Stressful life events, hopelessness, and suicidal intent in patients admitted with attempted suicide in a tertiary care general hospital.

BACKGROUND: Suicide is a psychiatric emergency. Stressors in life and social variables (like marital status, family, and social support) are among the determinants of suicide. Hopelessness and suicidal intent are among the psychological variables that have shown promise in the prediction of suicide. AIMS AND
OBJECTIVES: To assess stressful life events, hopelessness, suicidal intent, and sociodemographic variables in patients of attempted suicide.
MATERIALS AND METHODS: Fifty consecutive patients admitted with attempted suicide were interviewed. Presumptive Stressful Life Event Scale, Beck Hopelessness Scale, and Beck Suicidal Intent Scale were used along with a semistructured pro forma for interview. Data were analyzed with statistical tests.
RESULTS: Sixty-six percent of the participants were females, 72% were less than 30 years of age. Sixty-six percent of the patients had stressful life event score between 101 and 200 with the mean score of 127. The stressful life event score in those who considered they are in need of psychiatric help was significantly high. Most of the patients had mild (34%) and moderate (40%) degrees of hopelessness, and the mean score was 9.64. The mean suicidal intent in the participants was 25.14, when correlated with hopelessness score significant positive correlation was found.
CONCLUSION: Lethality of the attempt increases with the increase in hopelessness.

Introduction

Attempted suicide is self injury with a desire to end one's life but does not lead to death.[1] The prevalence of suicide in developing countries has been estimated to be 0.4%.[2] Large amounts of undesirable behavior results in suicidal behavior that is an expression of a specific form of vulnerability.[3] Patients with hopelessness systematically misconstrue experiences in a negative manner and tend to anticipate dire consequences for their problems.[4] The present study was carried out with the objective of evaluating stressful life events, hopelessness, suicidal intent along with sociodemographic characteristics of patients presenting with attempted suicide to a tertiary referral centre.

Methods

Ethics: The study protocol was approved by the institutional ethics committee and written, informed consent was taken from all patients. Confidentiality was maintained using unique identifiers.

Design and sample size: A cross sectional study in 50 consecutive patients with suicide attempts admitted either to the internal medicine ward or medical intensive care unit.

Selection criteria: Those above 18 years and willing to consent were included. Critically ill patients were excluded. All participants were interviewed within 48 hours of admission.

Instruments: The Presumptive Stressful Life Events Scale [PSLES], Beck's Hopelessness Scale [BHS] and Beck's Suicidal Intent Scale [BSIS] were used.

Presumptive Stressful Life Events Scale (PSLES)[5]: This scale is based on The Social Readjustment Rating Questionnaire (SRRQ) of Holmes and Rahe (1967). It is a list of 51 life events relevant to the Indian setting given a score based on the mean score of general population standardized for two time frames — Past 1 year and lifetime. The total score is used as stressful life event score.

Beck's Hopelessness Scale (BHS): It is a 20-item self-report instrument that assesses the positive and negative attitudes about the future during the past week as perceived by the patients. The total score ranges from 0 to 20 (0-3: Minimal, 4-8: Mild, 9-14: Moderate, and 15-20: Severe). The internal reliability of this scale ranges from 0.87 to 0.93.[6] One week test-retest reliability is 0.69.[6] The concurrent validity is well established across a wide variety of samples.[7]

Beck's Suicidal Intent Scale: This is an interviewer administered measure of seriousness of the intent to commit suicide among suicide attempters.[8] It contains 20 items to be scored on a 3-point Likert scale. Score is calculated from first 15 items, ranging from 0 to 30 (15-19: Low intent, 20-28: Medium intent, and 29 or more: High intent). The internal reliability of the scale is 0.95[8] while inter-rater reliability ranges from 0.81 to 0.95.[910]

Data analysis

Quantitative data were expressed using measures of central tendency and categorical data as proportions. Scores were assessed for normality using the Kolmogorov Smirnov test and non normal scores between men and women analyzed using the Mann Whitney U test. Correlation between BHS, BSIS and PSLES with the stressful life event was done using Sperman's rho. All analyses were carried out using SPSS version 11.0 and a p value of 5% was considered significant.

Results

The demographics mean age of the participants was 25.94 (±7.85) years with 72% less than 30 years of age. Majority of the participants (66%) had stressful life event score between 101 and 200, while 24% had scores less than or equal to 100 and only 10% patients had score more than 200. The mean stressful life event score for the total study population was 126.92 (±50.04). Most of the participants had mild (34%) and moderate (40%) degrees of hopelessness and few had minimal (10%) or severe (16%) degree of hopelessness. The mean score for the total study population was 9.64 (±4.33). Majority had medium suicidal intent (70%), 26% had high suicidal intent, and a very few had low suicidal intent (4%). The mean suicidal intent score in the sample population was 25.14 (±4.4).

Hopelessness and suicidal intent had significant positive correlation (Spearman's rho: 0.540, P-<0.000*); however, stressful life event had no significant correlation with either hopelessness (Spearman's rho: 0.142, P -0.326) or suicidal intent (Spearman's rho: −0.080, P -0.581).

Discussion

Majority of the participants in this study were females. Though females attempt suicide approximately three times as often as males,[11] Indian data suggest the ratio as 1:1.[12]

Maximum participants had stressful life event score between 101 and 200. The possible explanation can be as follows: Those with higher stress levels might have already sought help and prevented the event or might have adopted more lethal and planned measures so that they never reached the hospital. The participants with lesser stressful event score might have eventually coped with the situation rather than taking escape by attempting suicide.

The patients who believed they need psychiatric help had significantly higher mean stressful life event score [Table 1]. This finding supports the hypothesis that those with higher stressful event score may seek help to come out of it rather than attempt suicide. The stressful life events had no correlation to suicidal intent or hopelessness. This was similar to the study of Kar.[12] Different coping mechanisms, support system, and several other factors of the individuals result in different response and level of stress for each individual. Literature suggests that recent adverse life events contribute to the increased risk of suicide[13] and vulnerability for suicidal behavior.[3] Though stressful life events can’t be directly correlated to the occurrence of suicide attempt or suicide; social and situational factors appear to play a significant role in self-harm behavior and suicide.[14]

Table 1

Comparison of stressful life event score, hopelessness, and suicidal intent

		Stressful life event score		Hopelessness score		Suicidal intent score
		Mean	Unpaired t-test	Mean	Unpaired t-test	Mean	Unpaired t-test
Gender	Male (n = 17)	120 (±53)	P = 0.5	10 (±4)	P = 0.449	24 (±5)	P = 0.369
	Female (n = 33)	130 (±49)		9 (±4)		26 (±4)
Patient’s expected outcome of attempt	Death (n = 40)	130 (±54)	P = 0.356	11 (±4)	P = 0.003*	26 (±5)	P = 0.141
	Survival (n = 10)	114 (±29)		6 (±4)		23 (±3)
Perception of attempt as problem	Major (n = 20)	122 (±44)	P = 0.433	10 (±4)	P = 0.263	26 (±4)	P = 0.014*
	Minor (n = 30)	134 (±59)		9 (±4)		23 (±5)
Perceived need for psychiatric help	Yes (n = 30)	138 (±54)	P = 0.048*	10 (±4)	P = 0.519	25 (±4)	P = 0.938
	No (n = 20)	110 (±39)		9 (±5)		25 (±5)

There were fewer patients with severe hopelessness in this study than those with mild and moderate hopelessness. Participants who had expected themselves to die after the suicide attempt had significantly more hopelessness than those who thought they will survive after the attempt of suicide. Hopelessness prevents a person to think about future positively resulting in expecting the worse outcome and also predicts the ultimate suicide.[15]

Hopelessness and suicidal intent have a positive correlation. Hopelessness rather than depression per se is a determinant of suicidal intent[1617] and serves as the link between depression and suicide.[4]

There were a fewer patients with high suicidal intent than compared moderate suicidal intent. High suicidal intent has been associated with high lethality.[1819] The patients perceiving suicide attempt and reasons behind it as major problem had significantly higher mean suicidal intent score. This indicates that worse the perception of the situation at hand disastrous can be the consequences.

Conclusion

Stressful life event can’t predict suicide but is associated with more help-seeking behavior. Most patients of attempted suicide have moderate degree of hopelessness and medium suicidal intent. Suicidal intent increases with the increasing hopelessness. This study implies that suicide attempters should be specifically looked for hopelessness and their coping styles so as to plan appropriate psychiatric therapy to prevent future suicide attempt.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.