CHAPTER I

INTRODUCTION

Sulc~de I . a global tragedy. takrng at least 5,00,000 lives every year.

Lstimates run cvcn to 1 2 mill~on. because many cases go underreported due to the

associated stlglna S~ l~c lde 1s a problem both in the highly industr~alized aftluent

societies of developed countries and in the poorer developing countries, some of

these ranking high 111 respect of' s~iiclde rates. i t occurs among all groups and all

soclal classes. Although there arc large lntemational variations in suicide mortality,

the global plcrure lor the last feu decades has been one of rising trends. This has

been particularly noted among the younger age groups, even though the highest rates

are still found among rhe elderly (M.110. 1968) As a rcsult in a majority of countries,

suicide has now come to rank among the top ten causes of death for individuals of all

ages and among the three leading causes of death for adolescents and young adults. In

many countries such as Australia, l-fungary, Japan, Netherlands and Sweden, deaths

due to suicide are even more than those due to road accidents. But the problem of

suicide has not recelvcd adequate attention anywhere.

Su~cide behaviour statistics show that besides the rising number of suicides,

at least twentb as Inany make one-fatal suicide attempts serious enough to require

medical attent~on oAen resulting in irreversible disability. In many countries,

suicide attenipts conir~hute to tlie major emergency hospital admissions of young

people, putt~ng a heavy burden on their health care system. Moreover, they may also

form a pool tiom u i l~ch Inany future suicides may emerge.

In add~tion to the many m~llions who, for reasons of social and emotional

sufferinf, and lash ot' hope. connnit or attempt suicide, there are ~nnurnerable others,

such as fam~ly members, *lends. colleagues and care-givers, whose lives are

profoundly affected ( i ~ ~ e n that for cvery suicide and suicide attempt there are at least

five persons cmmed~ately related to the individual, then each year many million

survivors are added lo tlie tens of millions of persons already struggling, often for

many years, to cope w t h the impact of a suicide tragedy. Considering the service cost

for those exhibiting s u ~ c ~ d a l behaviour, it has been estimated that the global level of

economlc loss form su~cidal behavior amounts to about 2.5 percent of the total

economic burden duc to d~sease (Sathyavathi, 1991).

1.01 Context of the Study

Of the 1000 people killing themselves every day in the world, 100 belong to

the Indian subcont~nent Suicide IS now among the top ten causes of death in the

country, it being the cighth in America. Among those aged between 16 and 53,

su~clde is among tlie l~rs t three reasons for mortality. In India, suicide is on the rise

day by day, estimated to be one in every seven minutes. India ranks tenth in the

world with the IC)C)7 estimates of 9.1 su~cide per 10,00,000 population durirlg the last

few years (Times ot. India. 1998). 'The incidence is higher in the states of Kerala,

'Thripura, West t3engal. l'arnil Nadu. while it is lower in Jammu and Kashmir,

Manipur. Nagaland and Kajasthan Among the cities of India, Bangalore has highest

incidence (Sa th \a \a~l l~ . 1991 ).

Kerala stands first in surcide rates among all the states of India (Sathyavathi

1991) w ~ t h a figure of17 3 per Iakh ofpopulation, wh~ le Rihar is at the bottom. There

has been cons~derable increase in the rate of su~cide in the state of Kerala, the

estimates ibr 1997 herng 27 suicrdes in a population of 10,00,000, a rate almost three

times higher than thc national average. Completed suicide M > F (3:l) and attempt

suicide F , M (4: I )

The actual rate is likely to be higher as there is often under-reporting due to

various social reasons. Suicide is underrep.orted in part because of the stigma attached

to it and because deaths fiom self-destructive behaviour, such as accidents,

alcoholis~n and medical non-compliance , are not counted as suicide deaths. The

statistics that we have relate to thc number of people who actually succeed in their

suic~dal attempts I t appears ihat in Kerala, on an average, 135 to 217 people per

hundred thousand population make an attempt on their lives every year, ie. ,

approximately 30.000 to 60,000 individuals in a year (Sathyavathi, 1996).

Morc than .iOuio of those \\lie commit suicide see their physicians within a

month before the~r death and man\ communicate their suicidal intent. Hence, the role

of the Clin~cal Psvchologist is crucial in suicide prevention.

S u ~ c ~ d c attempt by a loved one is "one of life's universal crisis". Mental health

professionals espec~allv Clinical Psycholog~sts, can assist people in their crisis as

many of' 1t5 clernents are painful and hard to face. It is not only the persons who

attempt s u ~ c ~ d c but also their fam~ly members who have to bear the pain and shame

of the act hecause of the soc~al stigma attached to suicidal behaviour. A collective

effort of the comniunlty is necessanJ to improve the situation.

Su~c~dolog> IS a multi-profess~onal discipline devoted to the study of suicidal

phenomenon and its prevention. According to Goldenson (1984), the major group

concerned with s u ~ c ~ d e comprises Epidemiologists, Statisticians, Sociologists,

Clinicians, I'sychiatrists, Clinical Psychologists, Psychiatric Social workers and

educators (health educators in schoclls and colleges). .

Suic~de has cultural, Philosophical, religious, sociological, Psychological and

physical aspects. Su~cidal ideation or intention to commit suicide can be detected and

these aspects havc to be considered in planning the prevention. The practising

clinician rel~es on a comprehensive clinical review of the patient and his

situation, which includes demographic and social profiles, physical and mental

states, past histor\ and farnil! history. suicidal behaviour, and current social and

interpersonal s~tuation. lor evaluation of risk.

S L I I C I ~ C rate increases as people grow older Adolescent suicide is on the rlse,

above 45 years ol'age. there is lower risk. Male to female ratio for completed suicide

is 3 : I Studies suggest that males have appreciably higher risk than females, and

those in the older age group habe h~gher risk than younger patrents (Sathyavathi,

1973) In re\pect ol marital status. \eparated people have the h~gher r ~ s k , followed by

the divorced. widowed. single than married, especially more with teenage marriage.

Several other r~sli factors have heen studied in relation to suicide, (Sainbur et al

1980), poor iilterpersonal relationship (Faweett 1968), low socio-economic status,

poor physical and mental health, family history of suicide, previous suicide attempt,

(Cohen et al 1994). affective disorders, schizophrenia, neurosis, personality disorders

(Miles 1977. Iieard 1994); generally 40% suicides are due to alcoholism, (Roy,

1989). Mass media play an important role in suicide, (Roy 1988). Available research

reports are not commensurate with the magnitude of suicide in the country.

Most studies are retrospective and epidemiological in nature and there

is oversimpl~ficat~on of the causes of suicide. Suicidologists opine that, for suicide i

to occur it is necessary for a number of etiological variables to operate

simultaneously. It is interact~ve pattern between the individual and his

environment which is the critical variable leading to suicide rather than a single

condition. In vlc\\ of the lirnitat1,)ns of the studies reviewed and variations in the

reports, there I S a great need felt for well-designed, multicentric studies with

persistent attention on attempted su~cide and suicidal ideation in the Indian context.

Keeping in new the diversity of the socio-cultural background of Indians, and the

uniqueness o t Kcrala with its high i~teracy, high health indices, high suicidal rate and

low per caplta income. it is worthwhile to study the etiological factors in Kerala

which can alrnost he labelled the 'state of suicide" as per the present reports. The

Indian stud~es ava~lable are from states other than Kerala. Therefore, an in-depth

study is planned to explore the Psychological and Sociological factors underlying

suicidal behaviour and to develop tools which inay be helpful in identifying and

assist~ng those reclulrlng help. "This \vould not only pave the way for theory-building,

which is culture-spec~tic, but also tor rendering appropriate service to the suicide

attempters and those \+~ th suicidal Ideation by way of crisis intervention.

1.02 Need and Significance of the Study

In \ leu of the various limitations of the studies reported so far,

there IS great need for well-designed, in-depth studies with persistent attention

on the persons who had attempted suicides and their families, to enable the

researchers to get a better understanding of the phenomenon of suicide atte_mpts

In the contemporap Indian set u p , this would not only pave the way for

theory - hullding \ \ l l~c . l i is cilIti.ire-specific, but also for developing crisis

intervention service ti)r the suiclde attempters and their anxious relatives.

The inental llealth profess~otials focus attention on factors like stressful life

events. family Interaction pattern. coping pattem, social support systems and other

socio-cultural i5cror-s. \~Iiich contnhute to suicidal behaviour. As such problems are

on the increase in Kerala, it 1s necessary that studies be conducted from the

psycholog~cal point O I \ i t . \ + .

In most studlcs. only a few psycho-social risk factors are considered and there

is over-s1mpl11'1cation about the cause of suicide . The present study gives more

emphasis to psychological rather than socio-cultural variables. The suicidologist

labelled Kerala has thc highest suic~de rate in India for the last three decades. The

professionals and non-professionals in Kerala need to understand the risk-factors in

suicidal beha\lour. 111 order to be able to plan prevention strategies. No

comprehensive stud! ol. the various etiological factors involved is available

to provide the inti~rmation. Therefore, for the present investigation, many aspects

have been included. llke demographic and social profile. health, social activity,

psycholog~cal status and resources l'he various factors influencing suicidal behaviour

can then be understood and appropriate manpower can be developed. Since

no module is as yet a~allable to train helping professionals, it is important to

develop one l l i e in-depth inierviews with the attempters provide valuable

information which can be utilized for providing guidelines to train the professionals.

1.03 Statement of the Problem

'The prcsenr study aims at identifying the various factors likely to contribute to

attempted suicide and suicidal idealon The study is entitled "Aetiological Factors in

Suicidal Uehav~our'

1.04 Defining of Terms

The terms used in the statement of the present problem are defined below:-

Aetiology 1s the study or theory of the factors that cause diseases and the

method of their introduction to the host. the cause or origin of diseases or disorders

(Derlands, 1994). In the context of the present study, aetiological factors mean

psychological and soc~o-demographic factors leading to suicidal behaviour.

1.04.02 Suicidal Behavior (SH)

Thc generic lerin "suic~dal behavior" includes completed suicide,

nonfatal deliberate self-harm (for example suicide attempt, suicide gestures,

self-injury, sell-po~soning) with or without suicidal intent, suicide commynications

~nciuding suicide threats: and suicide ideation (Donald 1989). Three

broad categories of'suic~dal behaviour are: ( I ) completed suicide, including all deaths

in \vhich a \ v ~ l l u l . selll~nllicted, life-threatening act has resulted in death, (2) suicidal

attempt and (3 ) s~~lcldal ideation "Suicidal behavior" in the present study is limited to

attempted suic~dc and suicidal ldeat~on.

1.04.03 Suicidal Attempt (SA)

'.Sulc~dal attempt IS any act of self-injury consciously aiming at self-

destruction-.. (Stengel and Cook 1958) Suiclde attempt includes those situations in

which a person has performed an actual or seeming life-threatening behaviour with

the intent ot'leopardizlng his lifel or giving the appearance of such an intent, but

which has not resulted in death.

Sulc~dal attempt In the present study, refers to a non-fatal act by the

individual hlmself. carried out with the knowledge that it is potentially dangerous to

himself, as reported by the casualty medical of icer who attended to the immediate

medical management.

1.04.04 Suicidal Ideation (SI)

Suicldal ldeatlon 1s the frequent, intense, or prolonged thought of those

who have not attempted sulclde eper, but only nourished the tdea of surclde

(Goldenson. 1984)

111 rile prc~eiit study. L I I I ' is rakei~ as reported by Clinical Psychologists,

I'sychiatris~s. C'ouiiscllors or Mental health professionals from counselling, de-

add1ct1011 aiid ('ancer centers

1.05 Objectives

I he ohlcctives of the present study are d ~ v ~ d e d into two categories as

psycholoplc'il tdctor\ dnd soclo-dcmdgraph~c factors

I tic tollowing are the objectives of the psychological and soc~o-

demographic r ~ s k i'ac~ors in the present investigations.

I. Ps,.cltological risk facton

1 To stud) thc ~ntluence of ~~sychological risk factor, such as presuinptlve

stressful lit2 events, contributing to suicidal behaviour.

2 To stud) the influence of psychological nsk factors, such as soclal support,

contributing to suicidal behaviour

3. To study the influence of psychological risk factors, such as family

interaction pattern, contributing to suicidal behaviour.

4. -1.0 study the ~nfluence of psychological risk factors, such as independence of

famil) Ilfe. tamily cohesion, achievement, intelligence, family's conflict,

soc~al interactton, inoral behaviour, family discipline, contributing to suicide

beha lour

5. To stud) the influence of psychological r~sk factors, such as coplng pattern,

contrlbut~ng to iuic~dal behaviour

1 . 'To study thc influence of socio-demographic variables, such as age, sex,

relig~on. community, education. marital status, family types, place of

residcncc. occupational status, income, present living arrangement, family

size contributing to suic~dai behaviour

2. To study the influence of socio-demographic variables, such as illness,

durat~on 01' ~llness, famil) history, past history, number of suicidal attempts

contr~but~ng ro suicidal behaviour.

The prexnt ~nvest~gat~on 1s based on the assumpt~on that some of the psycho-

social and soc~o-demographic risk factors contribute to suicidal behaviour. The

assumption led to the formulation of the major hypothesis in the present study.

The hypothesis for the present investigation are listed below in &o section:

I Psychological Variables

1. There will be no significant difference among the study groups with respect to

psychological risk factors such as social support, presumptive stressful life

events, family interaction pattern, cohesion, achievement, intellectual

orientation, conflict, social mteraction, moral emphasis, discipline and coping

pattern on sulcidal behaviour.

I I Socio-demogruphic Variables

1 . There will he no significant difference among the study groups with respect to

socio-demographic variables such as age, sex, education, occupation, religion,

and communitv on suicide behaviour.

7 - . 'iherc h i l l hc no significant difference among the study groups with respect to

socio-dcmoqraph~c .. variables such as marital status, family types, place of

restdencc. present arrangement and family size on suicidal behavior.

3. There w111 be no significant difference among the study groups with respect to

socio-dcmo~raphic variables such as duration of illness, chronic illness, family

history and past history on su~cidal behaviour.

1.07 Methodology in brief

To establish the above hypothesis, an exploratory study was conducted on a

sample of 300 subjects in the age range of 13-59 years, 105 males and 195 females.

100 patients from General hospitals and Medical College hospitals reported by the

casuality medical otf'lcer to have anempted suicide, 100 subjects from mental health

centers, suicide prevention clinics, counseling centers with suicidal ideation, and 100

controls from general population formed the three main groups for the study.

The following tools were used for thts research.

1 . Personal Data Form (Prepared by the researcher)

2. Fam~ly lnteraction Scale (Asha, 1987)

3. Presumptive stressful life events scale, (Sing et al, 1987)

4. Measurement of social support scale (Mehra, 1989)

5. Coping check list, (Rao & Prabhu, 1989)

I'at~ents under treatment h r suicidal attempt were interviewed after the

critical per~od After- establishing a rapport with the patients and family members, the

tools were admintstered to the patlents in the ward setting The clients chosen from

the non-casualty scrrlngs, with suicidal ideation, were seen at the respective center

and tools were applied personally The control group was chosen, from the same

settings wlic'rc the attempters \\ere chosen but with no suicidal behaviour. After

explaining the research objectives, the investigator conducted personal interviews

using the same tools. in addition, information-providing documents like hosp~ral

records were also consulted.

Data were analyzed using stat~stical package for social sciences (SPSS). For

categorical \'ariables, the odds ratios and their 95% confidence interval were

calculated, the continuous variables were analyzed using one-way analysis of

variance followed by Duncan's ~nultiple range test.

1.08 Scope of the Study

Every year there is an increase in the number of cases of para-suicide brought

to the hospitals. even though there is a stigma attached to suicide. Efforts at research

would definitely pave the way for possible suicide preventive strategies.

From t h ~ s research investigation suicidologists may get an insight into the

planning of their activities, viz.. ( 1 ) prevention of suicide or suicidal behavior, (2)

Intervcnt~oli i n dl~c'rnpcd su~cidc. Lase\. and (3) postvention of the survivors of the

bereaved fanil I \

These findings help in understanding the magnitude of the problem of risk

factors, especlall\ psychological characteristics, and prevention strategies can be

developed. and auarencss programmes can be conducted fbr the potential groups.

These in-depth s tud~cs help in-ser\ Ice planning by mental health professionals in

Kerala settings. and these training modules can help to prevent suicidal behaviour.

1.09 Oragnization of the Report

'The report has been dev~deil Into six chapters. 'The problem for the present

research work the nlajor hypotheses and methodology are presented in brief in

chapter I . Theoret~cal aspects, risk factors, assessment and treatment are discussed in

chapter 11. Review of related studies has been presented in chapter 111. The details of

. methodology along with steps of investigation constitute chapter IV. The relevant

data analys~s and interpretations of the findings are the content of chapter V.

Summary adconcluslon are included in chapter VI.