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Alcohol Abuse/Use in Suicide Attempters: A Study in Psychiatric Out-Patient Clinic of a Teaching Hospital of Eastern Nepal

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Background: Alcohol use is common in Nepalese society. Substance use/abuse is described as one of the 3 of the deadliest combination for suicide. There is a scant data from Nepal about the relationship of alcohol with suicide. We aim to see alcohol use/ abuse in cases of suicide attempt. Methods: It is a hospital based descriptive study conducted among the cases with suicide attempt. All the patients consulting the investigating psychiatrist of a department of psychiatry of a teaching hospital in eastern Nepal within study period were enrolled after informed consent. With usual detailed work-up, suicidal state was ascertained. Relevant informations were recorded in the proforma. An intensive exploration was made in all suicide-attempt subjects into a range of alcohol use/ abuse. Alcohol use/disorder was operationally sorted out into various categories in relation to suicide attempt. Results: Out of 150 total cases of suicide attempt, 68% (102) were married and 58.7% (88) were female. Average age was 28.8 ± 12.329 years. More of the cases were from village and semi-urban settings. Some cases had used alcohol for the first time immediately prior to the attempt and some other had Alcohol dependence syndrome (ADS). A clear and possible association was seen in 56/150 (37%). Conclusion: Alcohol use/abuse is common and appears to precipitate and predispose the DSH attempt. Keywords: Alcohol use; Deliberate self harm; Alcohol use disorder; Nepal; Suicide
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Abbreviations: ADS, alcohol dependence syndrome; ARD,
alcohol related disorder; AUA, acute use of alcohol; AUD, alcohol
use disorders; BPKIHS, bp koirala institute of health sciences; DSH,
deliberate self harm; DSM, diagnostic and statistical manual of men-
tal disorders; HUA, harmful use of alcohol; ICD 10, the international
classications of diseases 10th edition; IERB, institute ethical review
board; SPSS, statistical package for social studies
Introduction
Suicide is a complex phenomenon with multi-factorial causation.1–4
Complex interplay of various psychological, social, cultural and
biological factors is implicated behind suicide and its attempt2–5 though
many of times; some particular precipitating event/factor stands out in
particular set-up and region indicating need for the identication and
some specic strategies.3 Among suicide attempters, the combination
of depression, hopelessness and substance/alcohol use/abuse has been
reported as the deadliest one as risk.5 Alcohol use/abuse is common
and suicide/attempt has been observed more among alcohol users in
Nepalese context too.6,7 Data on magnitude of alcohol use/abuse in
suicide/attempt will help guide devising needful strategies.3 There
is, however a dearth of information about alcohol use and related
disorders among suicide attempters in Nepalese setting. This study
was conducted in the department of psychiatry, B.P. Koirala Institute
of Health Sciences, Nepal in 2011 to sort out the alcohol use/ related
disorders among suicide attempters.
Methods
It is a hospital based-cross sectional descriptive study looking into
alcohol use/abuse among suicide attempters. All patients consulting
the investigating psychiatrists-team of B. P. Koirala Institute of
Health Sciences, Dharan, Nepal, within study period (12 months,
2010 October/ 2011 September) were enrolled after informed consent.
With usual detailed work-up, suicidal state was ascertained. Relevant
information’s were recorded in a predesigned proforma. An intensive
exploration was made in all the subjects into a range of alcohol use and
alcohol use disorders (ICD-10).8 Alcohol use/abuse was categorized
in relation to suicide attempt into:
a. Single and rst time use just prior to the attempt.
b. Occasional but not during attempt.
c. Occasional and also during attempt.
d. Harmful use and also during attempt.
e. Harmful use but not during the attempt.
f. Regular use/Alcohol dependence syndrome (ADS) but not
during attempt.
g. ADS and use during attempt. The information and views col-
lected from the subjects and their care takers (when the sub-
ject was not in position to respond) (through semi-qualitative
approach) regarding the role of alcohol use and disorder in
the suicide attempt were sorted out. The information was kept
condential. Ethical clearance was obtained from the Institute
Ethical Review Board of BPKIHS. Data were entered into a
computer and analyzed using ‘Statistical Package for Social
Studies’ (SPSS) - software 17.
MOJ Addict Med Ther. 2018;5(1):2529 25
© 2018 Shakya. This is an open access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and build upon your work non-commercially.
Alcohol use/abuse in suicide attempters: a study in
psychiatric out-patient clinic of a teaching hospital of
eastern Nepal
Volume 5 Issue 1 - 2018
Shakya DR
Department of Psychiatry, BP Koirala Institute of Health
Sciences, Nepal
Correspondence: Dhana Ratna Shakya, Professor, Department
of Psychiatry, BP Koirala Institute of Health Sciences, Dharan,
Ghopa-18, Sunsari, Koshi, Nepal, Tel 977-025-525555, Ext 3225,
5334, Email drdhanashakya@yahoo.com
Received: January 28, 2018 | Published: February 07, 2018
Abstract
Background: Alcohol use is common in Nepalese society. Substance use/abuse is
described as one of the 3 of the deadliest combination for suicide. There is a scant data
from Nepal about the relationship of alcohol with suicide. We aim to see alcohol use/
abuse in cases of suicide attempt.
Methods: It is a hospital based descriptive study conducted among the cases with
suicide attempt. All the patients consulting the investigating psychiatrist of a
department of psychiatry of a teaching hospital in eastern Nepal within study period
were enrolled after informed consent. With usual detailed work-up, suicidal state
was ascertained. Relevant informations were recorded in the proforma. An intensive
exploration was made in all suicide-attempt subjects into a range of alcohol use/abuse.
Alcohol use/disorder was operationally sorted out into various categories in relation
to suicide attempt.
Results: Out of 150 total cases of suicide attempt, 68% (102) were married and
58.7% (88) were female. Average age was 28.8 ±12.329 years. More of the cases were
from village and semi-urban settings. Some cases had used alcohol for the first time
immediately prior to the attempt and some other had Alcohol dependence syndrome
(ADS). A clear and possible association was seen in 56/150 (37%).
Conclusion: Alcohol use/abuse is common and appears to precipitate and predispose
the DSH attempt.
Keywords: alcohol use, deliberate self harm, alcohol use disorder, Nepal, suicide
MOJ Addiction Medicine & erapy
Research Article Open Access
Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital
of eastern Nepal 26
Copyright:
©2018 Shakya
Citation: Shakya DR. Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital of eastern Nepal. MOJ Addict Med
Ther. 2018;5(1):2529. DOI: 10.15406/mojamt.2018.05.00086
Results
a. Out of the total of 150 cases enrolled in this study; 88 were
female, with M : F ratio of 0.71: 1.
b. Average age was 28.8 ±12.329 years, with age range of 14-
81. Patients of age groups (20-29) and (<20) years constituted
the largest proportion 40.7% and 22.7%. Majority 102, 68.0%
were married; with 43, 28.7% single, 3, 2.0% widow and 1,
0.7% each divorcee and engaged. Great majority 82% were
educated to various levels (Table 1).
c. Caste/ethnicities classied as per the system of ‘Government
of Nepal, 2007 for Free Health services, District Health Ser-
vice Report 2064’ revealed: Upper Hill caste (e.g. Brahmin,
Chhetri, Thakuri, etc.), disadvantaged Hill Janajati (e.g. Ma-
gar, Rai, Tamang, Limbu, Sherpa, etc) and relatively advan-
taged Janajati (e.g. Newar, Gurung, Thakali) as the commo-
nest caste/ethnicities. Hindu cases (127, 84.7%) predominated
here; with 11, 7.3% Kirat; 6, 4.0% Buddhist; 4, 2.7% Muslim
and 2, 1.3% Christian. Half of the total 75, 50.0% were from
villages; 24, 16.0% from cities and 51, 34.0% semi-urban (Ta-
ble 2).
d. Majority of these subjects (115, 76.7%) had psychiatric disor-
der. The most common psychiatric diagnosis was depression
(unipolar mainly and some bipolar) (Table 3).
e. Consumption of poison was the most common mode (118,
75%) of suicide attempt*. Among the 118 subjects attempting
suicide by consuming poison, the commonest poison used was
Organophosphorous compounds. Two subjects had consumed
2 poisons (Table 4).
f. Many cases 71/150 had high intent and 58/150 had high le-
thality of effect of the attempt (Table 5).
g. More than half of subjects (82/150, 54.7%) reported to use
psychoactive substance, mainly alcohol (Table 6).
h. One third of the subjects 50/150, 33.3% reported to consume
alcohol immediately prior to the suicide attempt (Table 7).
i. In 56, 37.3% cases, some relationship (denite and possible)
was reported between alcohol use/abuse and suicide attempt
(Figure 1).
Table 1 Age, Marital status and Education of suicide attempt cases
Age group (yrs.) No. (%)
<20 34 (22.7)
20 - 29 61 (40.7)
30 - 39 26 (17.3)
40 - 49 18 (12.0)
≥05 11 (7.3)
Marital status
Single 43 (28.7)
Married 102 (68.0)
Separate/ divorce 1 (0.7)
Widow 3 (2.0)
Engaged 1 (0.7)
Education level
Illiterate 27 (18.0)
Age group (yrs.) No. (%)
Literate - 3 16 (10.7)
4 - 7 29 (19.3)
8 - SLC 52 (34.7)
PCL and above 26 (17.3)
Table 2 Caste/Ethnicity, Religion, Family type and Residential settings
Caste/ Ethnic groups No. (%)
Upper Hill 40 (26.7)
Upper Terai 15 (10.0)
Relatively Advantaged Janajati 16 (10.7)
Religiously Minorities/ Muslim 5 (3.3)
Disadvantaged Non-Dalit Terai 21 (14.0)
Disadvantaged Hill Janajati 39 (26.0)
Disadvantaged Terai Janajati 1 (0.7)
Hill Dalit 11 (7.3)
Terai Dalit 2 (1.3)
Religion
Hindu 127 (84.7)
Buddhist 6 (4.0)
Muslim 4 (2.7)
Christian 2 (1.3)
Kirat 11 (7.3)
Family Type
Nuclear 74 (49.3)
Joint 54 (36.0)
Broken/ Separated/ Alone/ Other 22 (14.7)
Residential Setting
Urban 24 (16.0)
Semi-Urban 51 (34.0)
Rural 75 (50.0)
Table 3 Psychiatric diagnoses*
ICD Code Psychiatric Diagnosis No. (%)
Suicide, Impulsive 35 (23.3)
Present 115 (76.7)
Physical Disease 8 (5.33)
F10-19 Psychoactive Substance Use 48 (32.00)
F20-29 Schizophrenia, Schizotypal &
Delusional 10 (6.67)
F30-39 Mood (Affective) 59 (39.33)
F30-34,38,39 Manic Episode, Bipolar Affective 1 (0.67)
Depressive Episode, Bipolar
Affective 4 (2.67)
Depressive (Including Dysthymia-
1) 54 (36.00)
Stress Related/Adjustment 17 (11.33)
Others Organic/ Mental Retardation/
Personality 16 (10.67)
*Multiple response category - One respondent may have one or more
responses.
Table Continued...
Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital
of eastern Nepal 27
Copyright:
©2018 Shakya.
Citation: Shakya DR. Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital of eastern Nepal. MOJ Addict Med
Ther. 2018;5(1):2529. DOI: 10.15406/mojamt.2018.05.00086
Table 4 Mode of Suicide attempt and Type of Poisons used*
Mode of
attempt No. (%) Mode of poisoning No. (%)
Poisoning 118 (74.55) Organophosphorous 92 (77.9)
Hanging 23 (15.33) Zinc Phosphide 15 (12.7)
Strangulation 5 (3.33) Drug Overdose 6 (5.1)
Cut/Injury 6 (4.00) Chemical 4 (3.4)
Other/Mixed 9 (6.00) Other/Mixed 3 (2.5)
Table 5 Intent and Lethality of suicide attempt
Intent of attempt No. (%) Lethality of attempt No. (%)
Low 26 (17.3) Low 38 (25.3)
Moderate 44 (29.3) Moderate 54 (36.0)
High 71 (47.3) High 58 (38.7)
Not available 9 (6.0) Not applicable 0 (0)
Table 6 Substance use among out patients with Suicide attempt*
Substance use No. (%)
None/Never 68 (45.3)
Occasional/Social Alcohol 20 (13.3)
Harmful Use of Alcohol 27 (18.0)
Alcohol Dependence 20 (13.3)
Alcohol + Other Substance 8 (5.3)
Other Substance 8 (5.3)
Inadequate 7 (4.7)
Table 7 Alcohol use during Suicide attempt
Substance use during suicide attempt No. (%)
Not Present 91 (60.7)
Never Used 68 (45.3)
Occasional but not During Act 13 (8.7)
Harmful Use but not During Act 9 (6.0)
Present 50 (33.3)
First time Use at the Time of Act 5 (3.3)
Occasional and Use During Act 7 (4.7)
Harmful and use During Act (Excluding First Time Use) 18 (12.0)
Regular and Use During Act 8 (5.3)
Increased Regular Use During Act 12 (8.0)
Inadequate Information 9 (6.0)
Discussion
Suicide and its attempts is a serious problem with great impact
for individual, family, society and nation.9,10 Its rate is reported to
increase in recent years,2 more so in the developing countries.10 Nepal
is also witnessing high and rising suicide rates, in various settings11,12
though we have a limited nationwide community based data.13
Suicide is the result of a complex process of interaction of protective
and risk factors, i.e. interplay of bio-psycho-socio-cultural factors.1–5
Hence, the prevention efforts are challenging and also required to
be multi-factorial and multi-dimensional.2,9 As with other health
problems, suicide prevention endeavours include primary, secondary
and tertiary prevention in the form of universal, selective, targeted
and indicated interventions.2,9 Related factors may predispose or
precipitate the suicide phenomena and may also contribute to cause
repeated attempts.2,9 Important perspective is to analyze and address
modiable factors in a particular setting and locality.3,14 Identication
of modiable factors and managing them consist of an important
aspect of suicide prevention.3 We have some studies looking
into associated clinical correlates including depression and other
psychiatric morbidities15 and common stressors16 in suicide attempt
subjects. We aim in this study to see the alcohol use and disorders
among suicide attempt cases coming in psychiatric department of a
teaching hospital in eastern Nepal. Since alcohol use and disorders are
remarkably high in this part,7,17 we view that this effort would make
a meaningful step towards comprehensive understanding and suicide
prevention here.
Occurrence of any factor in a health problem can be of coincidental,
co-occurrence or causal (cause and effect) relationship. Alcohol
use and its related disorders in suicide also may be one of these
possibilities; complex and still far from conclusive.2,3,9,14 In this study,
we aim to see the occurrence of a spectrum of alcohol use and alcohol
use disorders among the psychiatric patients seeking consultation for
suicide attempts. Alcohol use/abuse was operationally categorized in
this study in relation to suicide attempt into:
a. Single and rst time use immediately prior to the attempt.
b. Occasional but not during attempt.
c. Occasional and also during attempt.
d. Harmful use and also during attempt (excluding rst time use
just prior to the attempt in this study which is conceptually a
Harmful use).
e. Harmful use but not during the attempt.
f. Regular use/Alcohol dependence syndrome (ADS) but not
during attempt.
g. ADS and use during attempt. We explored in the subjects (by
semi-qualitative approach; i.e. their information and view)
into the possibility of the role of the alcohol use and related
factors in suicide attempt. Analysing (statistical and deni-
te) the relationship and mechanisms of alcohol and suicide
is beyond the scope of this study; however, this could be the
area of further study in this setting as well.
Other perspective is acute alcohol use (AUA) just prior to the
attempt and chronic long standing use resulting into alcohol use
disorder (AUD) among the cases of suicide attempt. Both of these
have been reported higher among suicide and suicide attempts.3 We
have 50/150 (33.3%) of the suicide attempt subjects using alcohol
before the attempt which is comparable to available literature.3,18,19
Nearly one third of the subjects (32%) fullled the criteria for one
or other alcohol use disorder (ICD-10: Acute Intoxication, Harmful
use, Alcohol dependence syndrome, other induced disorders)8 again
keeping this study in line with available data from other parts.3,20
Exploration was made through semi-qualitative approach into
the relationship/association of alcohol in suicide attempt. Some
Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital
of eastern Nepal 28
Copyright:
©2018 Shakya
Citation: Shakya DR. Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital of eastern Nepal. MOJ Addict Med
Ther. 2018;5(1):2529. DOI: 10.15406/mojamt.2018.05.00086
association was seen in 56/150 (37%) of the deliberate self harm
(DSH) attempters. Five cases had used alcohol for the rst time prior
to the attempt and some other had Harmful use (18%), and Alcohol
dependence syndrome (ADS) (13.3%) comparable to large scale
study from Canada.9 We have over all 50% of suicide attempt cases
who have alcohol use/abuse, replicating the similar nding in other
areas.1,9 It makes a strong ground for the alcohol prevention programs
here as well which will positively impact the public mental health and
help reduce suicide risk in/directly.2
Both suicide/attempt and substance are stigma laden issues and
their information is hidden.9 We made an attempt to collect information
about suicide and alcohol use/abuse in suicide attempt cases. Hence,
the collected information is liable to forgetting, modication and
hiding. In some cases, information was not available/inadequate in
this study to ascertain some important issues, i.e. intent/ lethality of
suicide attempt, substance/alcohol use/disorders in these suicide cases.
Many of these cases might add to the gure of substance/alcohol use/
abuse in these cases during the suicide and as a whole. Second issue
is that our study is hospital based and is among psychiatry patients
seeking consultation for suicide attempts. This bias may limit its
generalization to other setting. However, we believe that for a suicide
like phenomenon (relatively epidemiologically rare, complex and
stigmatized issue), it is a method3 and it does not make difference
for the study objective of looking into alcohol ab/use among suicide
attempters. Denite statistical correlational analysis and other in-
depth cause effect analysis is beyond the scope of this study which
could be the objective of further study though challenging in this
type of subject.2 We intended only to directly see the occurrence of
alcohol use/abuse in suicide attempt cases. We did not mean in this
work to intensively explore in-depth to other possible bio-psycho-
social and cultural factors somehow associated with suicide attempt
in acute alcohol use (AUA), e.g. circumstances/motivation to drink,
distress/mental state, impulsivity, etc. and in alcohol use disorder
(AUD) subjects, e.g. depressive disorder, AUD symptoms severity,
low social support, stressful life events, medical illness or complaints,
and unemployment or other indications of economic adversity etc.
which are not less important.3
This study is however expected to open avenues for the in-depth
and large study on the relationship of substance and suicide and might
indicate various future study areas, e.g. effect of acute (AUA) and
chronic use (AUD), many other associated factors. Overarching the
objective of this study would be to devise the strategies as targeted
and indicated measures for these high risk and survivors of suicide
attempts in this setting, e.g. sensible/reduced drinking, comprehensive
treatment including that for alcohol problem,3 exploring and
monitoring the suicide risk at intervals in follow ups and consultations.2
For this, it is important to give information and training to the related
stakeholders, e.g. general practitioners and other health professionals,
parents, teachers, clean ex-users of substance coming in contact with
at-risk individuals.2
Conclusion
Among the subjects seeking psychiatric consultation for suicide
attempt; female were more, majority were less than 30 years and
more were married. Three fourths had psychiatric disorder, the
most common being depression. Poisoning was the most common
mode of suicide attempt and the commonest poison used was
organophosphorous compound. Half of these subjects reported to use
psychoactive substance, mainly alcohol. One third of the cases had
consumed alcohol immediately prior to suicide attempt. Some (clear
and possible) relationship was seen between alcohol use/abuse and
the suicide attempt in 37% of the cases. This indicates the need to
explore and treat substance/alcohol use disorder simultaneously in
these suicide attempt cases and to screen and manage suicide risk in
alcohol ab/use cases.
Declaration
Ethics approval and consent to participate- Approval from
Institute Ethical Review Board (IERB) of BPKIHS (Ref. No.- Aca
216/068/069) and Consent to participate taken from the subjects.
Consent to publish- Since no individual detail, images, or videos
are involved and condentiality not breached, Not Applicable to this
study. Availability of data and materials since it is conducted among
the clinical subjects in a hospital setting and information needs to be
kept condential for individual subjects (participant condentiality),
kept with investigator team.
Acknowledgements
Prof. Rupa Singh, Department of Paediatrics and Neonatology,
BPKIHS.
Conict of interest
The author declares no conict of interest.
Funding
None.
Authors’ contributions
Overall responsibility born by the author (solo).
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Ther. 2018;5(1):2529. DOI: 10.15406/mojamt.2018.05.00086
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... The mean age of our subjects was 28.27 years and the age range was 13-75 years. This finding corresponds with the study by Shakya DR [18] in the same setting with the average age of 29.68 years, age range of 15-81, and age groups (20)(21)(22)(23)(24)(25)(26)(27)(28)(29) and < 20 years were the largest. This finding is in line of current literature indicating increasing suicide rates among young people. ...
... followed by Stress related and Neurotic disorder (34%) mainly Adjustment (22%) and mood disorder (22.1%). The preponderance of substance and mainly alcohol problem among suicide attempt cases was consistent with a previous study of same institute [20]. Among the mood disorders, most common was Severe Depressive Episode seen in (10.6%) of the subjects. ...
... The mean age of our subjects was 28.27 years and the age range was 13-75 years. This finding corresponds with the study by Shakya DR [18] in the same setting with the average age of 29.68 years, age range of 15-81, and age groups (20)(21)(22)(23)(24)(25)(26)(27)(28)(29) and < 20 years were the largest. This finding is in line of current literature indicating increasing suicide rates among young people. ...
... followed by Stress related and Neurotic disorder (34%) mainly Adjustment (22%) and mood disorder (22.1%). The preponderance of substance and mainly alcohol problem among suicide attempt cases was consistent with a previous study of same institute [20]. Among the mood disorders, most common was Severe Depressive Episode seen in (10.6%) of the subjects. ...
Article
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Introduction- Suicide attempt is a self-injurious behavior with a nonfatal outcome. Studies report increasing hospital admissions due to self-inflicted harm (SIH) as well as a higher likelihood of associated psychosocial factors in SIH cases. Objectives- To explore personality traits, socio-demographic profiles and psychiatric disorders among the suicide attempt cases in a tertiary care hospital setting of eastern Nepal. Methods- It was a descriptive study conducted with purposive sampling in a tertiary care hospital among suicide attempt cases who visited to out-patient department of psychiatry. A total of 113 cases (calculated sample size) were enrolled after written informed consent within study period of 1 year. Personality traits were analyzed by using ‘Personality Trait Inventory’ questionnaire. Psychiatric diagnosis was made as per the ICD-10 diagnostic criteria. Demographic variables were recorded in a semi-structured proforma. Results- Majority of the subjects were female, married and literate, with the most common age group being 20- 29 and <20 years. Most of them were Hindu, from low socioeconomic status, joint family and cities, and were homemakers. Poisoning was the most common mode of suicide attempt and organo-phosphorous compounds the most common poison used. Some (13.3%) had past and 5.3% had family history of suicidal attempt. Most cases 63 (55.8%) were referred from Departments of Internal Medicine, followed by Emergency 28 (24.8%), self18 (15.9%) and Pediatrics 4 (3.5%). The common ICD-10 psychiatric diagnoses were: Substance use disorder, main being alcohol (42%), Adjustment (34%) and mood disorders (22%). Emotional instability trait was the most common Personality Trait 70 (61.9%), followed by Depressive tendency 46 (40.7%). Personality disorder was present in 34%; most common being Emotionally unstable personality disorder. Conclusions- Emotional instability trait was found in the highest number of suicide attempt patients. Key Words: BPKIHS, mental illness, personality trait, Psychiatry out-patients, suicide attempt
... Mean age was 28.27 years, with mean standard deviation of 12.317. Age groups (20)(21)(22)(23)(24)(25)(26)(27)(28)(29) and (< 20) years were the largest. ...
... with a previous study of same institute.20 Among the mood disorders, most common was Severe Depressive Episode seen in (10.6%) of the subjects. ...
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Background- Suicide attempt is a self-injurious behaviour with a nonfatal outcome. Studies report increasing hospital admissions due to self-inflicted harm (SIH) as well as a higher likelihood of associated psychosocial factors in SIH cases. We conducted a study to explore personality traits, socio-demographic profiles and psychiatric disorders among the suicide attempt cases in a tertiary care hospital setting of eastern Nepal. Methods- It was a descriptive study conducted with purposive sampling in a tertiary care hospital among suicide attempt cases who visited to out-patient department of psychiatry. A total of 113 cases (calculated sample size) were enrolled after written informed consent within study period of 1 year. Personality traits were analyzed by using ‘Personality Trait Inventory’ questionnaire. Psychiatric diagnosis was made as per the ICD-10 diagnostic criteria. Demographic variables were recorded in a semi-structured proforma. Results- Majority of the subjects were female, married and literate, with the most common age group being 20–29 and < 20 years. Most of them were Hindu, from low socioeconomic status, joint family and cities, and were homemakers. Poisoning was the most common mode of suicide attempt and organo-phosphorous compounds the most common poison used. Some (13.3%) had past and 5.3% had family history of suicidal attempt. Most cases 63 (55.8%) were referred from Departments of Internal Medicine, followed by Emergency 28 (24.8%), self 18 (15.9%) and Paediatrics 4 (3.5%). The common ICD-10 psychiatric diagnoses were: Substance use disorder, main being alcohol (42%), Adjustment (34%) and mood disorders (22%). Emotional instability trait was the most common Personality Trait 70 (61.9%), followed by Depressive tendency 46 (40.7%). Personality disorder was present in 34%; most common being Emotionally unstable personality disorder. Conclusions- Emotional instability trait was found in the highest number of suicide attempt patients.
... It is estimated that many factors such as family and socioeconomic problems, increases in stress, isolation, and age increase the risk of suicide [5]. In addition to these psycho-socioeconomic factors, psychiatric and organic diseases may also play a role in the etiology of suicide [6]. ...
... Results showed that moderate-to-severe alcohol dependence was frequent (25.14%) in suicide attempters, which is comparatively higher to a study done in Nepal where alcohol dependence was present in 13.3% of suicide attempters. [22] In our study, suicidal ideation was present in 24.44% of alcohol-dependent individuals. Our study showed that certain sociodemographic and clinical variables of alcohol-dependent individuals increase the likelihood of suicidal attempts. ...
Article
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Background: Suicidal attempt is a phenomenon with a tremendous impact on the medical and social well-being of the individual, and alcohol abuse/dependence has consistently been implicated in the triggering of suicidal attempt. This complex interaction of alcohol and suicide needs further exploration. Aim: This study aimed to examine the frequency of alcohol dependence in suicidal survivors and assess the association of sociodemographic and clinical variables with the severity of dependence in suicide attempters. Materials and Methods: It is a hospital-based, cross-sectional, observational study set in a tertiary care institute where a total of 175 admitted cases of suicidal attempt were included. Patients referred to the department of psychiatry of a teaching hospital in Andhra Pradesh within the study period were enrolled after informed consent. With usual detailed workup, alcohol dependence was ascertained. Relevant information was recorded in a pro forma. Alcohol use/dependence was grouped into various categories in relation to suicidal attempt. Results: Alcohol was consumed by 43.43% of suicide attempters. Alcohol dependence constituted of 30.29%. Severe dependence was present in 9.14% of participants. There was a positive correlation between suicidal intent, lethality of attempt, history of smoking, and psychiatric comorbidity with the groups segregated based on the severity of dependence. Conclusion: High suicidal intent and lethality of attempt are risk factors of attempt in moderate-to-severe dependence. Effective treatment of alcohol dependence can mitigate suicidal attempts.
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Alcohol use and its disorders are associated with increased risk of suicidal behaviors Research has shown that 6-8% of those who use alcohol have a history of suicide attempt. Given the prohibition of alcohol use legally, the increased alcohol consumption, and the lack of strong evidence in favor of its use associated with suicide in Iran, this study was conducted to determine the link between suicide attempt and alcohol abuse. The case-crossover method was used in this research. Out of 305 referrals to the emergency room due to a suicide attempt, 100 reported drinking alcohol up to six hours before their attempt. Paired Matching and Usual Frequency were employed to analyze the data with STATA 12.0. The probability of attempting suicide up to six hours after drinking alcohol appeared increased by 27 times (95% CI: 8.1-60.4). Separate analysis for each of these hours from the first to the sixth hour after alcohol use was also performed. Fifty percent of attempted suicides happened one hour after alcohol use. Relative risk for the first and second hour was 10% and 5% respectively. Alcohol use is a strong proximal risk factor for attempted suicide among Iranian subjects. Prevention of alcohol use should be considered in setting up of the national Suicide attempt prevention program.
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Several original studies have investigated the effect of alcohol use disorder (AUD) on suicidal thought and behavior, but there are serious discrepancies across the studies. Thus, a systematic assessment of the association between AUD and suicide is required. We searched PubMed, Web of Science, and Scopus until February 2015. We also searched the Psycinfo web site and journals and contacted authors. We included observational (cohort, case-control, and cross-sectional) studies addressing the association between AUD and suicide. The exposure of interest was AUD. The primary outcomes were suicidal ideation, suicide attempt, and completed suicide. We assessed heterogeneity using Q-test and I2 statistic. We explored publication bias using the Egger's and Begg's tests and funnel plot. We meta-analyzed the data with the random-effects models. For each outcome we calculated the overall odds ratio (OR) or risk ratio (RR) with 95% confidence intervals (CI). We included 31 out of 8548 retrieved studies, with 420,732 participants. There was a significant association between AUD and suicidal ideation (OR=1.86; 95% CI: 1.38, 2.35), suicide attempt (OR=3.13; 95% CI: 2.45, 3.81); and completed suicide (OR=2.59; 95% CI: 1.95, 3.23 and RR=1.74; 95% CI: 1.26, 2.21). There was a significant heterogeneity among the studies, but little concern to the presence of publication bias. There is sufficient evidence that AUD significantly increases the risk of suicidal ideation, suicide attempt, and completed suicide. Therefore, AUD can be considered an important predictor of suicide and a great source of premature death.
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The current study is based on the hypothesis that alcohol-involved suicide attempts are characterized by lower premeditation and intent, but only when the use of alcohol is not motivated by the desire to facilitate the attempt. Test of this idea was conducted by comparing proximal suicide premeditation and intent of suicide attempts among three groups: individuals who (a) drank to facilitate the attempt (e.g., to "numb fears" about attempting), (b) drank for nonfacilitative motives, and (c) did not use alcohol before the attempt. Participants included 324 (62% female) recent suicide attempters presenting to a Level 1 trauma hospital. The Timeline Followback Interview for Suicide Attempts and a novel Suicide Facilitative Drinking Motives Scale were used to assess facilitative motives for drinking and characteristics of the attempt. One third of participants drank before the attempt, and most (73%) who used alcohol did not do so to facilitate the attempt. As hypothesized, attempts carried out by this group had shorter proximal suicide premeditation and lower suicide intent compared with the other study groups; in contrast, individuals who drank to facilitate the attempt were similar to non-alcohol users on these indices. Alcohol-involved suicide attempts are heterogeneous. Motives for drinking are a key source of heterogeneity insofar as fundamental characteristics of attempts (proximal premeditation, intent) differ as a function of drinking motivation. Clinical implications include that individuals making suicide attempts with facilitative motives for drinking cannot be assumed to be at lowered risk upon a drop in blood alcohol level.
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Background: Stressor is one of the three major risk factors of suicide, along with altered mental state and access to suicidemeans. There is scant data from Nepal about the stressors being common among suicide attempters. Objective: To identify common stressors among suicide attempters visiting a psychiatric service in Eastern Nepal Methodology: It is a hospital based descriptive study looking into stressors as revealed by patients and care-takers in psychiatric assessment. All patients consulting the investigating psychiatristteam within study period (12 months, 2011) were enrolled after informed consent. During detailed work-up; suicidal state was ascertained, relevant information were recorded in the proforma and an intensive qualitative exploration was made in all subjects into the stressors present during the time of suicide-attempt. Results: Fifty seven percent of subjects (66/115) were female, 70% (80/115) married and 88% (101/115) from rural and semiurban settings. Average age was 29.68 years. Nearly one fifth was illiterate or barely literate. Poisoning was the most common mode of suicide attempt. About 75% (86/115) had at least one ICD- 10 mental disorder. ‘Stress related disorder’ was present in 13% (15/115). In a great majority (112/115), at least one stressor was reported. The most commonly revealed stressor was interpersonal conflict, dispute or quarrel (72/115), followed by the stressor related to subject’s health issues, e.g. illness, treatment cost. Some cases reported easy access to suicide means as a risk factor. Conclusion: Interpersonal dispute, health problems and easy access to suicide means were reported as common stressor/factors among suicide attempters.
Article
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ABSTRACTS: Background: Physical complaints are common in a variety of psychiatric conditions and physically ill people may have psychological problems. Psychiatric service integrated into a general hospital has an added advantage of easy access for these cases. Objective: This study aims to sort out psychiatric morbidity profile and referral pattern among psychiatry outpatients. Methodology: A total of 200 consecutive out patients in psychiatry OPD coming into the contact of the investigators were enrolled during the study period of 6 months. Diagnoses were made according the ICD-10. Results: Out of total subjects, 53% were female, mainly of age groups 10- 39 years (72.5%). Main ethnicity groups seeking care were Mongols (35.0%), indigenous Terai tribes (19.5%) and Brahmins (17.5%). The cases were almost equally representing from cities, semi-urban and rural settings. About half were referred by other departments of the institute, most commonly by medicine, family medicine, gynaecology, paediatrics and ENT departments. Nearly half were advised by friends, other health professionals and media. More than one forth (27.5%) were dissatisfied and questioned about psychiatric referral. Greater proportions (62.0%) were comfortable and happy about the referral. About half of subjects presented with physical/ somatic complaints. Major psychiatric diagnoses were mood affective; somatoform and anxiety disorders. Fourteen per cent subjects had suicidal behaviours. Conclusion: Significant proportion of psychiatric patients visits other departments, with physical complaints. Common diagnoses among Psychiatric out-patients are mood affective, somatoform and anxiety disorders.
Chapter
Suicidal behaviour or suicidality can be conceptualized as a continuum ranging from suicidal ideation and communications to suicide attempts and completed suicide. A developmental process which leads to suicidal ideation, suicidal communication, self-destructive behaviour, in some cases even to suicide, and its consequences to the survivors is often referred to as a suicidal process. There is no single unanimously accepted definition of suicide, although in most proposed definitions it is considered as a fatal act of self-injury (self-harm) undertaken with more or less conscious self-destructive intent, however vague and ambiguous. Since the deceased cannot testify as to his or her intent, the conclusions about this must be drawn by inference. The evidence required for this inference depends on many factors, for example the mode of death, the use of autopsy, age, gender, social and occupational status, and the social stigma of suicide in the person’s culture. The assessment of suicide intent is always based on a balance of probabilities. This chapter discusses the suicide process and the act of suicide, epidemiology and public health aspects of suicide, basic characteristics of the suicide victim, and finally mental disorders and suicide.
Article
Introduction: Globally every 40 seconds a completed suicide case happens. Deliberate self-harm or suicide attempts are an universal phenomenon and may be having various underlying causes including psychiatric and personality disorders (PDs). A previous suicide attempt and its severity are considered as one of the strongest predictors of future completed suicide. Objectives: The objective was to study the clinico-sociodemographic profiles, personality, perceived stress level and severity of suicide attempt of suicide attempted patients, and to explore the relation between these factors if any. Materials and Methods: This cross-sectional study was conducted at a tertiary care teaching hospital in eastern Nepal. For this study, 100 suicide attempted patients admitted in various departments of the institute referred to and attending the psychiatric outpatient department were included and evaluated. Results: Majority of suicide attempters were female, young and mostly from rural areas. Major risk factors for suicide attempt included abnormally perceived stress level, various psychiatric disorders, PDs,and substance dependence. Conclusion: Effective intervention and management of various mental and behavioral disorders may prove to be one of the most effective ways for suicide prevention. Restriction of the availability of highly toxic pesticides and stress management can possibly reduce the risk of suicide.
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Suicide is the tenth leading cause of death in the United States, and its rate has risen by 16% in the past decade. Deliberate self-poisoning is the leading method of attempted suicide. Unlike more violent methods, which are almost universally fatal, survival following self-poisoning is common, providing an opportunity for secondary prevention. However, the long-term risk of suicide following a first episode of self-poisoning is unknown. To determine the risk of suicide and mortality from other causes following a first self-poisoning episode. Population-based cohort study using multiple linked health care databases. We identified all individuals with a first self-poisoning episode in Ontario, Canada, from April 1, 2002, through December 31, 2010, and followed up all surviving participants until December 31, 2011, or death, whichever occurred first. For each individual with a deliberate self-poisoning episode, we randomly selected 1 control from the same population with no such history, matched for age (within 3 months), sex, and calendar year. The primary analysis examined the risk of suicide following discharge after self-poisoning. The secondary analyses explored factors associated with suicide and examined the risk of death caused by accidents or any other cause. We identified 65 784 patients (18 482 [28.1%] younger than 20 years) who were discharged after a first self-poisoning episode. During a median follow-up of 5.3 years (interquartile range, 3.1-7.6 years), 4176 died, including 976 (23.4%) by suicide. The risk of suicide following self-poisoning was markedly increased relative to controls (hazard ratio, 41.96; 95% CI, 27.75-63.44), corresponding to a suicide rate of 278 vs 7 per 100 000 person-years, respectively. The median time from hospital discharge to completed suicide was 585 days (interquartile range, 147-1301 days). Older age, male sex, multiple intervening self-poisoning episodes, higher socioeconomic status, depression, and recent psychiatric care were strongly associated with suicide. Patients with a self-poisoning episode were also more likely to die because of accidents (hazard ratio, 10.45; 95% CI, 8.10-13.47) and all causes combined (hazard ratio, 5.55; 95% CI, 5.12-6.02). A first self-poisoning episode is a strong predictor of subsequent suicide and premature death. Most suicides occur long after the index poisoning, emphasizing the importance of longitudinal, sustained secondary prevention initiatives.
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This a big book: 11¼ × 8½ × 2⅝, 1,666 pages; 174 contributors; 35 pages of index; two editors; and price $24.75! Almost each section has multiple cross-references so that the volume is more like an encyclopedia. Sampling the volume convinces me that practically the entire field of psychiaitry is covered by distinguished authorities. No one item could be completely surveyed, but adequate references are appended to each section. The comprehensiveness is more apparent than depth; yet it is a valuable reference work for a rapid dig into almost every facet of psychiatry. It is a good book for the psychiatrist's library.
Article
Research on associations between substances of abuse and suicidal behaviors is a large, complex area. Herein, alcohol, the most commonly abused intoxicant worldwide, is examined with a focus on two topics: (1) acute use of alcohol (AUA) shortly prior to suicidal behavior; and (2) more chronic alcohol use disorder (AUD) and suicidal behavior. First, a brief summary of what is known about AUA, AUD, and suicidal behavior is provided. Next, we draw on preliminary evidence, practical considerations, and our own experience to offer recommendations for intervention research that may lower risk associated with AUA and AUD. The literature on AUD and suicidal behavior is more developed, thus we discuss separately research designed to: (1) prevent individuals with AUD with suicidal ideation from engaging in suicidal behavior; and (2) prevent individuals with AUD who have made a suicide attempt from reattempting. Our focus is on clinical intervention strategies for individuals at risk for suicidal behavior that use alcohol or have developed AUD. We also focus on applied research that may directly lead to practical prevention efforts. Although clinical interventions are important components of a comprehensive suicide prevention strategy, they should be complemented with primary prevention efforts.