|Year : 2021 | Volume
| Issue : 2 | Page : 191-197
Opinions and attitudes of postgraduates towards suicide attempts in a rural tertiary medical college of India
Gurappa Puttanna Gururaj, Navya Aswatha Gopalli, Mohan M Reddy, Ruth Sneha Chandrakumar
Department of Psychiatry, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
|Date of Submission||04-Jun-2020|
|Date of Decision||27-Jul-2020|
|Date of Acceptance||03-Aug-2020|
|Date of Web Publication||30-Jun-2021|
Dr. Gurappa Puttanna Gururaj
Department of Psychiatry, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Suicide, commonly defined as “an act of self-destruction, initiated and committed by a person who is aware of the fatal outcome and has substantial socioeconomic and cultural influences. The current suicide rate in India is 10.6/100,000 population. Doctors play an active part in the treatment and prevention of patients with suicide attempts, and their therapeutic endeavors may interrupt the ongoing suicidal process. The aims and objectives of this study were to assess the Opinions and Attitudes of the postgraduates of the various clinical departments towards suicide and to find out for any differences among postgraduates of Surgical and Medical groups who manage the consequences of the chosen methods of the suicidal attempts of the patients. Postgraduates of psychiatry were not included. Materials and Methods: It was a cross-sectional study done on various nonpsychiatric postgraduates between October and November 2019 in R L Jalappa Hospital, a constituent unit of Sri Devaraj Urs Academy of Higher Education and Research, who are assessed using structured and validated instruments, the Suicide Opinion Questionnaire, and Attitudes to Suicide Prevention Scale. Results: The majority of both the Surgical and allied science groups with the Medicine and allied science group nonpsychiatric postgraduates had a negative disposition towards suicide attempters and negative attitudes towards suicide prevention strategies and there was no statistical difference among them. Conclusion: There must be training for non-psychiatric specialists towards suicide regularly and change in their respective PG training curriculum towards the approach of patients with self-injurious behaviors.
Keywords: Attitudes, opinions, postgraduates, suicide attempts
|How to cite this article:|
Gururaj GP, Gopalli NA, Reddy MM, Chandrakumar RS. Opinions and attitudes of postgraduates towards suicide attempts in a rural tertiary medical college of India. Indian J Soc Psychiatry 2021;37:191-7
|How to cite this URL:|
Gururaj GP, Gopalli NA, Reddy MM, Chandrakumar RS. Opinions and attitudes of postgraduates towards suicide attempts in a rural tertiary medical college of India. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Nov 28];37:191-7. Available from: https://www.indjsp.org/text.asp?2021/37/2/191/320216
| Introduction|| |
Suicide represents a major public health problem worldwide and is commonly defined as “an act of self-destruction, initiated and committed by a person fully aware of the fatal outcome.” It has substantial socioeconomic and cultural influences.
The current suicide rate in India is 10.6/100,000 population. According to the WHO report, 2012, India ranked first in the world in the number of completed suicides. The rate of admissions to hospitals in India following suicide attempts has become a major public health concern., Patients with suicide attempts interact with health-care professionals at various levels in the health-care system such as the entry point (emergency department and intensive care and ward care), discharge, and continuity care. An Indian study found that medical doctors working in the emergency medicine department viewed suicide as unlawful and manipulative.
The more negative attitude expressed toward repeated attempters of self-harm is highly alarming as it increases the subsequent risk for suicide. Hence, health professionals' attitude influences their skills to assess and manage suicide risk as well as the quality of care., Doctors, including nonpsychiatric health professionals, also play an active part in the treatment and prevention of patients with suicide attempts, and their therapeutic endeavors may interrupt the ongoing suicidal process. Attitudes are often conceptualized as having three components: the affective component, the cognitive component, and the behavioral component. The affective component consists of a person's liking or emotional response to the issue or person about which he or she holds the attitude.
The cognitive component consists of the beliefs or knowledge about that person or issue. The behavioral component is the person's overt behavior concerning the person or issue.
Most of the studies done to date have focussed on medical students and nursing personal with a reported negative approach and unfavorable attitude to suicide attempters and preventive measures. Their views and approach to the patients, both verbal and nonverbal behaviors, have a definite bearing on the outcome and in the prevention of further attempts of self-harm in patients. There is an acute shortage of studies from India about nonpsychiatric postgraduates and their attitudes toward suicide and data are very much lacking, especially in rural areas with very few tertiary medical setups. Our aim in this study is to assess the opinions and attitudes toward suicide attempters and to compare with the postgraduates of the clinical departments of medical and surgical specialties, the primary contact doctors, who manage the consequences arising out of the chosen methods of the suicidal attempt of the patients.
| Methodology|| |
This cross-sectional study proposal was approved by the Institutional Ethics Review Committee dated 25.7.2019 with reference NO.SDUMC/KLR/IEC/63/2019–2020, and only after obtaining approval, the study was conducted. The inclusion criteria were the postgraduates of various medical with allied sciences and surgical with allied clinical departments. A total of 92 students are pursuing postgraduate courses in our college, but only 82 were enrolled for the study as the remaining 10 students, 7 from the surgical group, and 3 from the medical group, who were doing their External Institute postings could not be included.
Students with a history of drug dependence apart from nicotine were excluded as their opinions and attitude could be due to altered perceptual and belief changes secondary to addiction to drugs. After obtaining permission from the respective clinical head of the departments, postlunch hours were selected so that the postgraduates had adequate time to fill the scales meant for the study. The assessment was done during the 1st week of November 2019. Students were orally instructed by the principal investigator/coinvestigators about the study and its objectives and their written informed consent was obtained before the main instrument was given to them. They were all informed about their liberty to refuse to be part of the study keeping the sensitivity of the topic in mind. They were asked to read the questionnaire first and queries, if any, with regard to the filling the questionnaire, were addressed. All the forms were collected within a maximum of 1 h of giving the scale, with emphasis to answer every question of “suicide opinion questionnaire (SOQ).” All the postgraduate residents were made to sit separately making sure not to get any clues to the answers to the main scales of measurement and to prevent any discussion among the postgraduates while filling the forms. After obtaining their social demographic details, all the residents were instructed to fill the main instruments meant for the objective of the study, Part-1 of the scale, the SOQ, and then the Part-2 attitudes to suicide prevention scale.
The SOQ is a self-rated, 52-item, Likert scale which measures suicide attitudes based on the following factors: acceptability, perceived factual knowledge, social disintegration, perceived defects, and emotional perturbation., Its psychometric properties have been established.,,,
It has been widely used for the assessment of attitudes toward suicide among various health professionals.,,
Attitude on the individual item was scored on a 5-point Likert scale: 1 – “Strongly agree”, 2 – “agree”, 3 – “uncertain”, 4 – “disagree”, and 5 – “strongly disagree.” Median attitude values were categorized into “favorable,” “unfavorable,” and “Uncertain.”
Attitude scores between 1 and 2 are considered favorable attitudes or positive disposition, 3 is considered “Uncertain or not sure attitude,” and 4 and above “Unfavourable attitude” or “Negative disposition.” The descriptors are reversed for “negatively worded items were indicated by **at the end of the statements.
Attitude toward suicide prevention scale (Herron's)
It is a 14-item, self-rated, 5-point Likert scale with good internal consistency (Cronbach's alpha = 0.77) and high test–retest reliability. It has also been used in previous Indian studies to assess attitudes toward suicides.
Statistical analysis consisting of both the descriptive and inferential statistics was carried out using the statistical software, namely SPSS 22.0 for Windows (Boston, USA) and R environment Ver. 3.2.2 were used. Microsoft Word and Excel sheets were used to generate graphs, tables, etc.,
Frequencies and percentages were calculated for categorical variables and mean and standard deviations for continuous variables. Comparisons were made using Chi-square tests for categorical variables and t-tests for continuous variables.
P < 0.05 was considered significant.
Majority of postgraduates were females and all the postgraduates of both the gender were aged between 18 and 30 years. The majorities of the postgraduates were single and only 34% of them were married.
Almost 93.9% of the postgraduates were of South Indian origin and 4.9% of them were from the northern part of India and an equal percentage (11%) of postgraduates were pursuing medicine, dermatology, and pediatrics. The majority (two-third) of the students were pursuing a postgraduation course in surgery and allied sciences [Table 1].
|Table 1: Salient features – sociodemographic occupational status – of postgraduate|
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Positive disposition statements (positive beliefs)
Few postgraduates reported a “favorable” median responses with six direct statements like agreed that most persons who attempt suicide are lonely and depressed; disagreed that most suicides are triggered by arguments with a spouse; felt ashamed if a member of his/her family committed suicide; disagreed that people who commit suicide do not believe in an afterlife; disagreed that soldier committing suicide during the war is an act of heroism; and agreed that more the suicides, more the problems a nation is facing and by disagreeing to the following 10 negatively worded statements such as suicide happens without warning; people with incurable diseases should be allowed commit suicide in a dignified manner; suicide is greater for older people (60 years and above) than for younger people (20–30); only older people with little to live commit suicide; a large percentage of suicide victims don't come from broken families; once a person is suicidal, he is suicidal forever; the large majority of suicide attempts result in death; there may be situations where only reasonable resolution is suicide; there should be suicide clinics where people who want to die should do so painlessly and privately; and improvement following a suicidal crisis indicates that the risk is over and the probability of a repeat risk of another attempt is minimal [Table 2] and [Table 3].
|Table 2: Analysis of opinions in positively correlated items of (suicide opinion questionnaire)|
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|Table 3: Analysis of opinions for the negatively worded items in suicide opinion questionnaire|
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Negative disposition statements (negative opinions)
Majority of the postgraduates reported negative opinions through the following 19 direct statement with median unfavorable responses such as suicide is normal behavior and by disagreeing to the following statements like people who commit suicide are usually mentally ill; some people commit suicide as an act of self-punishment; suicide is clear evidence of the man has aggressive and destructive nature; 75% of people, who commit suicide, had attempted before and had a weak personality; a large percentage of suicide victims are from broken homes; message in suicide notes is one of unreturned love; people who set themselves on fire are doing to get attention to some political or religious groups; suicides are more common in people who are mentally unbalanced; people who commit suicide lack solid religious convictions; passive suicide, such as on overdose of sleeping pills, is more acceptable than violent suicide such as by gunshot; people who attempt suicide are, as a group, less religious; those who commit suicide are cowards who cannot face life's challenges; individuals who are depressed are more likely to commit suicide; suicide attempters are better off dead; from an evolutionary point of view, suicide is a natural means by which the less mentally fit are eliminated; suicide attempters who use public places are more interested in getting attention; sometimes, suicide is the only escape from life's problems; and if someone wants to commit suicide, it is their business and we should not interfere [Table 2].
Uncertain/”Not sure” responses in suicide opinion questionnaire
The majority of postgraduates also reported 12 “uncertain” responses to the statements like the higher incidence of suicide attempts are due to the lesser influence of religion; most suicide attempts are impulsive; an acceptable means to end an incurable illness; it should be acceptable for aged and infirm persons; rare for someone to think about suicide following listening by a “friendly ear;” overcrowding and increased noise are prone for suicides; suicides among young (e.g., college students) are particularly puzzling; victims of fatal motor vehicle accidents and alcoholism are unconsciously motivated for suicides; obese individuals are more likely to commit suicide; most people who commit suicide do not believe in God; and suicide attempters are more rigid and less flexible than nonattempters [Table 2] and [Table 3].
Findings of the attitudes among postgraduates toward suicide prevention
Majority of postgraduates reported six direct statements indicative of “Positive attitudes” with as they reported; not having resentment when asked to do more about suicide prevention; suicide prevention is their responsibility; working with suicidal patients was rewarding; don't feel uncomfortable when assessing someone for suicide risk; suicide preventive measures are not wastage of resources; and that majority of suicides are preventable.
More majority of postgraduates “Negative attitudes” indicated by 3 direct statements” were identified as they disagreed upon statements like making more funds available to the appropriate health services made no differences to the suicide rate; suicide patients who are serious about doing it don't tell anyone; and there is no way of knowing, who is going to commit suicide.
Postgraduates reported seven statements indicative of attitudes of “uncertain” with the statements like whether it is easy for people not involved in clinical practice to make judgments about suicide prevention; not sure of been defensive when people offered advice about suicide prevention; that they can do little as individuals to prevent unemployment and poverty; if a person survives a suicide attempt, whether was it a play for attention; about their attitude in handling suicidal patients; patients who survive from their attempts prove that they were doing it for the want of attention; and being uncertain that people have the right to take their lives.
The differences observed in mean scores in “SOQ” scale scores between medical and surgical allied specialties were not found to be statistically significant (t = 1.930, P = 0.05).
The differences observed in mean scores in “attitudes to suicide prevention” scale scores between medical and surgical allied specialties were not found to be statistically significant (t = 0.056, P = 0.956) [Table 4].
|Table 4: Analysis of attitudes toward suicide among postgraduates: Suicide prevention scale (Herron et al. 2001)|
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| Discussion|| |
This study used two standardized scales for assessing opinions and attitudes separately in Indian settings and also examined only nonpsychiatric postgraduates which make this study unique to this aspect.
More than half of the postgraduates were females in our study group and were in the age group of 18–30 years. Previous studies have shown female health professionals reporting favorable attitudes,, unlike one North Indian study on medical students where more males than females reported a more positive attitude.
We did not look for gender-based differences due to the unequal distribution of males and females and due to overall small sample size in our study.
Common suicide triggers as reported in the index study like a disturbed interpersonal relationship, small-family, suicide is more seen in broken families and weak personality, having cultural inhibitions in emotional expression, and national instability has an association of mental illness with suicide attempters, were similar to the different studies done in the past on mental health-care workers, emergency nurses in India as well as on medical students of Japan and Europe.,,,
Our participants reported positively regarding the role of religion toward suicide prevention in line with other studies that have shown favorable responses that strong religious convictions protect an individual from attempting suicide.
Most of the postgraduates in our study reported having positive opinions through statements like attitudes like most persons who attempt suicide are lonely and depressed.
They disagreed that most suicides are triggered by arguments with the spouse; felt ashamed if their family member committed suicide; agreed that working with suicidal patients was rewarding; agreed that suicide prevention is their responsibility; agreed that poverty and employment were the major triggers for suicidal attempts; agreed that they don't feel uncomfortable when assessing someone for suicide risk; suicide preventive measures are not wastage of resources; and that majority of suicides are preventable. These were similar to an Indian study finding done on 175 medical students in the urban Bangalore.
The negative beliefs and attitudes among our postgraduates expressing like suicide are normal behavior; people who commit suicide are usually not mentally ill; message in suicide notes is not of unreturned love; passive suicide is more acceptable than violent suicides; depressed people are not more likely commit suicide; suicide attempters are better off dead; suicide is a natural means by which the less fit are eliminated and if someone wants to commit suicide, doctors should not interfere; and is a serious drawback and ignorance among them; it indicates the absolute lack of knowledge and exposure in them toward suicidal ideas and acts which they come across in their routine clinical work.
The reasons for our postgraduates to have the above negative attitudes could also be attributed to the fact that there are no postgraduate trainings for psychiatry in our institute at the time of the study which could have deprived their chances of learning from regular interdepartmental postgraduate meetings as part of their curriculum. Furthermore, interactions with psychiatry postgraduate students would have given some inputs about every patient with suicidal attempts referred to the department of psychiatry seems to be considered as well.
The majority of the postgraduates had a negative belief that suicide happens without warning, which is slightly worse when compared to 50% in the study of medical students which is a source of concern indicative of still existing common prevailing myth as in the general public toward suicide and its preventive measures.
Our postgraduates were uncertain regarding patients' rights to life; In contrast, positive responses were given by health care providers in a study done at urban Bangalore reporting that people have no right to end their lives [Table 4]. This reflects a lack of knowledge in our postgraduates regarding basic human rights and inadequate knowledge that people have no right to end their lives. This reflects a lack of confidence in our postgraduates handling patients with suicidal ideation.
Our participants were uncertain regarding whether they had any role in reducing unemployment and poverty which can serve as a prevention measure against suicide indirectly which points toward poor knowledge regarding the role of rehabilitation and vocational services, which any health specialist can recommend.
There was no difference between surgical and medical postgraduates in our study, unlike the Korean study where physicians responded more positively than surgeons having more positive attitudes toward suicide and its preventive measures [Table 5] and [Table 6].
|Table 5: Comparisons of opinions toward suicide among postgraduates (suicide opinion questionnaire)|
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|Table 6: Comparisons of attitudes toward suicide among postgraduates: Attitudes to suicide prevention scale|
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We are currently living in a digital world, where with just a finger click, any updates about any illness across the world can reach us within milliseconds. This is a serious issue that points toward the lack of curiosity and undue importance to acquire proper information and knowledge about suicide among the postgraduates.
We did not analyze for any correlation of religion and domicile of postgraduates and their opinion and attitudes to suicide unlike the study of medical students in northern India where Hindus and students from rural background had favorable attitudes.
Limitation of the study
The main instrument of measure was the SOQ: first, the items were created approximately 30 years ago; thus, they may now be interpreted differently than when originally written. Second, while 65 items were created to evaluate opinions and 35 items were created to assess knowledge, respondents may answer items meant to assess opinions as if they are assessing knowledge.
Third, some respondents may answer based on well-thought-out opinions, whereas others may answer based on reactive opinions created “on the spot.” Finally, the items may assess too many constructs to establish stable factor structures. Taken together with other psychometric evaluations of the SOQ, future refinement of measures that assess suicide opinions is necessary.
Attitude toward the suicide prevention scale is not adapted for the Indian population. Solely, using the quantitative method has an inherent limitation of restricting responses to the given options. Other limitations of the study are that the findings cannot be generalized as the sample was drawn only from a medical institution of a rural district, southern India, and SOQ is not validated/generalized for the entire Indian population, and we also could not collect information about respondents' personal or family history of any suicidal idea or acts. Our sample size is too small and students are pursuing their course in a rural district and the findings cannot be generalized to all the postgraduates in the country.
| Conclusion and Recommendations|| |
Suicide is a complex human behavior with a complex etiology and a result of complex interactions between self, between individuals, his/her family members, the existing norms and expectations of his/her society, his/her country of origin, and the world at large.
Patients, who present with self-injurious behaviors, always pose a significant challenge to the health-care delivery system. Educational strategies to increase suicidal ideation assessment performance should be available to all professions involved in general and psychosocial patient care, starting with medical and residency schools.
This study also highlights the importance of increasing the knowledge and understanding of nonpsychiatric health professionals about patients with self-harm.
Postgraduate students are the future gatekeepers of their specialty and they will come across suicide attempters in the future course of their respective careers.
There must be training for nonpsychiatric specialists toward suicides regularly and change in their respective postgraduate training curriculum toward the approach of patients with self-injurious behaviors. It is recommended that frequent interdepartmental case discussions/conferences are incorporated into their postgraduate training with the department of psychiatry.
The Authors would profusely like to thank the entire teaching faculty who participated in the study with a special thanks to Mr. R. Ravishankar, Assistant Professor, Dept. of Community Medicine, SDUAHER, for his statistical inputs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]