeekh3, Manisha Sharma4
1 Associate Professor and Head of Department, Department of Psychiatry, Gadag Institute of Medical Sciences, Amritsar, India
2 Senior Resident, Department of Psychiatry, Gadag Institute of Medical Sciences, Amritsar, India
3 Senior Resident, Department of Psychiatry, Government Medical College, Amritsar, India
4 Professor, Department of Psychiatry, Father Muller Medical College and Hospital, Mangalore, Karnataka, India
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|Date of Submission||12-Sep-2021|
|Date of Acceptance||06-Jan-2022|
|Date of Web Publication||15-Apr-2022|
Introduction: Deliberate self-harm (DSH) is one of the leading causes of death and a major public health problem worldwide. According to the World Health Organization, DSH has increased by 60% over the past 50 years, of which 90% of victims had a psychiatric disorder.
Aims and Objectives: The aim is to analyze the frequency, type, and lethality of DSH in bipolar affective disorder (BPAD) patients.
Materials and Methods: This study included 150 patients diagnosed to have BPAD. Specially designed sociodemographic pro forma was used to record basic profile. DSH inventory was administered on BPAD patients who presented with DSH to analyze the type and lethality. Diagnosis of BPAD was made according to the International Classification of Diseases, tenth revision. Data were recorded, compiled, and analyzed using frequency and percentage with the IBM SPSS Statistics for Windows, Version 24.0.
Results: The frequency of DSH was found to be 33%, out of which 38 (35%) patients had manic episode and 11 (30%) patients had depressive episode. The most common type of DSH was found to be cutting self with sharp or blunt objects and consumption of poison with frequency of 12 (24.5%) each. The second most common DSH was banging head, which was present in (11) 22.4% of patients.
Conclusion: BPAD is associated with increased risk of DSH compared to the general population. The most common type of DSH was cutting self with sharp objects followed by consumption of poison. Patients who presented with DSH in depressive episode and severe mania had more lethal modes of DSH.
Keywords: Bipolar affective disorder, deliberate self-harm inventory, deliberate self-harm
|How to cite this URL:|
Ganiger FB, Bijjal S, Safeekh A T, Sharma M. A cross-sectional study of frequency, type, and lethality of deliberate self-harm in bipolar affective disorder patients presenting to tertiary care center. Arch Ment Health [Epub ahead of print] [cited 2022 Nov 29]. Available from: https://www.amhonline.org/preprintarticle.asp?id=343319
| Introduction|| |
Deliberate self-harm (DSH) is defined as “An act with nonfatal outcome, in which an individual deliberately initiates a behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences.”
Deliberate self-harm and psychiatric disorders
DSH is a complex event associated with psychosomatic, biological, social factors, and psychiatric disorders. The current literature on DSH countries worldwide shows that there is a rise in DSH rates in psychiatric disorders. Various psychiatric disorders are found to be commonly associated with people who have a history of DSH sometime in their lives, which warrants careful assessment for these psychiatric disorders. Out of all the psychiatric disorders, the most commonly associated with DSH is mood disorders. A study has shown that deliberate self-poisoning accounts for 100,000 hospital admissions in England and Wales every year with increasing incidence. Forty-six percent of these patients, however, had no psychosocial assessment at any time during their hospital contact. The average rate of patients with self-poisoning presenting to hospital services in this study was 310/100,000 population per year, which suggests that deliberate self-poisoning accounts for 170,000 hospital attendances in the United Kingdom annually. An Indian study assessing 1605 cases of self-harm, it was found that in 140 patients, self-harm was deliberate with the prevalence of 8.7%. Among these patients, the most common Axis I disorder was found to be depression (22.1%) followed by schizophrenia (15.7%). In Axis II, personality disorder was the most common (39.7%), and among personality disorders, emotionally unstable personality disorder was most prevalent.
Deliberate self-harm and bipolar affective disorder
People with bipolar disorder account for 3.4%–14% of all suicide rates, with self-poisoning and hanging as the most common methods used, and approximately 48% of patients with bipolar affective disorder (BPAD) make at least one suicide attempt. The odds ratio of subjects with bipolar disorder having a history of a suicide attempt relative to subjects in the control group was 6.2. Earlier age of depression onset, bipolar I subtype, female sex, unmarried status, a history of substance use disorder, panic disorder, sexual abuse, and psychosis were associated with significantly higher rates of attempted suicide. However, studies on the frequency of DSH in BPAD in India where DSH are high and under recognized are limited. Hence, this study will help in focusing on the frequency of DSH in patients with BPAD, so as to get a clearer idea of the percentage of people at risk of harming self.
| Materials and Methods|| |
This is a cross-sectional observational study, which was conducted in tertiary care center. The study was conducted from January 2018 to August 2019. Data collection was started after obtaining the Institutional Ethical Board Clearance. Informed written consent was obtained from all participants. Patients who were in acute manic or depressive episode, informed consent was obtained from their significant relatives or guardians after explaining details about the nature of the study. Participants were recruited according to the following criteria.
- BPAD patients diagnosed according to the International Classification of Diseases, 10th edition (ICD-10)
- BPAD patients in manic, depressive, or mixed episodes
- Age group between 18 and 60 years of either gender.
- Patients diagnosed with organic mood disorder
- Patients with mental retardation and other neurodevelopmental disorders
- Patients with substance-induced mood disorder
- Patients with chronic debilitating physical diseases.
A structured sociodemographic pro forma was used to collect patient's basic profile. Screening for psychiatry disorders was done by mini-international neuropsychiatric interview-plus (MINI-Plus). Diagnosis of BPAD was made according to the ICD-10. DSH inventory was used to assess the type and lethality of DSH. Details regarding the DSH were corroborated with family members who had witnessed the event to avoid recall bias as patients were in acute phase of illness.
Tools used for the study
- DSH inventory (DSHI): It is a 17-item, behaviorally based, self-report questionnaire developed by Gratz et al. to assess DSH. This measure assesses the type and lethality of self-harming behavior and has good validity and fair reliability. The DSHI is based on the conceptual definition of DSH as the deliberate, direct destruction, or alteration of body tissue without conscious suicidal intent, but resulting in injury severe enough for tissue damage (e.g., scarring) to occur
- Sociodemographic and clinical data pro forma.
| Results|| |
Out of 150 patients, 90 (60%) were male patients and 60 (40%) were females. Majority of the patients, 94 (62.7%) belonged to the Hindu religion and were unskilled laborers 98 (65.3%). Details regarding other sociodemographic profile are given in the following [Table 1].
Frequency of deliberate self-harm
Among the 150 patients, 109 (72.7%) patients presented with manic episodes, 37 (24.7%) presented with depressive episodes, and only four (2.7%) presented with mixed episodes. 49 (33%) of the patients had history of DSH attempt. Out of 49 patients who had history of DSH, 38 (35%) had manic episode, and 11 (30%) had depressive episode [Table 2].
Among 33% of the patients who had history of DSH, the most common type of DSH was found to be cutting self with sharp or blunt objects and consumption of poison with frequency of 24.5% each. The second most common type of DSH was banging head which was present in 11 (2.4%) of the patients followed by attempted hanging and punching self with a frequency of 10.2% each. One patient had history of rubbing sandpaper constituting 2% of overall DSH frequency according to DSHI [Table 3].
|Table 3: Data regarding type of deliberate self-harm according to deliberate self-harm inventory|
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In this study, a total of 57 DSH were reported among which 28 (49.1%) patients had at least one DSH attempt in their lifetime, 25 (43.9%) patients had two DSH attempts, and four (7%) had more than two DSH in their lifetime [Table 4].
22 (14.7%) patients had at least one past history of DSH in manic episodes, five (3.3%) patients had past history of two DSH attempts in manic episodes and one patient had past history of more than two DSH attempts in manic episodes and 12 (8%) patients had at least one DSH attempt in the past depressive episodes [Table 5].
|Table 5: Data regarding past deliberate self-harm in manic episodes and depressive episode|
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Eleven patients who had DSH in depressive episode had more lethal modes of DSH such as attempted hanging, consumption of poison, and cutting self.
| Discussion|| |
In this study, the frequency of DSH in patients with BPAD is 33%; that is, 49 patients presented with history of DSH out of 150 study samples. This frequency is in accordance with the World Health Organization reports of lifetime prevalence of suicide attempts in bipolar disorder which was published in the year 2015. This report was based on the study done by Chen et al., who reported lifetime prevalence of suicide attempts among 801 subjects with unipolar depression in comparison with 168 subjects with bipolar disorder and 5697 subjects with other Axis I psychiatric diagnoses. In another study by Leverich et al. involving 648 BPAD patients reported that the lifetime frequency of suicide attempts in BPAD patients to be 34%. However, the different studies have reported varying prevalence and frequency of DSH in BAPD. A study by Goodwin and Jamison et al. reported higher frequency of DSH compared to this study and stated that 48% of individuals with BPAD make at least one suicide attempt in their lifetime. Gao et al. in 2009, in cross-sectional study involving 561 BPAD patients found that 41% had at least one-lifetime suicide attempt. Valtonen et al. reported that, over their lifetime, the vast majority (80%) of psychiatric patients with bipolar disorders have either suicidal ideation or ideation plus suicide attempts. He also found that the prevalence of suicidal behavior in bipolar I and II disorders is similar, but the risk factors for it may differ somewhat between the two. National confidential inquiry into suicide and homicide and Clement C Jones et al. reported the prevalence of suicide attempt in BPAD to be 68% and 60%, respectively. However, study by Schaffer et al. reported that bipolar disorder accounts for 3.4%–14% of all suicide rates. An Indian study by Singh et al. aimed to assess psychiatric disorders among patients with a DSH attempt, who attended the emergency department of a tertiary care center for DSH over a 13-month period found that two (1.8%) patients among 109 patients who completed the study were diagnosed to have BPAD. This wide variation in the frequency might be due to the different methodology used in the studies, differences in the definition of DSH used for the studies, or due to differences in the diagnostic criteria used in these studies. However, the general consensus is that 5%–20% will eventually die by suicide., Even the studies with the lowest estimates of DSH reported higher figures for suicide compared to the general population (1.4%) of all deaths worldwide in 2012.
In this study, the most common method of DSH was found to be, cutting self and consumption of poison, which was present in 24.5% of the study sample with history of DSH. This was followed b attempted hanging and punching self, which was present in 10.2% of study sample with history of DSH. This finding is in agreement with study done by Schaffer et al. who reported that hanging and consumption of poison as the most common methods of DSH in BPAD. Furthermore, study by Clements C and Jones et al. revealed that hanging is the most common method of DSH in bipolar disorder. However, Indian studies are scarce in this regard.
Strengths of the study are, it is one of the few studies which assess the frequency, type, and lethality of DSH in patients with BPAD. The use of standard tools such as DSHI and MINI-Plus have made it more reliable. DSHI includes both lethal and nonlethal methods which give broader perspective to the problem. The study also has adequate sample size from in-patient setting.
Limitation of the study is its cross-sectional nature, which does not represent the general population as the sample taken is from the hospital setting, and there might be under reporting of DSH due to legal constraints. As many of the deliberate self-harm is not often reported, the results may be an underestimation of the actual prevalence. Other limitation was, personality of the patients was not assessed which might be a contributing factor in DSH.
Clinical implication of the study is that, as frequency of DSH is high in patients with BPAD compared to the general population, they should be evaluated for mode and lethality which in turn will help in providing timely care so that the morbidity and mortality associated with DSH can be minimized to a great extent.
| Conclusion|| |
Frequency of DSH is higher in patients with BPAD compared to the general population can be present in either manic or depressive episode. BPAD patients, who present with DSH, have to be evaluated thoroughly for mode and lethality of DSH as these patients carry higher risk of repeating DSH in future and many times lead to completed suicide. Patient's immediate caregivers should be psychoeducated regarding the same so that mortality due to DSH can be reduced to a great extent in such patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Platt S, Bille-Brahe U, Kerkhof A, Schmidtke A, Bjerke T, Crepet P, et al.
Parasuicide in Europe: The WHO/EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr Scand 1992;85:97-104.
Haw C, Hawton K, Houston K, Townsend E. Psychiatric and personality disorders in deliberate self-harm patients. Br J Psychiatry 2001;178:48-54.
Barraclough B, Bunch J, Nelson B, Sainsbury P. A hundred cases of suicide: Clinical aspects. Br J Psychiatry 1974;125:355-73.
Kapur N, House A, Creed F, Feldman E, Friedman T, Guthrie E. Management of deliberate self poisoning in adults in four teaching hospitals: Descriptive study. BMJ 1998;316:831-2.
Krishnaram VD, Aravind VK, Vimala AR. Deliberate self-harm seen in a government licensed private psychiatric hospital and institute. Indian J Psychol Med 2016;38:137-41. [Full text]
Goodwin F, Jamison K. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression. 2nd
ed. Oxford University press. 2007:247-69.
Chen YW, Dilsaver SC. Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other Axis I disorders. Biol Psychiatry 1996;39:896-9.
Gao K, Tolliver BK, Kemp DE, Ganocy SJ, Bilali S, Brady KL, et al.
Correlates of historical suicide attempt in rapid-cycling bipolar disorder: A cross-sectional assessment. J Clin Psychiatry 2009;70:1032-40.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al.
The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33.
Gratz KL. Measurement of deliberate self-harm: Preliminary data on the deliberate self-harm inventory. J Psychopathol Behav Assess 2001;23:253-63.
Leverich GS, Altshuler LL, Frye MA, Suppes T, Keck PE Jr., McElroy SL, et al.
Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 2003;64:506-15.
Valtonen H, Suominen K, Mantere O, Leppämäki S, Arvilommi P, Isometsä ET. Suicidal ideation and attempts in bipolar I and II disorders. J Clin Psychiatry 2005;66:1456-62.
Clements C, Jones S, Morriss R, Peters S, Cooper J, While D, et al.
Self-harm in bipolar disorder: Findings from a prospective clinical database. J Affect Disord 2015;173:113-9.
Schaffer A, Weinstock LM, Sinyor M, Reis C, Goldstein BI, Yatham LN, et al.
Self-poisoning suicide deaths in people with bipolar disorder: Characterizing a subgroup and identifying treatment patterns. Int J Bipolar Disord 2017;5:16.
Singh S, Kumar S, Deep R. Patients with deliberate self-harm attended in emergency setting at a tertiary care hospital: A 13-month analysis of clinical-psychiatric profile. Int J Psychiatry Med 2019;54:363-76.
Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry 1997;170:205-28.
Tondo L, Lepri B, Baldessarini RJ. Suicidal risks among 2826 Sardinian major affective disorder patients. Acta Psychiatr Scand 2007;116:419-28.
World Health Organization. Preventing Suicide: A Global Imperative. Preventing Suicide: A Global Imperative. Available from: http://who.int
. [Last accessed on 2019 Mar 23].
Department of Psychiatry, Gadag Institute of Medical Sciences, Gadag - 582 103, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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