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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 36  |  Issue : 3  |  Page : 225-229

Gender differences in individuals with suicide attempt from a general hospital setting in Bengaluru, India


1 Department of Psychiatry, St John's Medical College, Bengaluru, Karnataka, India
2 Department of Emergency Medicine, St John's Medical College, Bengaluru, Karnataka, India

Date of Submission04-Oct-2019
Date of Decision04-Jan-2020
Date of Acceptance29-Jan-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Priya Sreedaran
Department of Psychiatry, St John's Medical College, Sarjapura Road, Koramangala, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_103_19

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  Abstract 


Objective: Gender-related risk factors in individuals with suicide attempts vary according to the region in India. These gender-related factors have implications in determining the nature of psychiatric treatment in such individuals. This study reports on gender differences in individuals with recent suicide attempts evaluated by the Assertive Management of Attempted Suicide (AMAS) service in a general hospital setting in Bengaluru, India. Subjects and Methods: The authors extracted data pertaining to the demographic and illness details from 494 case records from January 2016 to December 2017. Results: Women were more likely to be married and homemakers, whereas men were more likely to be farmers, unemployed, and single. Women were more likely to overdose on the prescription drugs and be diagnosed with depression. Men were more significantly likely to be diagnosed with a psychiatric disorder (P < 0.019, odds ratio: 1.874, confidence interval at 95% interval: 1.109–3.169). Conclusions: There are definite gender-related differences with respect to marital status, occupation, mode of suicide attempt, and psychiatric diagnosis as noted in the AMAS. A focus on psychiatric diagnostic assessment without understanding other associated sociodemographic variables could lead to inadequate mental health treatment in individuals without a psychiatric diagnosis. Mental health interventions in all individuals with a suicide attempt should be formulated taking into account specific gender-related variables.

Keywords: Attempted suicide, deliberate self-harm, diagnosis


How to cite this article:
Sreedaran P, Jayasudha N, Murty S, Ruben JP. Gender differences in individuals with suicide attempt from a general hospital setting in Bengaluru, India. Indian J Soc Psychiatry 2020;36:225-9

How to cite this URL:
Sreedaran P, Jayasudha N, Murty S, Ruben JP. Gender differences in individuals with suicide attempt from a general hospital setting in Bengaluru, India. Indian J Soc Psychiatry [serial online] 2020 [cited 2022 Jan 26];36:225-9. Available from: https://www.indjsp.org/text.asp?2020/36/3/225/296250




  Introduction Top


Death due to suicide is a major public health problem in India.[1] Mental illnesses such as depression, schizophrenia, and substance use disorders are associated with suicide and suicidal behaviors.[2],[3] Contextual factors such as marital status and financial problems and major life events are also significantly associated with suicidal behaviors.[4] Individuals with recent suicide attempts continue to remain at an increased risk for death due to suicide even in the absence of a psychiatric diagnosis.[3],[5] This evidence shows that we should not limit mental health evaluations in such individuals to psychiatric diagnostic screenings only but should also study the additional risk factors including the gender-related variables.

The association between gender and suicide in India is complex.[6] From 2001 to 2013, suicide rates in Indian men have remained constant, whereas suicide rates in women have decreased.[6] A research from India with respect to gender and suicidal behaviors has demonstrated heterogeneity in findings. A study on individuals with recent suicide attempts from South India showed that men had higher rates of mental illness, were more likely to be single and were more likely to use organophosphate poisons in attempts to kill themselves. In the same study, women were more likely to live in rural areas, had lower educational status and lower rates of employment outside home.[7] In findings from a study conducted in a Mumbai general hospital, more women were diagnosed with depression as compared to men.[8] Men reported financial, work, and drinking problems as reasons for harming themselves, whereas women mentioned domestic problems and victimization.[8] In another study from Chandigarh, men were significantly more likely to be diagnosed with a psychiatric disorder as compared to women.[9]

Variables associated with gender and suicide attempts in India have differed with respect to the mode of suicide attempts and associated psychiatric diagnoses. In this context, we report on the gender differences from a real-world assertive clinical service setting that treats individuals with recent suicide attempts in general hospital settings in Bengaluru and discuss its implications with respect to suicide risk assessment.


  Subjects and Methods Top


Objective

The objective was to study the gender differences in Persons with Suicide Attempt (PSA) from a real-world assertive clinical service setting in a tertiary general hospital setting in Bengaluru.

Study methods

This is a chart review using the data extracted from the records of the Assertive Management of Attempted Suicide (AMAS) located in a tertiary general hospital setting in Bengaluru. We reviewed charts from January 2016 to December 2017. The AMAS was set up to provide mental health-care assertively to PSA admitted through emergency services of the same hospital. The primary person coordinating AMAS was a qualified and experienced staff nurse, and she performed the role of a service manager (SM). The SM was trained by a psychiatrist in clinical interviewing, making a psychiatric diagnosis on the basis of Mini International Neuropsychiatric Interview (MINI) 5.0 and basic counseling skills through observation of experienced psychiatrists and role-plays. SM was then monitored by multiple psychiatrists simultaneously for a period of 6 months to ensure adequate quality of work.

The SM would identify all such individuals admitted for at least 1 day in various medical wards from admission registers in emergency medicine. The SM would ensure that the individuals were seen by a psychiatrist as soon as they were medically stable regardless of whether a formal referral to psychiatry was sent. The psychiatrist would then review the patient and frame an individualized treatment plan. The SM would serve as a liaison between medical departments and psychiatrists to confirm that treatment was effected.

All case records in the AMAS had sociodemographic details (gender, religion, education status, and occupation), suicide attempts (mode of attempt and history of past attempt), and presence and type of psychiatric diagnosis. As part of the intake, SM would ascertain the psychiatric diagnosis using MINI 5.0.[10] The final diagnosis recorded in the case records was, however, made on the basis of a detailed clinical evaluation by the treating psychiatrist as per the International Classification of Diseases guidelines.[11] The role of SM in AMAS was to ensure that PSA received essential psychiatric care that was individualized according to their requirements. The type of psychiatric care was determined by a multidisciplinary team headed by a psychiatrist. For example, in case of a suicide attempt associated with marital discord, the focus of care would be marital therapy that would be delivered by qualified psychiatric social workers. However, in the case of suicide attempts associated with schizophrenia, the primary aim of treatment would be drug rationalization and psychoeducation of family and patient (after achieving improvement of insight).

The lethality of the attempt was assessed according to the Scale for Assessment of Lethality of Attempt (SALSA).[12] SALSA is a useful tool to assess the lethality of suicide attempts and has been developed and validated in India.[12]

We aim to report on the gender differences in PSA evaluated as part of the AMAS service from January 2016 to December 2017. We received institutional ethics clearance from the Institutional Ethics Committee (IEC) for this study (IEC: 224/2016).

We performed the analysis using SPSS 16 (Version 16.0, Chicago, IL, USA). We assessed normality using the Shapiro–Wilk test for continuous variables (age of a person and SALSA scores). As data were distributed in a skewed pattern, we performed comparisons using Mann–Whitney tests for independent samples. We compared categorical data using Chi-square and Fisher's exact test where applicable. We initially compared sociodemographic, suicide attempt-related details, and psychiatric diagnosis between men and women. In the event of any significant findings, we intended to determine if there were significant associations between gender and other variables using the appropriate statistical techniques. All tests were two tailed with confidence intervals at confidence interval levels of 95%.


  Results Top


A total of 494 individuals with recent suicide attempts were evaluated as part of the AMAS over a period of 2 years from January 2016 to December 2017. We chose a 2-year period, as this would provide us an adequate sample size. We excluded data from 27 records due to reasons like death of PSA during medical treatment before the review by SM, revision of diagnosis of “suicide attempt” to that of “harm to self-due to accidental causes,” and inadequate data due to premature discharge of patients against medical advice. There was no significant difference between men and women with respect to age, (median of ages in men = 27.5, range = 15–76, whereas in women, median = 25, range = 16–72; Mann–Whitney U-test = 23656.5.00; P = 0.063).

Comparison of religion, occupation, relationship status, and education levels between both genders is mentioned in [Table 1].
Table 1: Gender differences in sociodemographic characteristics

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There were no significant differences between men and women with respect to the lethality of their attempts as assessed by the SALSA (in men, median = 13, in women, median = 13; Mann–Whitney U-test = 23792.5; P < 0.077).

We compared the presence of psychiatric diagnoses between both genders. Significantly more men were diagnosed with a psychiatric diagnosis as compared to women (in men, 75.8%, n = 144 men out of 190, in women, 65.7%, n = 182 out of 277; χ2 = 5.439; P < 0.02). The comparison between both genders with respect to the type of attempt, history of attempt, and type of psychiatric diagnosis is shown in [Table 2]. As shown in [Table 2], women were more significantly likely to use prescription overdose as a mode of suicide attempt. Men were more significantly likely to be diagnosed with substance use disorders.
Table 2: Gender differences in mode of suicide attempt, history of suicide attempt and psychiatric diagnoses

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We performed a binomial logistic regression to confirm whether there was a significant association between the gender and presence of psychiatric diagnosis and adjusted for confounding variables such as marital status, type of attempt, and type of occupation. Men were significantly more likely to be given a psychiatric diagnosis as compared to women in the adjusted analysis (P < 0.019, odds ratio: 1.874, confidence interval at 95% interval: 1.109–3.169).


  Discussion Top


This study has systematically assessed the relationship between gender and attempted suicide using data from an existing clinical service in a general hospital setting in Bengaluru. These findings are relevant with respect to the type of mental health treatment that these individuals should receive, especially in India.

A significantly greater number of women were likely to be homemakers, whereas more men were farmers, skilled employees, or unemployed. These findings are similar to those reported from other studies.[13],[14] Patel et al. reported a significant association between agriculture as an occupation and suicide in India.[13] Research from South Asia has shown that homemakers were at higher risk for deliberate self-harm.[15] While there has been prominent media coverage of farmer suicide in India, this study-in addition to others-identifies women homemakers as a potentially high-risk group for suicide.[16] While studies from some Asian countries have indicated that being single is a risk factor for suicide, findings from this study along with other research suggest that marriage is not necessarily a protective factor for women in the South Asian subcontinent.[15],[17],[18],[19]

More men attempted suicide by consuming common chemicals (pesticides, household solvents etc.) similar to other published findings.[20] However, the increased use of prescription drug overdose in women as a mode of a suicide attempt is supported by some authors, others have shown women use methods like self-immolation.[20],[21],[22] Prevention and restriction of access to lethal means of suicide is an important strategy in suicide prevention.[23] Studies have explored the feasibility of pesticide storage in common places rather than homes in reducing related suicide attempts and deaths.[24],[25] Legislation mandating a reduction in analgesic pack sizes has shown a decrease of lethal overdoses by 43%.[26],[27] Findings from this study emphasize the need for policies in India to ensure stringent monitoring of prescription and dispensation of all types of drugs as yet another measure of restriction of access to lethal means of suicide.

More women were diagnosed with depression and adjustment disorders, while substance use disorders were more noted in men similar to other studies.[21],[28] The AMAS also showed that a significantly greater proportion of women did not meet the criteria for a psychiatric diagnosis as compared to men. This finding suggests that psychosocial interventions might have an important role in women who attempt suicide. In a survey of medical colleges in South India, only 66% had specialist psychiatric services for individuals with recent suicide attempts.[29] Ongoing training on suicide risk assessment and management was available only in 34% of these services.[29] We opine that suicide risk assessments that focus only on the determination of a psychiatric diagnosis without consideration of other gender-related variables are inadequate in Indian settings. Such mental health assessments are detrimental to individuals including women, in whom the absence of psychiatric diagnosis might lead to inadequate psychiatric treatment. We reiterate that mental health evaluations in individuals with recent suicide attempts should incorporate the identification of gender-specific vulnerabilities that can lead to individualized treatments. This opinion is supported by Indian research that has shown that personality traits like aggression are significantly more in men who attempt suicide.[30]

The strengths of this study include a systematic assessment of gender and its association with sociodemographic and clinical factors in individuals with recent suicide attempts in a real-world clinical service setting in Southern Indian metropolitan city. Limitations include retrospective design and setting of the study. The study findings might not be generalizable to other community settings.


  Conclusions Top


This study shows that there were significant differences between men and women who attempt suicide with respect to marital status, mode of attempt, and presence of psychiatric diagnosis. Men were more likely to be diagnosed with a psychiatric disorder. We infer that mental health evaluations in individuals with recent suicide attempts should not be limited to the identification of a psychiatric diagnosis. Such mental health evaluations could miss identifying other risk factors that are not included in diagnostic criteria but could be targeted for specific interventions. This could also lead to gender bias and suboptimal mental health treatments in individuals without a psychiatric diagnosis. We recommend that suicide prevention services in India actively collect and analyze data on gender-related variables in PSA and incorporate the same while planning mental health treatment.

Acknowledgments

No financial conflicts of interest for any of the authors are reported for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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