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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 1  |  Page : 7-21

A gender-specific analysis of suicide methods in deliberate self-harm


1 Department of Psychiatry, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
2 Department of Psychiatry, The Oxford Medical College, Hospital and Research Centre, Bengaluru, Karnataka, India

Date of Web Publication13-Feb-2017

Correspondence Address:
Kiran K Kumar
Room No. 112, Department of Psychiatry, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru - 560 066, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.200098

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  Abstract 

Background: Deliberate self-harm (DSH) is a major public health concern. Gender differences in suicide methods are a controversial realm with various regional and cultural variations. This study compared and assessed the methods used in DSH attempters as undertaken by men and women, and investigated the possible role of gender and other clinical variables in the selection of suicide method. Materials and Methods: Two hundred subjects fulfilling the inclusion and exclusion criteria were recruited in the study. The sociodemographic details were recorded in the semi-structured pro forma. Detailed assessment of psychiatric morbidity and DSH was done by clinical interview and validated by Mini International Neuropsychiatric Interview-Plus 5.0 and Beck Suicide Intent Scale. Data were analyzed using SAS version 9.2 and SPSS version 17.0. The sample was disaggregated by gender to compare the known correlates of suicide risk on the two most common methods of suicide – poison consumption and drug overdose using multivariate analyses. Results: The analysis revealed that majority of the attempters were in the age group of 11–40 years (91%). Females (63%) outnumbered males (37%); poisoning was the most common type of method (50.5%), followed by drug overdose (35%). There were no statistical differences between the two genders with respect to other sociodemographic variables. Males from urban/semi-urban background (odds ratio [OR] = 4.059) and females living alone (OR = 5.723) had high odds ratio of attempting suicide by poison consumption. Females from urban/semi-urban background (P = 0.0514) and male subjects from nuclear families had an increased odds ratio (OR = 4.482) to attempt suicide by drug overdose. There were no statistical differences when the two genders were compared for other variables such as intentionality, lethality, impulsivity, and number of attempts. Conclusions: It appears that gender differences among DSH attempters appear less pronounced in the Indian setting compared to the worldwide literature on the subject. Nevertheless, the unique, gender-specific characteristics pertaining to DSH attempters in our population emphasize the need for gender-specific interventions in future clinical treatment.

Keywords: Deliberate self-harm, drug overdose, gender, poison consumption


How to cite this article:
Kumar KK, Sattar FA, Bondade S, Hussain MS, Priyadarshini M. A gender-specific analysis of suicide methods in deliberate self-harm. Indian J Soc Psychiatry 2017;33:7-21

How to cite this URL:
Kumar KK, Sattar FA, Bondade S, Hussain MS, Priyadarshini M. A gender-specific analysis of suicide methods in deliberate self-harm. Indian J Soc Psychiatry [serial online] 2017 [cited 2017 Dec 12];33:7-21. Available from: http://www.indjsp.org/text.asp?2017/33/1/7/200098


  Introduction Top


Suicide is one of the major causes of unnatural death worldwide. Every year, more than 800,000 people take their own life and there are many more people who attempt deliberate self-harm (DSH). Suicide does not just occur in high-income countries, but it is a global phenomenon in all regions of the world. In fact, 75% of global suicides occurred in low- and middle-income countries in 2012.[1] In India, the number of suicides in the country during the decade (2003–2013) has recorded an increase of 21.6% (134,799 in 2013 from 110,851 in 2003) according to the National Crime Records Bureau (NCRB) data.[2] The all India rate of suicides was 11.0/1 lakh population during the year 2013 and the suicide rate in Karnataka was 18.5/1 lakh population.[2] However, we are aware of the fact that the suicide rates published by the NCRB has its own methodological flaws and the numbers are just the tip of the iceberg; furthermore, the prevalence of DSH is about 20 times that of the suicide rates.[1] Though an act of suicide attempt is a highly individualistic behavior, its determinants are multidimensional.

Incidence of DSH and the methods used vary from country to country due to the variations in cultural, religious, and social background. A number of sociodemographic and clinical variables interplay in determining the outcome of suicidal behavior. While numerous factors contribute to the choice of a suicide method, societal patterns of suicide can be understood from basic concepts such as the social acceptability of the method (i.e., culture and tradition) and its availability (i.e., opportunity).[3] Globally, attempted suicide is more common in women and completed suicide is more common in men. The methods used for suicide varies between the two genders widely and so are the intentionality and lethality of the attempt [Table 1]. The current study was conducted with an aim to analyze the relationship between suicide methods and gender in DSH.
Table 1: Recent Indian studies on suicide methods

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  Materials and Methods Top


This was a cross-sectional hospital-based study conducted from May 2013 to May 2015 at the Department of Psychiatry, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India. In this study, DSH was defined as “an act with nonfatal outcome, in which an individual deliberately initiates a nonhabitual behavior that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences (WHO, 1986).”[11] Two hundred persons who attempted DSH, referred from various departments, were included after obtaining a written informed consent through purposive random sampling. Patients whose injuries were considered to be accidental in origin with no suggestion of self-harm intention and those succumbed to their injuries were excluded from the study. The patients were interviewed once their general condition improved. Next of kin (NOK) of each patient were interviewed with the patients' consent for any additional information. Confidentiality of the information obtained was ensured to the patient. Patients who did not consent for the study and who were critically ill to co-operate for assessment were excluded from the study. The study protocol was approved by the Institutional Ethics Committee [Figure 1].
Figure 1: Study sample

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Tools used

  • Informed consent
  • Semi-structured pro forma for recording sociodemographic variables, details of suicide attempt, contributing psychosocial factors, medical and psychiatric history [Appendix 1]
  • Kuppuswamy's socio-economic status (SES) scale [12]
  • Mini International Neuropsychiatric Interview (M.I.N.I. Plus 5.0, USA: D. Sheehan, J. Janavs, R. Baker, K. Harnett-Sheehan, E. Knapp, M. Sheehan. University of South Florida - Tampa.)[13]
  • Beck Suicide Intent Scale:[14] It is a 20-item interviewer-administered assessment of the intensity of an attempter's wish to die at the time of the index attempt. The scale is completed using retrospective data obtained from the patient. The total scores obtained are categorized into the following subgroups: (1) Low intent (0–6) (2) moderate intent (7–12) (3) high intent (13–20) and (4) very high intent (21+) [Appendix 2].



Written informed consent was taken following an explanation about the nature and purpose of the study in a language best understood (local language Kannada and Hindi for other patients) by the patient and NOK. The sociodemographic variables of the patient were recorded in the semi-structured pro forma. A detailed history, physical examination, and mental status examination were recorded in a pro forma designed for the study. Psychosocial factors contributing to the attempt was documented with the help of a semi-structured pro forma for assessing psychosocial factors. The assessment of DSH was done by a clinical interview and supported by the Beck Suicide Intent Scale. The psychiatric morbidity was assessed independently by a consultant psychiatrist (Dr. KK) and validated with M.I.N.I. Plus 5.0 and coded as per the International Classification of Disorders Tenth Edition. The author (Dr. KK) was trained to administer M.I.N.I. Plus 5.0 as part of a drug trial.[15]

Statistics

Data were analyzed using SAS/STAT ® version 9.2 of the SAS system for windows. Cary, NC, USA, SAS Institute Inc.)[16] and SPSS Inc. Released. SPSS Statistics for Windows, Version 17.0., (Chicago: SPSS Inc.).[17]


  Results Top


Descriptive analyses

The current study had a sample of 200 cases. The study participants ranged in age from 13- to 75-year-old. Majority of the participants who attempted DSH were in the age group of 21–30 years (52.5%) and females (63%) outnumbered males (37%). Almost 51% were married, over 45% were single, 3.5% were separated, and 0.5% were divorced. Most of the study subjects hailed from urban/semi-urban background (68%), belonged to Hindu religion (92%), and were from middle socio-economic strata (66%) [Table 2].
Table 2: Sociodemographic characteristics (n=200)

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Relevant descriptive information about the clinical characteristics of DSH attempters is shown in [Table 3]. In the present study, the most common method of attempting DSH was by poison consumption (50.5%), followed by drug overdose (35%), while 9.5% preferred hanging as the method, 3% used sharp objects, 1.5% attempted drowning, and 0.5% attempted self-immolation. Majority of them were 1st time attempters (83.5%). Most of the attempts were impulsive in nature (83.5%) and 77.5% of attempters had not communicated to the family members [Appendix 3]. Most of the attempts were of low lethality (68.5%) and low intentionality (58.5%). In our evaluation of various psychosocial factors, 23.5% of them had marital discord, 23% had interpersonal conflict, 16.5% suffered financial loses, 13.5% of them had family dispute, 10.5% had property dispute, 7% of them had health-related issues, 3.5% of young population had scholastic issues, and 2.5% of them had occupational-related stressors.
Table 3: Clinical characteristics of deliberate self-harm attempters (n=200)

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In our study, we found that 48% of subjects had psychiatric diagnosis as assessed by M.I.N.I. Plus. The most common diagnosis was adjustment disorder (23.5%), followed by major depressive episode (14.5%), 3% of them suffered from schizophrenia and related disorders, and 3% of them had recurrent depressive disorder has the current diagnosis. 1.5% each had alcohol dependence syndrome and acute stress reaction has the diagnostic label. One subject had a diagnosis of delusional disorder and benzodiazepine dependence [Table 4].
Table 4: Psychiatric morbidity (n=200)

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Gender-specific analysis is shown in [Table 5] and [Table 6] by using bivariate analysis. Majority of the DSH attempters were in the age group of 11–40 years (91%) and females (n = 121) outnumbered males (n = 61) and it was statistically significant (P = 0.0012). There were no statistical differences between the two genders with respect to other sociodemographic variables. There were slight, but no remarkable differences among the genders in terms of method of DSH. With respect to the two most common methods of DSH adopted in the current study, males (62%) outnumbered females (43%) with poison consumption and females (38%) surpassed males (29%) with drug overdose; however, the differences were not statistically significant. Among the gender differences, male subjects (n = 15) attempted under the influence of alcohol when compared to females (n = 2) and the difference was statistically significant (P < 0.0001). There were no statistical differences when the two genders were compared for other variables such as intentionality, lethality, impulsivity, and number of attempts.
Table 5: Gender-specific sociodemographic characteristics (n=200)

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Table 6: Gender-specific details of deliberate self-harm attempt (n=200)

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Multivariate analyses

The multivariate logistic regression analyses were carried out [Table 7] and [Table 8]. Each outcome variable was modeled in terms of the odds of decedents using a particular method (coded as 1) and all other methods (coded as 0). Gender was coded with male as 0 and female as 1.[18] Analysis was carried out only on the two most common methods of attempted DSH, namely poison consumption and drug overdose. The logistic regressions split the sample by gender to compare the effects of the variables relevant to suicide risk. To examine the potential impact of gender interactions with other factors related to suicide risk on the two methods of suicide, the sample was split by gender. To ascertain if the odds ratios (ORs) for a particular covariate are equivalent across gender, we computed Z scores and associated probabilities that the ORs for males and females were significantly different. As shown in [Table 7], this represents the OR and confidence intervals (CIs) of poison consumption by gender; males from urban/semi-urban background had 4 times the odds of attempting poison consumption as the method of choice (OR = 4.059) when compared to females (OR = 0.904) and it was statistically significant (Z score = −1.8310, P < 0.10). Females who were living alone had a high odds of attempting suicide by poison consumption (OR = 5.723) and was significant when compared to males living alone (P = 0.0521). Unmarried male subjects had 3 times the odds of attempting suicide by poison consumption (OR = 3.192) compared to unmarried females (OR = 1.077). Males also had an increased odds of high lethal attempts (OR = 5.437) when compared to females (OR = 1.130), but was not statistically significant.
Table 7: Odds ratio and confidence intervals of poison consumption by gender

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Table 8: Odds ratio and confidence intervals of drug overdose by gender

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[Table 8] shows the OR and CIs of drug overdose by gender; females from urban/semi-urban background had increased odds of attempting suicide by drug overdose (P = 0.0514) and male subjects from nuclear families had an increased odds (OR = 4.482) when compared to females (OR = 0.815) to attempt suicide by drug overdose, however the difference was not statistically significant.


  Discussion Top


The current study had a sample of 200 cases and females (63%) outnumbered males (37%). This “gender paradox” has been regularly emphasized in literature, and studies have shown that women have higher rates of suicidal behavior, i.e. ideation, planning, and suicide attempts compared to men.[19] However, the rates of completed suicide are in general higher in men, the 2013 NCRB data reports the overall male: female ratio of suicide victims for the year to be 67.2:32.8.[2] The male: female suicide ratio was 1.78 in India in 2008 and 2009 and was 2.05 in 2013. The increase in male suicide can be attributed to various cultural factors and psychosocial factors that shape the gender role. However, when compared to global figures, the male: female suicide ratio is higher in developed countries; 3.8, 3.9, 4.1, and 3.4 in Australia, Canada, the United States, and the UK, respectively.[19] Majority of the DSH attempters were in the age group of 21–30 years (52.5%) and about 91% of the attempters were in the age group of 11–40 years and females (n = 121) again outnumbered males (n = 61) in this productive age group as well. About 37.8% of suicides in India are carried out by those below the age of 30 years and 71% of suicides in India are among people who are below the age of 44 years as mentioned by other authors.[20] This is of huge concern because of its socio-economic implications on the society. About 50% of the male subjects were unmarried and 54% of female attempters married, majority of them were from urban/semi-urban background (71%), Hindu by religion (92%), from nuclear family (74.5%), and hailing from middle SES (66%). These sociodemographic differences among both the genders were not statistically significant and concurred with studies from the sub-continent.[20],[21],[22]

Mental disorders occupy a premier position in the matrix of causation of DSH. Studies in India show varying results with rates of psychiatric disorders ranging from 9.5% to 24.9%.[23],[24] It is generally acknowledged that over 90% of those who committed suicide had a psychiatric diagnosis at the time of death.[25] In the current study, 48% (n = 96) of the study population had a diagnosable psychiatric morbidity. Adjustment disorder was the most common diagnosis (23.5%) followed by major depressive episode (14.5%). This is similar to findings by other authors in similar settings.[26],[27]

This study found that poison consumption (50.5%) was the most common method of DSH for both men and women. About 62.16% of men and 43.65% women chose poisoning as the method of choice. In India, according to the 2013 NCRB data, the share of “poisoning” as a means, adopted by suicide victims was 27.9%.[2] The poisons used were those usually used in the houses as insecticides or pesticides. Factors such as feasibility, accessibility, credibility, and rapidity of action could be behind the choice of method for the attempt. Studies show that consumption of pesticides, such as the readily available agricultural pesticides, is the most common means of suicide and attempted suicide in India.[22],[28],[29] Even global data suggest that poisoning by pesticide was common in many Asian countries and in Latin America.[3] A study by Menon et al. conducted in South India also reports similar figures, “pesticide use was the most favored mode by both males (70.4%) and females (56.9%).”[10] In our study, males from urban/semi-urban background had 4 times the odds of attempting poison consumption as the method of choice (OR = 4.059) when compared to females (OR = 0.904) and it was statistically significant (Z score = −1.8310, P < 0.10). The greater gender differential in urban areas may reflect the occupational differences of males and females. Sociocultural and historical features of communities such as shared norms, traditions, values, and interests; networks of community support; social cohesion and social capital; and mobility into and out of communities have been proposed to explain urban–rural differences in DSH.[30] Other factors such as easy accessibility to health care in urban areas can also explain the high rates of DSH survivors from urban population. In our study, single females living alone had a high odds of attempting suicide by poison consumption (OR = 5.723) and was significant when compared to single males (P = 0.0521). Divorced, separated, widowed, and single people are more likely to commit suicide than married people; persons living alone are at particular risk and the findings have been replicated by various studies,[20],[21],[22],[31] and it indirectly validates Durkheim's concept of “coefficient of preservation.”[27] In our study, males also had an increased odds of high lethal attempts (OR = 5.437) with poison consumption. Males are known to make more lethal attempts.[32] High lethality can also explain the higher rates of completed suicide in males.

The second most common method of DSH attempt in our study was drug overdose (35%) and females (38%) surpassed males (29%) with drug overdose. According to Gunnell et al.,[33] the methods of DSH commonly employed are influenced by their availability and access. Literature review suggests that more women are being admitted to hospital as a result of the ingestions of medicines and other substances.[34] This is likely to be a reflection of reduced availability of pesticides, perhaps secondarily to the gradual urbanization of the country, this has been noted in our study where OR of drug overdose of females from urban/semi-urban background had increased odds of attempting suicide by this method (P = 0.0514). Both males and females reported that their reason for choice of substance was accessibility. According to Vijayakumar, women tend to use self-poisoning for suicidal acts and it is over-the-counter medications which often have low lethality.[22] Females are less frequently the victims of fatal suicides, which indicate that they tend to be the “attempters” and “survivors” rather than “performers” of suicides. This finding may be associated with many factors, among which the mode of attempt seems to be important. As in our study, females attempted with less lethal form, i.e. drug overdose rather than other violent forms.

Other methods in our study were 9.5% preferred hanging as the method (male = 8.10% and female = 10.31%), 3% used sharp objects (all were females), 1.5% attempted drowning (all females), and 0.5% attempted self-immolation (all females). Hanging is consistently reported as one of the common methods of suicide in Asian population and is also considered as a more lethal method.[2],[4] It is generally assumed that the use of hanging and other traditional suicide methods is largely governed by their acceptability and by sociocultural norms.[3] Hanging, for example, is a selective method because it is violent; it needs some preparation, and it needs some degree of courage and determination. Typically, the greater the obstacles, the lower the acceptability of the method.[3] In our study, the gender difference between the two groups with respect to hanging as the chosen method did not vary significantly. However, since the paper discusses about DSH attempts, there is an under-representation of hanging as a method. Usually, in cases of suicide completers, hanging is one of the common methods used. Violent methods such as drowning, jumping from a height, and strangulation are less common.[35] Even in our study, there were few cases who attempted these methods.

Both genders exhibited low intentionality (males = 58.10% and females = 58.73%) and low lethality of attempts (males = 67.56% and females = 69.05%). Studies report that DSH attempters usually have low intent and attempt less lethal methods in general.[32] An interesting thing to note in the current study is the “less lethal” approach in urban male attempters, probably indicating the current changing “gender roles” in our culture, in addition in our current study, majority of the males who attempted DSH (n = 61, 82.43%) were in the age group of 11–40 years and it is a known phenomenon that lethality gradually increases as the age advances and elderly male subjects are known to have high suicide rates with high lethality.[36]

About 79.53% of males and 85.71% of females attempted DSH impulsively and most of them (77.50%) had not communicated to the family members. In young individuals, impulsiveness and short-term triggers such as relational conflicts may often set off suicidal events when they are superimposed on long-term underlying reasons that account for the vulnerability for suicidal behavior in stressful situations. Many young DSH attempters report that they spent only minutes between the decision and the actual attempt indicating a high degree of impulsiveness.[37] In general, an acute situational crisis of deep despair, hopelessness, and unbearable suffering can also precipitate suicidality impulsively.

An important finding in the present study was that male subjects (n = 15) attempted under the influence of alcohol when compared to females (n = 2) and the difference was statistically significant (P < 0.0001). This may reflect substance use patterns in India where rates of substance use in men are considerably higher than that of women. This gender difference is consistent with previous studies where attempted suicide under intoxication was common in males.[38]


  Conclusions Top


The gender-related differences in the methods of DSH attempts are an interesting ever-evolving area. Various psychosocial and cultural factors play an important role in determining the method chosen. In our current study, the most common methods of attempts in both genders were poison consumption and drug overdose. Majority of the attempters (91%) were in the age group of 11–40 years, the most productive and reproductive age group. Continuing with the older findings, females (63%) outnumbered males (37%), however the gender-specific DSH rates are considerably low when compared to developed countries and the gender disparity is slowly reducing in India. Males from urban background and single unmarried females had higher odds of attempting DSH by poison consumption and females from urban background had higher odds of attempting DSH by drug overdose. Most of the subjects were 1st time attempters with low intentionality, low lethality, and high impulsivity. Most of the attempts were precipitated by a psychosocial stressor and in case of males, suicide attempt in an intoxicated state was significantly high when compared to females. It seems that gender differences among DSH attempters appear less pronounced in the Indian setting compared to the worldwide literature on the subjects. Nevertheless, the present study does point to some important differences between male and female DSH attempters that may have implications for preventive work.

Limitations

The current study is an observational cross-sectional hospital-based study with a small sample size and hence the results cannot be generalized. An English version of M.I.N.I. Plus was used and requires translated versions for use in study population. In this regard, a community-based sample may be more representative and may avoid referral biases and issues of gender-related difficulty in access to treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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