Methodological considerations in studying psycho-social aspects of suicide.

Sir,

I read carefully both the article by Kumar and George[1] and their response to a letter in the current issue of this journal which focuses on the psychosocial correlates of suicide. This important issue has been largely unexplored in Indian subcontinent. The study is well conceptualized and the scales and questionnaires used are highly suitable for use in Indian population. However, I would still like to highlight few limitations of the study, which are as follows:

Universe of sample for controls is not adequately explained.

General Health Questionnaire-12[2] screens for current nonpsychotic illnesses only and not enough sensitive to detect ongoing psychotic illness. Hence, the possibility of unidentified psychotic illness and unreliable response for scales and questionnaires among a number of individuals in the control group is not ruled out. Either obtaining a detail clinical history (medical and psychiatric) and mental state examination by mental health professionals or by using screening instrument like mini-international neuropsychiatric interview.[3] Would have served the purpose adequately.

Using these scales and questionnaire 1 week immediately after an attempted suicide increases the possibility of colored responses particularly in the Social Support Questionnaire, psychological, social relationship domain of WHO-QOL Bref scale,[4] hence leading to possible false low score among suicide attempters. The possibility of false score remains high among those with adjustment disorder, depression.

The possibility of unreliable responses among subjects with ongoing psychotic illnesses like schizophrenia in all the scales cannot be ruled out completely.

These scales could have picked up reliable responses if used among those suicide attempters currently in remission for any psychiatric illness. This could be ascertained by validated instruments with cut-off scores, mental state examination and also obtaining or confirming history from a defined key informant.

History of medical comorbidity among both groups, which might produce low score on WHO-QOL Bref, also has not been ruled out.

Albert Einstein College of Medicine (AECOM) coping styles questionnaire[5] having 87 items has been wrongly quoted as “AECOM coping style scale” having 95 items.