Paroxysmal nocturnal hemoglobinuria : (a report of 20 cases).
Suicide and suicidal behaviour are important community health problems.  The incidence of suicide is about 10 to 40 per 1,00,000 per year. The incidence of suicidal behaviour is about 8 to 10 times that of suicide. Suicidal behaviour constitutes a significant proportion of the case load in the public hospital. In a large public hospital, about 1% of the total admissions in a year were for attempting suicide. The number of the patients admitted for suicidal behaviour was only slightly less than the total number of admissions for rest of the psychiatric illnesses. About 10% of the psychiatric patients are those referred for suicidal behaviour? There is an increasing concern about prevention of suicide-a personal and social tragedy. The identification of the profile of the potential suicidee is an important aspect of prevention of suicide. The study of suicidal behaviour is helpful in this direction as 10% of them are eventually successful in committing suicide and 60% of the suicidees have previous suicidal attempts. Psychiatric evaluation and management of the suicidal behaviour and understanding their appeal for help is thus a pragmatic approach in the prevention of suicide.
And hence, this prospective study was undertaken to evaluate the demographic and social aspects of persons displaying suicidal behaviour.
All the patients admitted in the K.E.M. Hospital, for suspected suicidal behaviour or poisoning over the period of one year (From January 1968 to December 1968), were included in the study. The information was collected as soon as possible, even during the times of crisis. A resident doctor and a psychiatric social worker went round the hospital everyday. The information was collected from the patients and one or more relatives over a period of several interviews and a specially designed proforma was filled up. Psychiatric examination was done by the consultant psychiatrists. The patients were transferred to the psychiatric ward whenever they had suicidal intention, required observation and for treatments of psychiatric disorder. Psychological tests were carried out whenever required. Every case was discussed in detail at a clinical conference and a decision was taken regarding the behaviour being suicidal or non-suicidal. The demographic and social findings are reported here.
Six hundred and forty six patients were admitted for poisoning in one year. Twenty patients died; in 105 patients it was thought that the behaviour could be accidental. The data from 521 patients (316 male and 205 females) who were diagnosed as having "suicidal behaviour" is reported in this paper.
Only 49% of the patients and the relatives admitted of suicidal behaviour at the first interview. 33.4% accepted it later. However inspite of efforts, 8.1% persisted in denying though clinically it was clearly a suicidal behaviour. Apart from this, 9.4% of the patients- denied after having accepted initially.
The incidence was higher in the 16-30 year age group [Table 1]. It was more common in the young female and elderly male patients. The incidence was higher in Christian and Muslim females than in the males. The incidence was higher in the migrant males from U.P. than in the females, and in the migrant females from Andhra Pradesh. There was a higher incidence of suicidal behaviour in the educated male patients [Table 2]. The incidence was more in the unemployed, white collar and professional male workers. It was more in the unmarried males (63.6%) and married females (62%) [Table 3]. 62% patients had per capita in come of less than Rs. 25 p.m., 36.7% patients had between Rs. 25-100 p.m. and only 1% of the patients had per capita income of more than Rs. 200 p.m.
30.3% of the suicidees were eldest children and only 17.7% were the youngest. 33.8% of the patients had neurotic traits in childhood. Childhood environment was unfavourable in 73.3% of the patients. 38% of suicidees were victims of faulty parental attitudes. 57% of suicidees belonged to the unitary families while 40% belonged to joint families.
19% patients had interpersonal difficulties with siblings, 4.6% with parents and 3.6% with children. 35% of the suicidees had moderate to severe marital stress. Significant financial stress was present in 59% of the patients though it was a precipitating factor only in 10% of the patients. Significant precipitating factors were found in 67% of suicidees, 62% in males and 74% in females, indicating a high sensitivity of females to the environmental factors. Strained, interpersonal relationship, unemployment, financial stress, physical illness, failure in love and failure in examination were the common precipitating factors.
In this study, 8.1% patients persistently denied though clinically it was clearly a suicidal attempt. Apart from this, 9.4% of suicidees denied after having accepted initially their suicidal intention. Suicidal intention is denied in order to escape the legal action and to avoid social stigma.
Lal and Sethi9 had observed that suicidal attempts by poisoning constituted 1.67% of total hospital admissions. In this study, suicidal attempts constituted about 1% of total hospital admissions.
The incidence was maximum (46.4%) in the 21-30 year age group. 85.4% of the attempters were under 30 years of age. In India, Venkoba Rao, Lal and Sethi, Sethi et al and Badrinarayanl have observed similar figures about 80% of the attempters were under 30 years of age. However, Weissman in his review of literature observed that in western countries about 50% of the attempters were under 30 years of age. Wexler et al have observed increasing suicidal behaviour in adolescents over the years. In our study also 39% of the patients belonged to 10-20 year age group.
The ratio of male to female attempters is reported as from 1: 3 to 1:1.3 from western countries. However in our study, males outnumbered females (MY = 3:2). Similar findings were reported by Venkoba Rao M: F - 1: 0.93), and Sethi et al (M: F = 3:2). Venkoba Rao attributes the male preponderence to increased incidence of depression in Indian males. In our study, both males and females were almost equally literate and only 18% were illiterate. However, Lal and Sethi9 observed that 57.3% of males had at least secondary education while only 11.3% females had secondary education. In their study, 19.1% males and 72.8% females were either illiterate or just literate. The higher incidence was observed in unemployed, business, white collar and professional groups. Weissman has observed similar distribution. However in the series of Lal and Sethi, only 4.5% were unemployed as opposed to 25.4% in this series.
The suicidal attempt was more common in unmarried males and married females. Unmarried males are prone to many psychiatric illnesses while married females have adjustment difficulties with the in-laws.
In India, the eldest child has to shoulder many of the family responsibilities, which he may not be able to cope up. Like other psychiatric illnesses, the incidence of suicidal behaviour is higher in the eldest child.
It appears that family system per se, i.e. unitary or joint does not act as precipitator or protector of suicidal behaviour. A similar incidence of unitary and joint family systems was observed in depression-58% unitary-42%, joint; in epilepsy 80% unitary, 20% joint; and diabetes mellitus 56% unitary, 44% joint. However in schizophrenia the incidence of unitary family was only 37% and that of joint family was 63%. The study of family dynamics demonstrated that poor interpersonal integration acts as a precipitator of suicidal behaviour.
Weissman and Sethi et al also have observed the role of disturbed interpersonal relations, marital distress, unemployment, financial stress and physical illness in precipitating suicidal behaviour. According to Durkheim's criteria, suicidal behaviour because of poor interpersonal relationships can be regarded as egoitic suicidal attempt and that resulting from unemployment, financial stress and physical illness can be regarded as anomic suicidal attempt.
It appears that a combination of vulnerability and psychosocial stress results into suicidal behaviour.