Medical students' attitude toward suicide attempters.

BACKGROUND: Majority of health professionals have unfavorable attitudes toward the patients presenting with self-harm, which further compromises their therapeutic endeavors and outcomes.
OBJECTIVES: This study was aimed to assess the medical students' attitudes toward suicide attempters.
MATERIALS AND METHODS: A cross-sectional study was conducted in a tertiary care medical institute of Haryana, a Northern state of India. Two hundred and five final year medical students were recruited through total enumeration method. "Suicide Opinion Questionnaire" was administered to assess their attitudes toward suicide attempters.
RESULTS: Only minority had previous exposure of managing any suicidal patient and attended suicide prevention programs. Majority agreed for suicide attempters being lonely and depressed. Nearly half of the students reported small family, disturbed interpersonal relationship, weak personality, self-punishment approach, cultural inhibitions in emotional expression, national instability, and disbelief in afterlife, as a major push to attempt suicide. Compared to boys, girls reported the greater contribution of weak personality and self-destructive behaviors and lesser contribution of family disturbances and religious convictions as suicide triggers. They held favorable attitude for only one-third of the attitudinal statement, and they were uncertain for two-third of the attitudinal statements.
CONCLUSIONS: Such a high proportion of uncertain responses imply toward lack of awareness and clinical expertise for managing suicide attempters. It also signifies the urgent need for enhancing their educational and clinical exposure, to improve their attitudes toward patients presenting with self-harm.

Suicide represents a major public health problem worldwide and commonly defined as “an act of self-destruction, initiated and committed by a person fully aware of the fatal outcome.”[1] It has substantial socioeconomic and cultural influences.[2] The current suicide rate in India is 10.6/100,000 population.[3]

Suicide attempters pose considerable strain on attending medical and nursing professionals and subsequently their attitudes toward this population, which is a key element for explaining and predicting human behavior, directly affects the quality of care.[4] Doctors play an active part in the treatment and prevention of patients with suicide attempts, and their therapeutic endeavors may interrupt ongoing suicidal process.[5]

Medical students are a vital resource for future medical practices. Therefore, studying their attitudes toward suicide attempters is of great significance for understanding and addressing the health needs of these budding health professionals. There are several studies from the different parts of the world[1678910111213] but only one from India.[2] This literature gap has impelled us to study the medical students' attitudes toward suicide attempters.

MATERIALS AND METHODS

This study was approved by the college authorities. Final year medical students pursuing MBBS course were recruited from Postgraduate Institute of Medical Science, Rohtak, Haryana. Total enumeration method was employed, in which all the present final year MBBS students were recruited to provide a complete statistical coverage. Sociodemographic pro forma and Suicide Opinion Questionnaire (SOQ)[1415] were distributed in their classroom setting. Students were explained about the study aim and implications. Their doubts were clarified and subsequently written informed consent was taken from all the participants. The questionnaire was filled anonymously in nearly 30 min.

Following instruments were administered: Sociodemographic pro forma was used to assess their demographic profile and information about their experience of managing patients with suicide attempts and participation in suicide prevention workshops.

SOQ is a self-rated, 52-item, Likert scale which measures suicide attitude on the basis of following factors: acceptability, perceived factual knowledge, social disintegration, personal defects, and emotional perturbation.[1415] Its psychometric properties have been established,[14161718] and it has been widely used.[192021222324]

Statistical analysis

SPSS version 14.0 for Windows (Chicago, IL) was used. Frequencies with percentages were calculated for categorical variables, and mean and standard deviation were calculated for continuous variables. Comparisons were made by Chi-square test for categorical variables and t-test for continuous variables.

Attitude on individual item was scored on a five-point Likert scale: 1 - “strongly agree,” 2 - “agree,” 3 - “don't know,” 4 - “disagree,” and 5 - “strongly disagree.” Mean attitude values were categorized into “favorable,” “unfavorable,” and “uncertain.” Attitude scores between 1 and 2.4 were considered “favorable attitude” or “positive disposition,” between 2.5 and 3.4 “uncertain attitude” or “unsure,” and 3.5 and above “unfavorable attitude” or “negative disposition.”[21] The descriptors were reversed for negatively-worded items.[21]

RESULTS

Sociodemographic profile

As shown in Table 1, total sample consists of 205 final year medical students, pursuing MBBS course. All were single and males were slightly over numbered than females. Majority were Hindus, from urban locality and nuclear family, with the mean age of 21.9 years (range 19–26 years). Only minority of students have attended workshops or lectures on the management of patients with suicide attempts and actually managed such patients.

Table 1

Sociodemographic profile

Attitude toward suicide attempters (items mentioned in Table 2)

Attitude scores were derived for individual items and were categorized into three categories: “favorable attitude,” “uncertain attitude,” and “unfavorable attitude.” They had favorable attitude for one-third of attitudinal items (18 statements). Students had uncertain responses for the remaining two-third of attitudinal statements (34 items). Thus, overall their attitude toward suicide attempters remained predominantly uncertain.

They had a positive disposition by agreeing the following eight direct statements: majority of suicide attempters were lonely and depressed; I would be ashamed if a member of my family committed suicide; most suicide attempts were impulsive in nature; unreturned love was a main content in suicide notes; suicide rates were going to reduce substantially on allowing them for emotional expression; alcoholism and other self-destructive behaviors were different forms of unconscious suicide attempts; suicide attempters were cowards; and depressed individuals were more commonly attempting suicide and by disagreeing the following ten negatively-worded items: Suicide was an acceptable measure to end an incurable illness as well as for aged and infirm persons; most of suicide victims were older with little to live for; possibility of suicide attempts was greater in older than younger population; suicide was the only reasonable solution in certain situations; suicide was a normal behavior; if anyone wanted to attempt suicide, one should not be interfered; suicide clinics should be established where interested individuals could die in a painless and private manner; suicide would occur only in civilized societies; some people were better off dead.

Opinion related to characteristics of suicidal patients

Majority of the students agreed for suicide attempters being lonely and depressed. Nearly half of the students reported small family, disturbed interpersonal relationship, weak personality, cultural inhibitions in emotional expression, national instability, and disbelief in afterlife, as a major push to attempt suicide. Nearly half were agreed that most of the suicidal people will not reveal their suicidal plans to others. One-third of the students considered unemployment and poverty as a main cause of suicide and were quite hopeless about those factors.

Opinion related to suicide prevention measures

More than half of the students agreed for their responsibility for suicide prevention. Nearly half of the students considered it rewarding in working with suicidal patients, whereas other half were not comfortable in assessing suicidal patients (girls >boys). Only minority of the students were defensive about suicide prevention and considered suicide management efforts as waste of resources and time.

Relationship between respondents' characteristics and attitude

Gender

Compared to females, males had more favorable attitude for following 14 items: Most suicide attempters were lonely and depressed (1.56 ± 0.74 vs. 1.79 ± 0.67, t = −2.28*1); most suicides were triggered by arguments with a spouse (2.50 ± 0.77 vs. 2.97 ± 2.13, t = −2.17*); higher suicide rates were due to lesser religiosity (3.05 ± 1.09 vs. 3.37 ± 0.82, t = −2.37*); I would have been ashamed if a member of my family committed suicide (2.16 ± 1.04 vs. 2.69 ± 1.08, t = −3.55***2); suicide attempter would remain suicidal forever (3.18 ± 1.03 vs. 3.51 ± 0.81, t = −2.50*); suicide survivors were having minimal probability for subsequent suicide attempts (3.26 ± 1.07 vs. 3.67 ± 0.78, t = −3.06**3); suicide represents a normal behavior (3.97 ± 1.07 vs. 3.67 ± 0.78, t = −3.27**); suicide remains a natural mean to eliminate mentally unfit (3.24 ± 1.23 vs. 3.72 ± 0.98, t = −3.04**); suicide attempters used to have weaker religious convictions (2.96 ± 0.99 vs. 3.21 ± 0.71, t = −2.01*); passive suicide was more acceptable than violent suicide (2.94 ± 1.01 vs. 3.23 ± 1.04, t = −2.06*); suicide used to occur only in civilized societies (3.51 ± 1.06 vs. 3.79 ± 0.78, t = −2.06*); mostly atheist would commit suicide (3.22 ± 1.01 vs. 3.60 ± 0.96, t = −2.73**); children from larger families would have lesser risk of suicide (2.62 ± 1.13 vs. 2.96 ± 0.92, t = −2.29*); and suicide attempters used to be less religious people (3.13 ± 0.93 vs. 3.46 ± 0.74, t = −2.77**). Compared to boys, girls reported the greater contribution of weak personality and self-destructive behaviors and lesser contribution of family disturbances and religious convictions as suicide triggers.

Religion

Students of Hindu religion had more favorable attitude for two attitudinal items compared to students of other religions: some people used to commit suicide for self-punishment (2.58 ± 0.92 vs. 3.44 ± 0.72, t = −2.76**); and suicide attempter would remain suicidal forever (3.30 ± 0.95 vs. 4.0 ± 0.70, t = −2.17*).

Locality

Compared to students from urban locality, students from rural locality had more favorable attitude for four attitudinal items: most suicides were triggered by arguments with a spouse (2.91 ± 1.91 vs. 2.43 ± 0.76, t = 2.18*); I would be ashamed if a member of my family committed suicide (2.57 ± 1.13 vs. 2.17 ± 0.99, t = 2.63**); suicide used to happen without warning (2.99 ± 1.04 vs. 2.62 ± 1.14, t = 2.42*); and suicide rates were a good indicators of the stability of a nation (3.20 ± 1.19 vs. 2.81 ± 1.09, t = 2.37*).

DISCUSSION

Medical students reflect a group of future gatekeepers, insofar as they will be concerned with suicidal patients in their professional life.[2] Many studies have also shown that negative attitudes toward suicide prevail among medical students[910] although for some these attitudes may change over the years of medical training.[8] In this regard, Indian data are grossly lacking,[2] to fill this research gap, index study was conceptualized to study final year medical students' attitudes toward suicide attempters.

Attitudes of medical professionals toward suicide not only influence their motivation to treat patients in suicidal crises[25] but also their approach at times of personal crises as due to job complexity they themselves have high risk of depression[26] and suicide.[27]

Suicide attempters' psychological assessment is recommended as comprehensive care, but many patients are usually not assessed.[2829] However, when assessed, the majority of patients perceived it superficial and rushed.[30] In real world practice doctors', unfavorable attitudes toward suicide attempters have been reported with favorable attitudes among older and experienced doctors.[12]

Common suicide triggers were reported somewhat similar to earlier studies[2231] such as disturbed interpersonal relationship, small family, weak personality, cultural inhibitions in emotional expression, and national instability. Again in line with earlier studies,[89] nearly half of our participants opined for the common association of mental illness and broken homes with suicide attempters.

Our participants held predominantly uncertain attitude toward patients presenting with self-harm, whereas other studies on health professionals reported favorable[3233] or unfavorable attitude[34] more commonly. It points toward their lack of awareness, education, and experience of managing patients with self-harm.

Earlier studies[51935] reported more positive attitude in female health professionals, whereas index study found more favorable attitude in males. Suicide was considered as an impulsive behavior in index as well as earlier study.[36]

In earlier studies, greater professional experience was found to be associated with improvements in attitude in psychiatric setting,[53738] but not in general hospital setting.[3539] Greater education was more consistently associated with positive attitudes.[4041] Our mean attitude scores were similar to other study,[31] but we could not find any of such association as our participants were nearly of same age, with limited clinical experience and minority has attended any workshop/lecture on suicide prevention.

Cultural factors play a significant role in individual's suicidal behavior and in attitudes toward suicide attempters as shown among Indian and Austrian,[2] Austrian and Turkish, and[11] Japanese and American medical students.[7] The only Indian study reported very restrictive attitude of medical students in Madras (India), whereas more permissive attitude toward suicide was found in Vienna (Austria).[2]

Index study has several limitations: findings cannot be generalized as the sample was drawn only from a medical institution of Northern India, SOQ is not validated for the Indian population, and we could not collect information about respondents' personal or family history of any suicidal idea or acts. Minority of the students have attended awareness lectures and educational sessions on the management of suicide attempters and they also had limited experience of managing this population; thus, we could not establish any association between the knowledge and expertise with their attitudes.

However, with these limitations, the study leads to the following conclusions: small family, disturbed interpersonal relationship, weak personality, cultural inhibitions in emotional expression, national instability, and disbelief in afterlife, were commonly considered as a major push for suicide. Only minority had previous exposure of managing any suicidal patient and attended any related educational program. Their attitude toward suicide attempters was predominantly uncertain. This imply toward the lack of knowledge and exposure for this complex public health concern and also signifies the urgent need for enhancing their educational and clinical exposure, to carve their favorable attitude toward patients presenting with self-harm.

Future studies should assess health professionals' attitude toward suicide attempters with a larger sample size in different educational, hospital, and community settings, by additionally employing qualitative methods, to examine interrelationship between professionals' attitude, demographic profile, perceived social support, coping strategies, spiritual and religious practices, personal or family history of suicidal behaviors, etc.

Since the majority of the medical students may not find psychiatry as their specialty, therefore, acquisition of appropriate attitudes toward suicidal patients among all medical students during medical training is of vital importance. Undergraduate medical school curricula provide an important platform and opportunity to equip future doctors with education and clinical skills for assessment, management, and prevention of suicide.

Medical students are future doctors, who frequently encounter suicide attempters and therefore they must be aware of their attitudes toward this group of patients as part of their professional training. Therefore, the index study has several implications for improving medical students' attitudes toward suicide attempters through awareness and educational programs for suicide risk assessment, management, and prevention of future attempts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 2

Suicide Opinion Questionnaire