Pattern of deliberate self-harm seen at a tertiary teaching hospital in Meghalaya , India

1Assistant Professor, Department of Psychiatry, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India, 2Consultant Psychiatrist and Ex. Senior Resident, Department of Psychiatry, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India, 3Schizophrenia Research Foundation, R/7A, North Main Road, Anna Nagar West Extension, Chennai, Tamil Nadu, India


Introduction
"Suicide" or "completed suicide" is defi ned as "a death from injury, poisoning, or suff ocation where there is evidence (either explicit or implicit) that the injury was self-infl icted and that the decedent intended to kill himself or herself " while "suicide attempt" is defi ned as "a potentially selfinjurious behavior with a nonfatal outcome, for which there is evidence (either explicit or implicit) that the person intended at some (nonzero) level to kill himself/herself.[1] According to these defi nitions, a suicide attempt is a potentially selfinjurious behaviour with a nonfatal outcome.An identifi able injury does not need to occur for a behaviour to be classifi ed as a suicide attempt.
Suicide is major public health issue worldwide.Per the World Health Organization (WHO) report, 800,000 die by suicide every year around the world.[2] Suicide accounts for 1.4% of total deaths worldwide making it the 15th leading cause of death.[3] Nearly 75% of the suicide deaths occur in the low-and middle-income countries.[4] Even though suicide occurs in all age groups, it is the second most common cause of death among 15-29 years group globally.[5] Th e economic and human cost of suicidal behaviour to individuals, families, communities, and society is high.[6] Th e suicide rate in India is 10.6/100,000 population.[7] Th e suicide rate diff ers among various states such as Maharashtra with suicide rate of 43.2/100,000 and Lakshadweep with 1.3/100,000.[8] Various risk factors such as mental illness, family history of psychopathology, and recent life events have been identifi ed as important risk factors for suicide.In India, social and economic reasons are the major causes for suicidal death in men while emotional and personal problems are the causes in women.[9] It was also observed that hanging is the most common method of suicide in both men and women followed by insecticide poisoning.In one study conducted in North-East India, depression and gender were found to be signifi cant determinants of suicide attempt in the study population.[10] Th e exact rate of deliberate self-harm (DSH) is not available in India.It is estimated that for each one suicidal death there are 25 attempted suicides in the youth population while this number comes down to 1:4 in the elderly.[11] It is also observed that females attempt suicide three times more common than males.[12] Th e important factors that have been implicated for attempted suicide are previous self-harm, personality disorder, psychiatric illness, alcohol abuse/drug dependence, and living alone.[13,14] Studying the magnitude of DSH and its associated demographic and life stressors would help in understanding the problem at hand and develop specifi c measures to prevent further suicidal attempts and deaths.Very few studies have explored the pattern and factors associated with attempted suicide in North Eastern part of India.Th e aim of the present study was to identify the pattern of DSH seen in a tertiary care centre in Meghalaya and to explore the socio-demographic factors and stressors associated with DSH.

Materials and methods
Th e study was conducted at North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGRIHMS) in Shillong, Meghalaya, India.It was designed as a hospital-based cross-sectional study with consecutive sampling.Institutional Ethics Committee approval was obtained before the start of the study.Th e study was conducted from February 2012 to August 2013.Individuals who presented to the hospital with a history of DSH were recruited into study aft er obtaining informed written consent.Th e subjects were recruited from casualty, outpatient departments and inpatient wards.Individuals who were critically ill aft er the suicide attempt requiring intensive care and who did not give consent were excluded from the study.
At the point of contact, detailed history and mental state examination was done and subjects were diagnosed according to WHO ICD-10 by a psychiatrist (AN, SST).[15] A semistructured questionnaire specially designed for the current study was used to collect information about the patients' socio-demographic details, stressors, and information regarding DSH.Subjects were treated accordingly based on the diagnosis and further follow-up of the subjects were advised.
Th e measures were a socio-demographic proforma and a clinical datasheet.Th e Suicide Intent Scale which is a 15 questions questionnaire that are marked as zero, one, or two.[16] Items one to eight assess the objective circumstances (e.g.isolation, precautions against discovery, suicide note) and items nine to 15 assess the subjective intention and expectations regarding the attempt given as less than ten signifying 'low-intent' , ten to 15 'intermediate-intent' , and a score of >15 points signifi es 'high-intent' suicide attempt.

Results
A total of 50 individuals with the diagnosis of DSH and fulfi lling the inclusion and exclusion criteria were taken up for the study.Table 1 depicts the socio-demographic profi le of the study population.Nearly 65% of the study population was in the age group of 15-25 years while 25% of the study population was in the age group of 26-44 years.Females were predominant when compared to the males (0.6 males/ female).While 24% of the study population was from the rural background, the majority (76%) were from urban setup.Home was the most common place of DSH with maximum attempts happening during the 6:00 PM-6:00 AM period (48%).Medication overdose (24%) and chemical ingestion (44%) were the two most common methods of DSH while hanging (eight per cent) and jumping from heights (six per cent) were the least common methods.Alcohol ingestion was present along DSH attempt in 20% of the study population.Suicide note was not written by any of the study population before attempting DSH (Table 2).
In our sample 38% (n=19) attempters had family history of suicide and 42% (n=21) had a past history of psychiatric illness.Ninety two per cent (n=46) of suicide attempters had a life stressor in last one month of the attempt of which, family and relationship issues were the most common stressors in 68% (n=34) (Table 3).

Discussion
DSH is an important public health issue and it has huge impact on the individual, families and the society at large.Understanding the regional epidemiology of DSH pattern is an important component for initiating measures to address and prevent further DSH in the community.Similar to previous studies from other parts of India and world, we found that the most common age group to attempt DSH is the 15-25 years followed by 26-44 years.[17][18][19] Data released from WHO also concords with our results that Females attempted more DSH (62%) when compared with the males and this distribution is consistent with other studies.[12,21,22] Th e major mode of DSH was poisoning either by prescription medications or pesticides.Similar pattern is also seen in other parts of India and other developing countries.[23][24][25][26][27] Th is is in contrast with the developed countries where fi rearms are the major mode of self-harm.Many studies have shown that restricting the pesticides in a safe commonplace, reviewing the pesticide regulatory policies, and community interventions have reduced the incidence of DSH by pesticides.Here prescription overdose has signifi cant proportion of the total poisoning and this trend is alarming.While hanging is the second most common form of DSH in other studies, we found that cutting with sharp objects were more common than hanging in our study population.
In our study, we found that more DSH were attempted during the weekdays than the weekends.Similar pattern is observed in other recent studies.[28] We also noted a diurnal variation in the DSH pattern.While most of the DSH were attempted in the night between 6:00 PM and 6:00 AM, there was lesser DSH in the noon to 6:00 PM when compared to 6:00 AM to noon.Th is is in contrast with other studies which have shown a steady increase in the DSH attempts as the day progressed from morning to night.[26,29] But, another study has shown that the maximum attempts happen in the early morning and hits the nadir at night.[30] Th e exact reason for this diurnal variation in DSH is not known.It has been suggested that increased adrenergic activity and lowered serotoninergic activity could possibly play a role.[31] To our knowledge, this is the fi rst study that has looked into the pattern of DSH from the North-Eastern part of India.Th e present study shows the major pattern of DSH from this part of the country and it would be helpful in planning preventive strategies in the North-Eastern part of India.Th e major limitation of the present study is that this was a crosssectional hospital-based study.Another major limitation of the study is the lack of follow-up of the subjects aft er their discharge from the hospital.dialectical behavioural therapy (DBT), and mentalisationbased therapy (MBT).
In conclusion, DSH has an increasing trend and it aff ects the young productive age group.Th e major means of DSH is poisoning by pesticides and prescription medications.In contrast to other studies, we have seen an increased frequency of DSH in the weekdays when compared to the weekend.Further community-based studies should be done to determine the prevalence and pattern of DSH in the community.

Future
studies should be prospective in nature and with built-in mechanisms for follow-up of the patients with DSH to know about the long-term outcome in these patients.Various factors leading to DSH should be studied and patterns to be identifi ed.Th e understanding from these studies should translate into meaningful interventions for the prevention of DSH.Th e intervention strategies could include pharmacological interventions such as antidepressants, electroconvulsive therapy (ECT) and psychological interventions such as cognitive behaviour therapy (CBT),

Table 1 :
Socio-demographic profi le of the study population

Table 3 :
Psychological profi le of individuals presented with deliberate self-harm (DSH)