The role of mental illness in nonfatal deliberate self-harm (DSH) is controversial, especially in Asian countries. This prospective study examined the role of psychiatric disorders, underlying social and situational problems, and triggers of DSH in a sample of 89 patients hospitalised in primary care hospitals of the Sundarban Delta, India. Data were collected by using a specially designed DSH register, Explanatory Model Interview Catalogue (EMIC), and clinical interview. Psychiatric diagnosis was made following the DSM-IV guidelines. The majority of subjects were young females (74.2%) and married (65.2%). Most of them (69.7%) were uncertain about their “intention to die,？ and pesticide poisoning was the commonest method (95.5%). Significant male-female differences were found with respect to education level, occupation, and venue of the DSH attempt. Typical stressors were conflict with spouse, guardians, or in-laws, extramarital affairs, chronic physical illness, and failed love affairs. The major depressive disorder (14.6%) was the commonest psychiatric diagnosis followed by adjustment disorder (6.7%); however 60.7% of the cases had no psychiatric illness. Stressful life situations coupled with easy access to lethal pesticides stood as the risk factor. The sociocultural dynamics behind suicidal behaviour and community-specific social stressors merit detailed assessment and timely psychosocial intervention. These findings will be helpful to design community-based mental health clinical services and community action in the region. 1. Introduction Presently both fatal and nonfatal deliberate self-harm (DSH) are major public health concerns globally. Fatal DSH (i.e., suicidal death) accounted for more than 900,000 lives lost in 1995 [1]. The rate of non-fatal DSH is 10 times more than fatal DSH [2]. In India, the suicide rate is approximately 11.6 per 100,000 populations [3]. Research has revealed that young age, female sex, low educational level [4], being married [5], and housewife status [6] are potential risk factors for both fatal and non-fatal DSH. Several studies also document psychiatric illness, especially major depression, as associated with DSH behaviour [7, 8]. However, the relationship between suicidal behaviour and designated psychiatric illnesses is a matter of great controversy. Unlike some western studies [9–11] in which psychiatric and personality disorders are referred to as predominant DSH antecedents, some Indian urban studies [12, 13] have pointed out that many people who come to clinical attention after DSH do not have any designated
References
[1]
J. M. Bertolote and A. Fleischmann, “A global perspective in the epidemiology of suicide,” Suicidology, vol. 7, pp. 6–8, 2002.
[2]
R. F. W. Diekstra, “The epidemiology of suicide and parasuicide,” Acta Psychiatrica Scandinavica, vol. 371, pp. 9–20, 1993.
[3]
National Crime Records Bureau, Accidental deaths and suicides in India. New Delhi, Ministry of Home Affairs, Government of India, 2002, http://www.indiastat.com/.
[4]
A. Schmidtke, U. Bille-Brahe, D. DeLeo et al., “Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992, results of the WHO/EURO Multicentre study on parasuicide,” Acta Psychiatrica Scandinavica, vol. 93, no. 5, pp. 327–338, 1996.
[5]
G. D. Shukla, B. L. Verma, and D. N. Mishra, “Suicide in Jhansi city,” Indian Journal of Psychiatry, vol. 32, pp. 44–51, 1990.
[6]
R. C. Sharma, “Attempted suicide in Himachal Pradesh,” Indian Journal of Psychiatry, vol. 40, pp. 50–54, 1998.
[7]
M. S. Mullick, M. E. Karim, and M. Khanam, “Depression in deliberate self harm patients,” Bangladesh Medical Research Council Bulletin, vol. 20, no. 3, pp. 123–128, 1994.
[8]
D. Chibanda, M. B. Sebit, and S. W. Acuda, “Prevalence of major depression in deliberate self-harm individuals in Harare, Zimbabwe,” East African Medical Journal, vol. 79, no. 5, pp. 263–266, 2002.
[9]
C. Haw, K. Hawton, K. Houston, and E. Townsend, “Psychiatric and personality disorders in deliberate self-harm patients,” British Journal of Psychiatry, vol. 178, pp. 48–54, 2001.
[10]
A. L. Beautrais, P. R. Joyce, R. T. Mulder, D. M. Fergusson, B. J. Deavoll, and S. K. Nightingale, “Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case-control study,” American Journal of Psychiatry, vol. 153, no. 8, pp. 1009–1014, 1996.
[11]
E. Ferreira de Castro, M. A. Cunha, F. Pimenta, and I. Costa, “Parasuicide and mental disorders,” Acta Psychiatrica Scandinavica, vol. 97, no. 1, pp. 25–31, 1998.
[12]
S. R. Parkar, V. Dawani, and M. G. Weiss, “Clinical diagnostic and sociocultural dimensions of deliberate self-harm in Mumbai, India,” Suicide and Life-Threatening Behavior, vol. 36, no. 2, pp. 223–238, 2006.
[13]
S. R. Parkar, V. Dawani, and M. G. Weiss, “Gender, suicide, and the sociocultural context of deliberate self-harm in an urban general hospital in Mumbai, India,” Culture, Medicine and Psychiatry, vol. 32, no. 4, pp. 492–515, 2008.
[14]
E. M. Mcmahon, U. Reulbach, P. Corcoran, H. S. Keeley, I. J. Perry, and E. Arensman, “Factors associated with deliberate self-harm among Irish adolescents,” Psychological Medicine, vol. 40, no. 11, pp. 1811–1819, 2010.
[15]
L. Webb, “Deliberate self-harm in adolescence: a systematic review of psychological and psychosocial factors,” Journal of Advanced Nursing, vol. 38, no. 3, pp. 235–244, 2002.
[16]
D. T. L. Shek and L. Yu, “Self-harm and suicidal behaviours in Hong Kong adolescents: prevalence and psychosocial correlates,” The Scientific World Journal, vol. 2012, Article ID 932540, 14 pages, 2012.
[17]
A. N. Chowdhury, A. Brahma, S. Baherjee, and M. K. Biswas, “Deliberate self-harm prevention in the Sundarbans region need immediate public health attention,” Journal of the Indian Medical Association, vol. 107, no. 2, pp. 88–93, 2009.
[18]
B. De, West Bengal District Gazetteers: 24 Parganas. Government of West Bengal, Saraswasti Press, Calcutta, India, 1994.
[19]
Census, Office of the Director of Census Operations, West Bengal. A census view series, 20, South 24 Parganas. Kolkata, India, 2001.
[20]
A. N. Chowdhury, D. Sanyal, S. K. Dutta, and M. G. Weiss, “Deliberate self-harm by ingestion of poisons on Sagar Island in the Sundarban Delta, India,” International Medical Journal, vol. 10, no. 2, pp. 85–91, 2003.
[21]
A. N. Chowdhury, S. Banerjee, A. Brahma, and M. K. Biswas, “Pesticide poisoning in nonfatal deliberate self-harm: a public health issue,” Indian Journal of Psychiatry, vol. 49, pp. 117–120, 2007.
[22]
A. N. Chowdhury, A. K. Chakraborty, and M. G. Weiss, “Community mental health and concepts of mental illness in the Sundarban Delta of West Bengal, India,” Anthropology and Medicine, vol. 8, no. 1, pp. 109–129, 2001.
[23]
A. N. Chowdhury, A. Brahma, and S. Banerjee, “How to operationalise community mental health service at the primary care? Experience of IRMC model from Sundarban, India,” International Medical Journal, vol. 11, no. 2, pp. 105–110, 2004.
[24]
R. A. Sansone, M. W. Wiederman, and L. A. Sansone, “Self-Harm Inventory (SHI): development of a scale for identifying self-destructive behaviours and borderline personality disorder,” Journal of Clinical Psychology, vol. 54, pp. 973–983, 1998.
[25]
American Psychiatric Association, Diagnostic and Statistical Manual, Washington, DC, USA, 4th edition, 1994.
[26]
M. B. First, R. L. Spitzer, M. Gibbon, and J. B. W. Williams, Structured Clinical Interview for DSM-IV Axis I Disorders, patient eds. (SCID-I/P, Version 2.0,8/ 98 revision), Biometrics Research Department, New York Psychiatric Institute, New York, NY, USA, 1998.
[27]
M. G. Weiss, “Cultural epidemiology: an introduction and overview,” Anthropology & Medicine, vol. 8, no. 1, pp. 5–29, 2001.
[28]
P. N. Suresh Kumar, “Age and gender related analysis of psychosocial factors in attempted suicide,” Indian Journal of Psychiatry, vol. 40, pp. 338–345, 1998.
[29]
B. L. Narang, B. P. Mishra, and N. Mohan, “Attempted suicide in Ludhiana,” Indian Journal of Psychiatry, vol. 42, pp. 83–87, 2000.
[30]
M. K. Srivastava, R. N. Sahoo, L. H. Ghotekar, S. Dutta, M. Danabalan, T. K. Dutta, et al., “Risk factors associated with attempted suicide: a case control study,” Indian Journal of Psychiatry, vol. 46, pp. 33–38, 2004.
[31]
R. Ponnudurai, J. Jeykar, and M. Saraswathy, “Attempted suicide in Madras,” Indian Journal of Psychiatry, vol. 28, pp. 59–62, 1986.
[32]
K. Hawton, J. Fagg, S. Simkin, E. Bale, and A. Bond, “Deliberate self-harm in adolescents in Oxford, 1985–1995,” Journal of Adolescence, vol. 23, no. 1, pp. 47–55, 2000.
[33]
World Health Organisation, Guidelines for poison control. WHO Bulletin, WHO, Geneva, Switzerland, 1999.
[34]
S. P. Dhanya, T. H. Dhanva, R. N. Bindu Latha, and C. G. Hema, “A retrospective analysis of the pattern of poisoning in patients admitted to Medical College hospital,” Calicut Medical Journal, vol. 7, no. 2, p. e3, 2009.
[35]
A. K. Bhattacharya, S. Bhattacharjee, S. Chattopadhyay, P. Roy, D. Kanji, and O. P. Singh, “Deliberate self-arm: a search for distinct group of suicide,” Indian Journal of Psychological Medicine, vol. 33, pp. 182–127, 2011.
[36]
A. N. Chowdhury, S. Banerjee, A. Brahma, and M. G. Weiss, “Pesticide practices and suicide among farmers of the Sundarban region in India,” Food and Nutrition Bulletin, vol. 28, no. 2, supplement, pp. S381–S391, 2007.
[37]
A. N. Chowdhury, S. Banerjee, A. Brahma et al., “A prospective study of suicidal behaviour in Sundarban delta, West Bengal, India,” National Medical Journal of India, vol. 23, no. 4, pp. 201–205, 2010.
[38]
B. D. Garfinkel, A. Froese, and J. Hood, “Suicide attempts in children and adolescents,” American Journal of Psychiatry, vol. 139, no. 10, pp. 1257–1261, 1982.
[39]
R. Ponnudurai, K. A. Patnaik, R. Sthianthan, and K. Subhan, “A study on the venues of suicide,” Indian Journal of Psychiatry, vol. 39, no. 1, pp. 34–36, 1997.
[40]
A. N. Chowdhury, A. Brahma, S. Banerjee, and M. K. Biswas, “Pattern of domestic violence amongst non-fatal deliberate self-harm attempters: a study from primary care of West Bengal,” Indian Journal of Psychiatry, vol. 51, no. 2, pp. 96–100, 2009.
[41]
J. J. Sheu, J. D. Wang, and Y. K. Wu, “Determinants of lethality from suicidal pesticide poisoning in metropolitan HsinChu,” Veterinary and Human Toxicology, vol. 40, no. 6, pp. 332–336, 1998.
[42]
K. Chakrabarti and K. C. Devkota, “Retrospective study of suicide cases admitted in Nepal Medical College Teaching Hospital,” Nepal Medical College Journal, vol. 6, no. 2, pp. 116–118, 2004.
[43]
H. T. T. Thanh, G. X. Jiang, T. N. Van, D. P. T. Minh, H. Rosling, and D. Wasserman, “Attempted suicide in Hanoi, Vietnam,” Social Psychiatry and Psychiatric Epidemiology, vol. 40, no. 1, pp. 64–71, 2005.
[44]
NHS Centre for Reviews and Dissemination, “Deliberate self-harm,” Effective Health Care Bulletins, vol. 4, pp. 1–12, 1998.
[45]
A. I. Hatzitolios, M. L. Sion, N. P. Eleftheriadis et al., “Parasuicidal poisoning treated in a greek medical ward: epidemiology and clinical experience,” Human and Experimental Toxicology, vol. 20, no. 12, pp. 611–617, 2001.
[46]
S. S. Patil, M. C. Yadavannavar, and S. P. Chaukimath, “Deliberate self harm and psychiatric comorbidity: a hospital based study,” Asian Journal of Experimental Biological Science, vol. 2, pp. 367–371, 2011.
[47]
M. S. Bhatia, N. K. Aggarwal, and B. B. L. Aggarwal, “Psychosocial profile of suicide ideators, attempters and completers in India,” International Journal of Social Psychiatry, vol. 46, no. 3, pp. 155–163, 2000.
[48]
P. D. Bansal and R. Barman, “Psychiatric morbidity and the socio-demographic determinants of deliberate self harm,” Journal of Clinical and Diagnostic Research, vol. 5, no. 3, pp. 601–604, 2011.
[49]
G. M. Soomro, “Deliberate self-harm (and attempted suicide),” Clinical Evidence, vol. 2008, p. 1012, 2008.
[50]
P. G. Sharma and D. G. Sawang, “Suicide in rural areas of Warrangal district,” Indian Journal of Psychiatry, vol. 3, pp. 79–84, 1993.
[51]
L. Vijayakumar, “Suicide prevention: the urgent need in developing countries,” World Psychiatry, vol. 3, pp. 158–159, 2004.
[52]
S. Bridge, “Suicide prevention: targeting the patient at risk,” Australian Family Physician, vol. 35, no. 5, pp. 335–338, 2006.
[53]
A. Kaplan, “China’s suicide patterns challenge depression theory,” Psychiatry Times, vol. 16, pp. 1–7, 2004.
[54]
L. D. Hankoff, “Suicide and attempted suicide,” in Handbook of Affective Disorders, E. S. Paykel, Ed., pp. 416–428, Churchill Livingstone, New York, NY, USA, 1982.
[55]
E. Arensman and A. J. F. M. Kerkhof, “Classification of attempted suicide: a review of empirical studies, 1963–1993,” Suicide and Life-Threatening Behavior, vol. 26, no. 1, pp. 46–47, 1996.
[56]
A. K. Hagaman, B. H. Wagenaar, K. E. McLean, B. A. Kaiser, K. Winskell, and B. A. Kohrt, “Suicide in rural Haiti: clinical and community perceptions of prevalence, etiology and prevention,” Social Science and Medicine, vol. 83, pp. 61–69, 2013.
[57]
D. J. Gunnell and M. Eddleston, “Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries,” International Journal of Epidemiology, vol. 32, no. 6, pp. 902–909, 2003.
[58]
M. Eddleston, “Patterns and problems of deliberate self-poisoning in the developing world,” Quarterly Journal of Medicine, vol. 93, no. 11, pp. 715–731, 2000.
[59]
J. M. Bertolote, “Suicide prevention: at what level does it work?” World Psychiatry, vol. 3, pp. 147–151, 2004.
