Methodological considerations in studying psycho-social aspects of suicide: Reply to the criticism.

Sir,

Thank you very much for your positive criticism on the article “Psychosocial correlates of attempted suicide” published in the recent issue of Indian Journal of Psychiatry. As you have rightly indicated, we have attempted to explore the psychosocial aspects of attempted suicide with special reference to our own cultural background and tried to elucidate relevant prevention strategies specific to our population. The study is well conceptualized and the scales and questionnaires used are highly suitable for use in Indian population. However, we would like to clarify the methodological flaws that you have raised in your critical appraisal, which are as follows:

Universe of sample for controls was selected from the community. Age, sex, and marital status matched individuals who are not blood related to the cases and after screening by GHQ-12[1] to rule out common mental disorders formed the control group. However, due to practical limitations, no other specific method was employed to recruit controls.

We do agree that, in screening controls, nothing would be as perfect as a detailed clinical examination by a mental health professional. But, due to time constraints and operational issues, we had to resort to a screening tool. GHQ may be poorer in picking up psychotic illness as compared with non-psychotic illness. But, it does not mean that GHQ cannot identify psychotic illness. Studies from Indian setting using GHQ-12 and, even shorter versions, have provided a reasonable yield of psychosis diagnosis.[23]

Considering the overwhelming predominance of mental illness in suicides, finding respondents with no psychiatric illness or waiting for a period until all psychiatric illness has resolved to complete the evaluations may defeat the purpose of the whole study. This would affect the generalisability of the study population. With an increasing interval after the immediate emotional crisis, there could be recall bias and minimization, especially considering the fact that a major proportion of these attempts in India are impulsive in nature. In fact, a number of studies evaluating the psychosocial aspects of suicide attempters happened in an emergency room setting in the immediate aftermath of the attempt.[45]

It seems unfair that, in patients with schizophrenia, one has to wait until their illness is in remission (which may take months or years) to do any assessment on their recent suicidal attempt. Also, in a study population including patients with personality disorders and substance use disorders, one can argue regarding the unreliability of responses for a variety of motives at various points in time after a suicide attempt. Therefore, isolating patients with psychosis in this regard does not seem appropriate.

Moreover, in this study, unreliable responses were unlikely. Inconsistencies in responses in the study subjects would have been mostly identified because a psychiatrist did the initial assessment (which included detailed history and mental status examination). In some cases (like students staying in hostels), friends or colleagues were able to give better information. Medical comorbidity has been assessed in both the groups, and no significant difference was found between them, as detailed in Table 1 of the original article. Albert Einstein College of Medicine Coping Styles Questionnaire[5] having 87 items has been wrongly quoted as ‘AECOM Coping style scale’ having 95 items.