Self-reported suicidality and its predictors among adolescents from a pre-university college in Bangalore, India

Asian Journal of Psychiatry 7 (2014) 38–45

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Self-reported suicidality and its predictors among adolescents from a pre-university college in Bangalore, India Poornima Bhola a,*, Dorothy P. Rekha a,1, Vidya Sathyanarayanan a, Sheila Daniel a,2, Tinku Thomas b a b

Department of Psychiatry, St. John’s Medical College & Hospital, Bangalore 560034, India St. John’s Research Institute, Bangalore 560034, India

A R T I C L E I N F O

A B S T R A C T

Article history: Received 17 June 2013 Received in revised form 3 October 2013 Accepted 6 October 2013

There is increasing concern about suicide rates in the vulnerable developmental stage of adolescence. The experiences and expressions of suicidality among adolescents are often ‘‘hidden’’ and occur due to complex and cumulative interactions of multiple factors. A cross-sectional survey assessed self-reported suicidal ideation, suicide attempts and helpseeking behaviour among adolescents attending a pre-university college in Bangalore, India. This formed part of a 2-year teacher training project for Adolescent Mental Health and Suicide Prevention in the college. 1087 male and female adolescents aged 16–18 years, completed the Columbia Teen Screen which assessed self-reported suicide attempt/s (lifetime, past 3 months) as well as suicidal ideation (current, past 3 months) and associated intensity, severity and duration. Adolescents’ perceptions about the need for help and mental health consultation were also assessed. Emotional and behavioural difficulties were reported on the Strengths and Difficulties Questionnaire. The results indicated that 25.4% of the adolescents reported suicidal ideation (past 3 months) and 12.9% of the total sample expressed their need for seeking help. The rate of suicide attempt was 12.9% (lifetime) and 6% (past 3 months). Logistic Regression analysis identified factors associated with recent suicidal ideation and attempt. Females had higher rates of suicide ideation and attempts than males (Ideation OR = 1.4, CI = 1.04–1.9; Attempt OR = 2.2, CI = 1.0–4.5) and adolescents with abnormal emotional and behavioural problems were at higher risk for suicidal ideation (emotional difficulties OR = 4.6, CI = 3.2–6.6; hyperactivity/ inattention OR = 2.1, CI = 1.3–3.2). The findings add to the limited database on youth suicidality in India and have implications for prevention and intervention. ß 2013 Elsevier B.V. All rights reserved.

Keywords: Suicidal ideation Suicide attempts Adolescents Screening Predictors

1. Introduction Adolescence is a critical developmental stage with multiple challenges during the transition to adulthood. While many may navigate this phase successfully, a proportion of teenagers experience psychosocial stressors and manifest emotional and

* Corresponding author. Present address: Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bangalore 560029, India. Tel.: +91 9844026260. E-mail addresses: [email protected] (P. Bhola), [email protected] (D.P. Rekha), [email protected] (V. Sathyanarayanan), [email protected] (S. Daniel), [email protected] (T. Thomas). 1 Present address: Department of Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences, Bangalore 560029, India. 2 Present address: Sreesha Hospital, Coimbatore, India. 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.10.003

behavioural problems. With adolescents, aged 10–19 years, comprising nearly one-fifth of the total population in India (Census of India, 2001), there are unique challenges in understanding their needs and providing adequate mental health care. There is little information about the prevalence and patterns of emotional and behavioural disturbances among Indian adolescents (Bhola and Kapur, 2003). Most school and community-based epidemiological studies focused on children or merged the data for children and adolescents. Data about the mental health needs of adolescents at the cusp of adulthood, between 16 and 20 years, is particularly limited. Globally, suicide rates among the adolescent and young adult ˜ o, 2010) and this is an important segment are worrying (Minin public health issue in India as well (Jena and Sidhartha, 2004; Vijayakumar, 2010). Exploration of risk factors have spanned multiple areas; biological or genetic factors, culture and sociodemographic factors, psychopathology, previous suicide attempts,

P. Bhola et al. / Asian Journal of Psychiatry 7 (2014) 38–45

adverse developmental and psychosocial contexts, stressful life events, maladaptive coping, sexual orientation, and access to lethal means. A cluster of recent Indian studies, with diverse methodologies, have focused on assessing rates of suicide attempts, ‘suicidal behaviours’, suicidal ideation and deliberate self harm among adolescents in community settings (Aaron et al., 2004; Arun and Chavan, 2009; Pillai et al., 2009; Sharma et al., 2008; Sidhartha and Jena, 2006; Singh et al., 2012). A majority of these studies have also explored select demographic and psychosocial variables as risk factors of suicidal ideation or behaviour. Sidhartha and Jena (2006) estimated suicidal ideation and attempts in 12–19 year old adolescents in Delhi. The prevalence of suicidal ideation (lifetime), suicidal ideation (last year), suicide attempt (lifetime), suicide attempt (last year) were 21.7, 11.7, 8 and 3.5%, respectively. The risk factors predictive of suicidal ideation included Hindu religion, female sex, older age, physical abuse by parents, perceived parental neglect, history of running away from school, history of suicide by a friend, death wishes and past deliberate self harm. Another cross-sectional study (Sharma et al., 2008) assessed 550 adolescents aged 14–19 years, from schools and colleges in Delhi. The results indicated that 15.8% had serious thoughts of attempting suicide while 5.1% had made a suicidal attempt in the past one year. The rates of suicidal ideation and attempt were both higher among females. The number of role models seen smoking or drinking was also predictive of suicidal ideation. Rates of suicidal behaviour in the recent three months, among a large sample of 16–24 year old rural and urban youth from Goa were lower at 3.9% (Pillai et al., 2009). Psychosocial variables associated with suicidal behaviour included female gender, not attending school or college, independent decision-making, premarital sex, physical abuse at home, sexual abuse and presence of probable common mental disorders. A recent study by Arun and Chavan (2009) explored the relationship between stress, psychological health, and presence of suicidal ideas in 2402 Indian high school students. The results indicated that 6% reported suicidal ideas and 0.39% of the students reported a suicidal attempt on a visual analogue scale. The findings emphasised that academic problems and unsupportive home environment were associated with perceptions of life as a burden and higher rates of suicidal ideation. A study conducted by a team from Christian Medical College, Vellore (Aaron et al., 2004) reported remarkably high rates of completed suicide among young people in Southern India. The mortality rates were analysed for 10 years, from 1992 to 2001, for the age-group 10–19 years. Suicides accounted for about a quarter of all deaths in young men and between 50 and 75% of all deaths in young women. The average suicide rate for young women was 148 per 100,000, and for young men 58 per 100,000. These high rates emphasise the need for intervention in this vulnerable group. In another recent study (Singh et al., 2012), active or passive suicidal ideation was reported by 39% of college youth from Bangalore, aged 18–25 years. The rate of suicidal ideation with active or passive desire as well as preparation was 15% and this was associated with early traumatic experiences like physical abuse and self-reported affectionless parental control and neglectful parenting. Overall, the few school and college based studies reported fairly high rates of suicidal ideation, with a wide variation in rates, and some of the studies found that female students were particularly vulnerable. Although the rates of suicide attempts are relatively lower than rates of expressed suicidal ideas, they are still a matter of concern. Global literature has linked suicidal ideation with other indices of psychopathology and psychosocial dysfunction (Lewinsohn et al., 1996), and identified this as one potential risk factor for future suicide attempts (Borges et al., 2010). Findings have

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emerged with respect to select demographic and psychosocial contexts in the Indian studies. Associations with possible mental health vulnerabilities remain relatively unexplored. The need to understand the phenomenon of suicide among youth in our unique cultural context (Vijayakumar et al., 2005) and to tailor effective prevention strategies (Vijayakumar, 2007) has been emphasised. The Million Death study in India found that suicide was the second leading cause of death for youth aged 15–29 years, with an age-standardised rate per 100,000 population as 25.5 among males and 24.9 among females (Patel et al., 2012). Regional variations were noted, with the Southern states of Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu having significantly higher suicide death rates than some of the North Indian states. Statistics from the National Crime Records Bureau of India ranked Bangalore as the metropolitan suicide capital of the country in 2010 and in second place in both the 2011 and 2012 reports (National Crimes Records Bureau of India, 2010, 2011, 2012). The NCRB (2012) figures of 480 male and 472 female suicides in the age band 15–29 years, reported from Bangalore city, are likely to be underestimates. Together, these findings point to youth forming a vulnerable segment and consistent reports of high rates of suicide deaths from Bangalore. However, there is limited research exploring this phenomenon specifically among adolescents and young adults in Bangalore. The realities are that the limited resources and multiple barriers to recognition and help seeking mean that many young people may slip through without receiving any primary, secondary or tertiary mental health inputs. Both boys and girls in this age group are vulnerable to pressures related to educational expectations from parents and teachers, relationship issues and peer pressure. The present study was planned in response to a spate of youth suicides in an educational institution in Bangalore and formed part of a 2-year teacher training project for Adolescent Mental Health and Suicide Prevention. This research aims to contribute to the existing knowledge on suicidality and psychopathology among pre-university students in India. 2. Methodology 2.1. Aims and objectives of the study To survey self-reported suicidal ideation and attempts and their predictors among pre university students in a college in Bangalore. 2.2. Sample The sample included 1087 male and female students enrolled in the first and second year of an English medium pre-university college in Bangalore. Informed assent and consent for participation was sought from all 1336 students enrolled in the pre-university college, and their parents. 2.3. Tools 2.3.1. Sociodemographic data sheet Socio-demographic data such as age, sex, educational course details, family composition and other relevant socio-demographic details were collected from the students using a structured questionnaire. Participants’ perceptions of difficulties in the following domains – academic, family, peer and health, were also assessed in a yes/no format. 2.3.2. Strengths and difficulties questionnaire (SDQ) The Strengths and Difficulties Questionnaire (Goodman et al., 1998) is a 25 item self-report behavioural screening questionnaire. These 25 items are divided between 5 scales: emotional symptoms

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P. Bhola et al. / Asian Journal of Psychiatry 7 (2014) 38–45

(5 items), conduct problems (5 items), hyperactivity/inattention (5 items), peer relationship problems (5 items) and prosocial behaviour (5 items). These are added together to generate a total difficulties score based on 20 items (excluding the prosocial items). Scores can be classified as normal, borderline and abnormal to help identify potential ‘‘cases’’ with mental health concerns. Experience gained with the SDQ in varied cultures and languages has supported European evidence of good psychometric properties and clinical utility of this questionnaire (Woerner et al., 2004). The SDQ has been used to assess the incidence of childhood psychiatric disorders among 10–17 year olds in the community setting in India (Malhotra et al., 2009) and in other Indian studies with adolescent samples (Bharath Kumar Reddy et al., 2011; Srikala and Kishore Kumar, 2010). 2.3.3. Columbia Suicide Screen This 14 item self-report screening questionnaire was developed for assessing risk of suicidal behaviours for youth aged 11–18 years (Shaffer et al., 1996). It includes items on suicide-risk behaviours (i.e., suicidal ideation in the past 3 months and suicidal attempts, ever and in the past 3 months), ‘emotional items’ including depression, anxiety and substance use, as well as general health problems. If the respondent answers positively to the Yes/No stem questions about suicidal behaviour, s/he is then directed to a series of Yes/No questions assessing the seriousness of the problem and aspects of helpseeking. The stem questions for depression, anxiety and about alcohol and drug abuse ask the respondent how much of a problem s/he is having with these areas on a 1 (no problem) to 5 (very bad problem) scale. If the problem is rated as a ‘‘bad problem’’ or a ‘‘very bad problem,’’ respondents are then asked Yes/No questions about whether they are concerned about the problem, have seen a mental health professional, or have an appointment to see a mental health professional. Adequate test-retest reliability was reported and the concurrent validity for identifying youth at risk for suicidal behaviours was assessed against the NIMH DISC-2.3. Findings related to predictive validity indicated that a classification of ‘‘at risk’’ yielded 78% sensitivity and 53% specificity in predicting suicide attempts a year since the initial screen (Shaffer and Craft, 1999). More recently, Shaffer et al. (2004) reported a scoring algorithm with sensitivity of 0.75, specificity of 0.83 and positive predictive value of 16%. 2.4. Procedure Ethical clearance was obtained from the institutional ethical review board. A pilot study was conducted to determine the time taken for completion and comprehension of instructions and items. Appropriate changes in the wording of two items were made. The word ‘siblings’ in the sociodemographic data sheet was replaced by the term ‘brothers and/or sisters’. The statement ‘I skip school’ in the Strengths and Difficulties Questionnaire (SDQ) was modified to ‘I skip (bunk or miss) college’. The college teachers were given an orientation regarding administration of the questionnaires. The parental consent forms were sent to all parents by the college authorities and 1334 consented for participation within the time period given for return. Two parents did not give consent for their wards to participate in the study. The group administration of the questionnaires was done by the teachers and investigators in the classroom setting including all 1004 students who were present and provided written informed assent. The instructions were given by an investigator, while the teacher introduced the investigator and assisted in distributing and collecting questionnaires. The investigators responded to any questions or doubts expressed by the students. A second round of

administration was conducted at a later date during which 133 students who were absent on the first occasion were given the questionnaires after they provided informed consent. Fig. 1 describes the procedure of administration and the number of students who participated. The total number of questionnaires collected after the two rounds of administration was 1137. The total number of completed questionnaires suitable for analysis was 1087. The survey participation rate was 81.4%. All participants were provided with information about the counselling resources available at the college and about mental health services at various locations in the city. The researchers also planned and participated in the Mental Health Day programme at college and addressed parents at another programme, to increase awareness about mental health and help seeking options. 2.5. Analysis Categorical data are presented as number (%) and continuous data as Mean  SD. The association of socio-demographic characteristics with suicidal ideation and suicide attempt/s was examined using chi-square test and logistic regression. Characteristics that were significant in the chi-square test were considered in the logistic regression analyses. The results of this analysis are expressed as Odds Ratio, 95% Confidence Interval (OR, 95% CI). Statistical significance

Total Students N= 1336 Parents refused consent N= 2 N = 1334

Total Students present on Administration Time 1 N= 1044

Absent Students at Administration Time 1 N = 290

Students did not assent N = 40 Total questionnaires collected with assent N = 1004

Total students approached on Administration Time 2 N= 290

Students absent or did not assent N= 157

Total questionnaires collected with assent N= 133

Total Responses Time 1 and Tine 2; N = 1137

Total complete questionnaires for data analysis; N = 1087 Fig. 1. Flowchart representing administration and data collection.

P. Bhola et al. / Asian Journal of Psychiatry 7 (2014) 38–45

was considered at p < 0.05 and all analyses were performed using SPSS Version 18.0.

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Table 2 Emotional and behavioural difficulties reported by the sample of pre-university students (N = 1087). SDQ domains

3. Results The sample consisted of 1087 pre-university students from a college in Bangalore, with a mean age of 16.4 years. There were more males than females (57.5% vs. 42.5%). The sample was almost equally divided between the first and second year of pre-university college. The religious background of the students was predominantly Hindu. About 3/4th of the sample was living in nuclear families. Of the sample, 63.2% lived in an urban area; 23.6% were from a rural area and 13.3% lived in a semi-urban area and more students were from the Commerce stream (53.6%). Paternal education levels tended to be higher than maternal education levels (Table 1). The results in Table 2 indicate that 20.6% of the sample had Total Difficulty scores in the abnormal range on the SDQ. Frequency analysis of subscale scores indicated that 22.4% scored in the abnormal range on Emotional Symptoms; 18.8% had abnormal scores on Conduct Problems; 12.6% on the Hyperactivity/Inattention subscale and 9.4% on the Peer Problems subscale. Over 80% of sample had adequate prosocial behaviour with 7.9% scoring in the abnormal range. Table 3 presents the frequency and percentage of college youth who responded to the various ‘emotional items’ of the Columbia Suicide Screen as a ‘bad’ or ‘very bad problem’. The most frequently endorsed items pertained to ‘losing temper/being in a bad mood’ (15.2%), ‘feeling unhappy’ (12.5%) and being ‘nervous or afraid’ Table 1 Sociodemographic characteristics of the sample of pre-university students (N = 1087). N Age (years), mean  SD Gender Male Female Education level P.U.C. 1st year P.U.C. 2nd year Education stream Science Commerce Religion Hinduism Islam Christianity Others Type of family Joint Nuclear Extended Residence of family Urban 665 Rural Semi-urban Maternal education status Not formally educated Upto 5th Std. Upto 10th Std. Upto P.U.C. Graduation Postgraduation Paternal education status Not formally educated Up to 5th std. Up to 10th Std. Up to P.U.C. Graduation Postgraduation

%

16.4  0.83 625 462

57.5 42.5

540 542

49.9 50.1

498 575

46.4 53.6

1014 38 24 6

93.7 3.5 2.2 0.6

235 754 53

22.6 72.4 5.1

63.2 248 140

23.6 13.3

95 101 449 195 194 47

8.8 9.3 41.5 18.0 17.9 4.3

53 61 321 225 283 136

4.9 5.7 29.7 20.9 26.2 12.6

Total difficultiesa Emotional symptoms Conduct problems Hyperactivity/inattention Peer problems Prosocial behaviour

Abnormal

Borderline

Normal

N

%

N

%

N

%

224 243 204 137 102 86

20.6 22.4 18.8 12.6 9.4 7.9

234 135 201 115 273 70

21.5 12.4 18.5 10.6 25.2 6.4

628 708 680 834 708 903

57.8 65.2 62.7 76.8 65.4 85.6

a Total difficulty score = Sum of scores on the 4 subscales; emotional symptoms, conduct problems, hyperactivity/inattention and peer problems.

Table 3 ‘Emotional items’ on the Columbia Suicide Screen (CSS) reported by the sample of pre-university students (N = 1087).. CSS emotional itemsa

N

%

% need help

% seen professional

Losing temper/bad mood Feeling unhappy Feeling nervous or afraid Withdrawal Problem getting along Drugs or alcohol

160 131 81 37 38 10

15.2 12.5 7.8 3.6 3.6 1.0

61.4 62.2 64.8 62.8 59.6 60.9

4.7 2.8 3.9 4.5 5.6 8.6

Note: Total numbers of respondents vary slightly due to missing data. a Response as ‘bad’ or ‘very bad problem’ on CSS emotional items.

(7.8%). Difficulties related to social withdrawal, difficulties getting along with peers or the use of substances were reported as problematic by a much smaller proportion of respondents. Over 60% of those individuals, who reported significant problems in any of these domains, recognised and expressed the need for help. In contrast, only 2.8–8.6% of these youth had met a mental health professional. The results in Table 4 indicate that 25.4% of the adolescents reported recent suicidal ideation (past 3 months). Responses pertaining to the severity and pervasiveness of the suicidal ideation indicated lower percentages of suicidality. This included frequent suicidal thoughts (17.7%), serious thoughts (11.6%), long duration (9%), and current suicidal thoughts (11.4%). While 13.5% of the sample expressed the need for help to deal with these thoughts, a minimal proportion had contacted or seen a mental

Table 4 Suicidal ideation and attempts reported by the sample of pre-university students.

Suicidal ideation Thought of killing self (past 3 months) Still thinking Often thought Thought seriously Thinking for long time 93 Think get help Seen mental health professional (past 3 months) Appointment scheduled with professional Suicidal attempt Tried to kill self (ever) Tried to kill self (past 3 months) Think get help Seen mental health professional (past 3 months) Appointment scheduled with professional Risk algorithma

N

%

263 118 183 120 9.0 140 12 17

25.4 11.4 17.7 11.6

134 65 60 11 12

12.9 6.4 5.8 1.1 1.2

116

11.2

13.5 1.2 1.6

Note: Total numbers of respondents vary slightly due to missing data. a Risk algorithm for the Columbia Suicide Screen: any recent suicidal ideation OR prior lifetime suicide attempt AND 3 or more emotional items rated as a medium, bad, or very bad problem.

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health professional. Among individuals reporting suicidal ideation in the past 3 months, 4.6% had contacted a mental health professional and 6.5% had a scheduled appointment. Table 4 indicates that 12.9% of the adolescents had made a suicidal attempt and 6.4% reported a recent attempt during the past three months. Over 90% of those individuals, who reported a recent suicide attempt, (5.8% of the sample), expressed the need for help. There was a large gap in the percentages of those individuals who needed help and those who had accessed or had planned to access mental health care. Among vulnerable individuals who reported a suicide attempt in the past three months, 16.9% had met a mental health professional and 18.5% had a scheduled appointment. A scoring algorithm, combining any recent suicidal ideation or prior lifetime suicide attempt, with significant difficulties on emotional items of the CSS (self-reported depression, anxiety, substance use), screened 11.2% of the adolescents as ‘at-risk’. Two logistic regression analyses explored the predictors of recent suicidal ideation (past three months) and suicide attempt (past three months), among the range of socio-demographic factors and domains of emotional and behavioural difficulties assessed on the SDQ (Table 5). Chi square analysis was first done to examine the association between these variables and recent suicidal ideation and recent suicidal attempt to identify those to be entered into the two regression analyses. These included gender, educational level, education stream, type of family (nuclear, joint or extended), maternal educational level, paternal educational level, SDQ emotional symptoms, SDQ conduct difficulties, SDQ hyperactivity-inattention, SDQ peer problems and SDQ prosocial behaviour. Based on the results of the chi square analysis, select variables; gender (p  .000**), Type of family (p = .02*), SDQ emotional symptoms (p  .000**), SDQ conduct difficulties (p  .003**), SDQ hyperactivity-inattention (p  .000**) and SDQ peer pressure (p  .000**); were entered into the regression analysis as potential predictors of recent suicidal ideation. The chi square analyses identified gender (p  .002**), educational stream (p  .03*) and SDQ emotional difficulties (p  .008**) to be entered into the second regression analysis as potential predictors of recent suicidal attempt. Among the socio-demographic variables, gender alone was significantly associated with recent suicidal ideation such that female students were more likely to express suicidal ideation than male students (OR = 1.4, 95% CI: 1.04–1.9). Students who had emotional difficulties in the abnormal range were 4.6 times more likely and those in the borderline range were almost twice as likely to express suicidal ideation (OR = 1.9, 95% CI: 1.2–3.04) than students who were in the normal range. Similarly, individuals with

hyperactivity and/or inattention in the abnormal range and those in borderline level of hyperactivity/inattention were more likely to report suicidal ideation when compared to those without these difficulties (OR = 1.9, 95% CI: 1.2–3.0 and OR = 1.1, 95% CI 1.7–2.7 respectively). Female students had significantly higher odds of attempted suicide in the past three months when compared to male students (OR = 2.2, 95% CI: 1.0–4.5). None of the other characteristics were associated with recent attempted suicide. 4. Discussion The assessment of suicidality revealed that one-fourth of the pre-university youth reported recent thoughts about suicide. The rates dropped to between 9 and 11.6% when the seriousness, persistence and duration of suicidal thoughts were assessed. Global estimates of point prevalence of suicidal ideation in adolescence are not widely discrepant, at15–25%, ranging in severity from thoughts of death and suicide to specific suicidal ideation with intent or plan (Grunebaum et al., 2004). In fact, Marcenko et al. (1999) summarised studies that reported worryingly high lifetime prevalence rates of suicidal ideation among non-clinical populations of adolescents, ranging from 60 to 70%. They also suggested that these rates were likely to be realistic estimates among youth, given the likelihood of concealment and underreporting of such thoughts. Developmental perspectives that explain this dramatic upsurge of suicidal ideation during this life stage, focus on the rapid biological and psychological changes, coupled with the advent of abstract thinking (Marcenko et al., 1999). The limited data base, varied sample characteristics, definitions of suicidal ideation, differing instruments or time frames for assessment and widely diverse methodologies in Indian research on suicidality make it difficult to contextualise the present findings. The rates of suicidal ideation among Indian youth varied widely from 6.0 to 39% in community-based studies (Arun and Chavan, 2009; Sharma et al., 2008; Sidhartha and Jena, 2006; Singh et al., 2012). The relatively high rates of suicidal ideation in the present study when compared with most other Indian studies could be partly related to methodological variations. Screening for suicide risk with the Columbia Suicide Screen has reported high sensitivity, but at the expense of specificity (Shaffer et al., 2004). Two of the highest rates of suicidal ideation among youth in India have emerged from the present research and from the study by Singh et al. (2012); both from Bangalore. One might speculate whether this reflects a regional imbalance in India, with higher suicide deaths being reported in Southern states (National Crimes Records Bureau of India, 2012; Patel et al., 2012). This has been partly attributed to a combined effect of prevalent suicidal

Table 5 Logistic regression analysis for significant correlates of recent suicidal ideation and attempt (in the past three months). Correlates

Categories

Gender (ideation)

Male Female

Emotional difficulties (ideation)

Hyperactivity/inattention (ideation)

Gender (attempt)

SE

Odds ratio (95% CI)

P value

0.353

0.161

1 (reference) 1.4 (1.04–1.9)

– .03*

Normal Borderline Abnormal

0.667 1.524

0.228 0.189

1 (reference) 1.9 (1.2–3.04) 4.6 (3.2–6.6)

– .003* >.000**

Normal Borderline Abnormal

0.545 0.723

0.237 0.220

1 (reference) 1.7 (1.1–2.7) 2.1 (1.3–3.2)

– .022* .001**

Male Female

0.782

0.371

1 (reference) 2.2 (1.0–4.5)

.035*

B: logistic regression coefficients; SE: standard error; CI: confidence interval. * p value <.05. ** p value <.001.

B

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thoughts and planned in the context of social acceptance of suicide as a response to stress and difficulties (Manoranjitham et al., 2007). Suicidal ideation may range from fleeting thoughts to more persistent and intense preoccupations with clear plans; not all suicidal ideation results in an attempt on life. Nevertheless, it is a matter of concern, both because of short-term risk and the potential long-term implications for adult mental health. In a longitudinal study, suicidal ideation at age 15 was found to be a marker of distress and a predictor of compromised functioning, psychopathology and suicidal ideation and behaviour at age 30 (Reinherz et al., 2006). Research also indicates that the severity (high intent or planning) and pervasive nature (high frequency or duration) of the suicidal ideation increases the likelihood of a suicide attempt (Lewinsohn et al., 1996). Worldwide, lifetime estimates of suicide attempts among adolescents range from 1.3 to 3.8% in males and 1.5 to 10.1% in females (Andrews and Lewinsohn, 1992; Fergusson and Lynskey, 1995; Lewinsohn et al., 1996). Of course, the actual number of suicide attempts would be grossly underestimated, because of inadequate treatment seeking and documentation (Hawton and Goldacre, 1982; Lewinsohn et al., 1994). The information gap about suicide attempts would perhaps be wider in India due to stigma, difficulties in access to medical and mental health care and current legislation making suicide attempts a punishable offence under the Indian Penal Code. The present study revealed relatively high rates of self-reported suicide attempts: lifetime (12.9%) and recent (3 months; 6.4%). However, the estimates did not factor in information about the lethality or intentionality of the attempts. Related Indian studies exploring youth suicidality reported rates (for durations between 3 months and one year) ranging between 0.4 and 6.1% (Arun and Chavan, 2009; Sharma et al., 2008; Sidhartha and Jena, 2006). In another study, suicide attempt/s (lifetime) were reported by 8% of surveyed adolescents (Sidhartha and Jena, 2006). One of the most salient findings of the study brings into sharp focus the low helpseeking rates among youth-at-risk. While the large proportion of vulnerable youth acknowledge the need for help, this felt need clearly does not translate into contact with mental health services. In a developing country like India, this is likely to reflect a complex amalgamation of internal and external barriers; awareness, availability, personal and social acceptability and affordability. Efforts to reduce this large gap between need and help seeking for mental health and wellbeing at the critical life stage would need to be responsive, targeted and multi-pronged. The current scenario calls for mental health literacy and stigma reduction in tandem with sensitisation of key gatekeepers situated squarely within educational institutions to facilitate early identification. Mental health screening programmes within educational institutions need to be used with caution, perhaps as a starting point, to be followed up by clinical assessments. Practical algorithms to identify vulnerable youth can lower rates of ‘false positives’ and provide feasible numbers of those in greatest need. Information about predictors of youth suicidality can aid in targeted outreach to more vulnerable segments. Gender emerged as a consistent predictor of both self-reported suicidal ideation and attempts. Beautrais (2002) summarised conclusions from Western literature that indicated double the risk of suicidal ideation and attempts among young females when compared with young males. Conversely, males were three- to fourfold more likely to die by suicide than females. These consistent differences could reflect complex reasons including differences in methods, intentionality, the cultural beliefs related to suicide, psychopathology (for example; substance abuse, mood disorder, externalising behaviours and propensity to violence), and psychosocial differences between males and females.

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The emergent findings about gender differences in suicidal ideation and attempts are consonant with reviews of Indian work (Vijayakumar et al., 2004). Interestingly, in developing nations, like India, the male-female gap was found to be much narrower and approaching equality (Vijayakumar et al., 2004). The present findings, coupled with previous data, converge to suggest that young females may form a particularly vulnerable group. Suicide prevention programmes in India need to be informed by the research base on gender differences in youth suicidality. Understanding the relationship between mental health difficulties and suicidality among youth has important implications for planning suicide prevention initiatives. Earlier research has demonstrated links between psychiatric disorders and suicidality among adolescents (Lewinsohn et al., 1996). The present findings suggest that the most vulnerable youth were those with emotional difficulties in the abnormal range on the SDQ, being more than four times more likely to express suicidal ideation than those who did not report emotional difficulties. It may be noted that youth with emotional difficulties in the borderline range demonstrated a higher (almost double) risk for experiencing suicidal ideation when compared with youth in the normal range. The recent large multi-country Empowering Young Lives in Europe (SEYLE) study also reported that both subthreshold and threshold levels of depression and anxiety predicted increased risk of suicide among adolescents (Bala´zs et al., 2013). Together, these results highlight the need to broaden the net, while identifying youth at risk for suicide, to include those with sub threshold symptoms of depression and anxiety. The findings also strengthened the case for early identification and intervention for symptoms of hyperactivity and inattention among youth. These symptoms, in both the borderline and abnormal range, were associated with 1.7–2.1 times the risk of reporting suicidal ideation. These results find support in the Youth Gazel Cohort study (Galera et al., 2008) which reported that hyperactivity-inattention symptoms predicted suicidal plans/ attempts in adolescence. In a study of the effects of psychiatric disorders on suicidal behaviour in adolescents aged 12–19 years, Kelly et al. (2004) found attention deficit-hyperactivity disorder increased the risk for attempted suicide among males. However, Daviss and Diler (2012) found that past and current ADHD symptoms and signs were not associated with lifetime suicidal behaviour in adolescents aged 11–18 years. The links between symptoms of hyperactivity-inattention and suicidality among youth warrant further scrutiny in future research. The results of the study provide information about suicide risk and psychopathology among the vulnerable and at-risk segment of pre-university students in a college in Bangalore. They emphasise the need to reach out to youth in need and expand the focus of mental health care to educational and community settings. The gap between perceived needs and help seeking with mental health professionals in our resource-poor context could be narrowed by integrating counselling resources and life skills programmes into the educational system. The development and strengthening of multiple, alternate avenues; teachers, peer counsellors, telephone helplines and internet-based resources; is imperative. Schools and colleges should be an integral part of evolving mental health delivery systems in India for early identification, sensitisation, mental health promotion, multilevel interventions and referral pathways involving all stakeholders. These efforts need to be realistic and examine issues related to training content, duration and delivery, feasibility and evaluation, multiple roles and responsibilities of teachers, systemic barriers as well as sustainability of programmes. Gatekeeper training to sensitise teachers to early identification and referral could be an important thrust area for youth mental health and suicide prevention in the country.

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The limitations of the study include the non-representative sample and the purposive sampling method carried out in a single centre, and the lack of information about socioeconomic status of the sample, which restricts the generalisability of findings to youth in other contexts. The Columbia Suicide Screen measure has not been validated for use in the Indian context. The research design could have benefited from a more comprehensive assessment of suicidality, inclusion of impairment ratings on the SDQ and other putative risk factors implicated in the literature. The lack of a clear distinction made between nonsuicidal self-injurious behaviours and suicidal ideation or attempts could have influenced reported rates of suicidality. Common-method variance, arising out of the use of self-report measures to assess both suicidality and emotional and behavioural problems may have impacted the associations between the variables. While the study provided estimates of potential ‘atrisk’ youth, screening programmes in educational institutions would require methodologically superior assessments with adequate predictive power. 5. Conclusions The results can provide a springboard for future research in terms of large-scale epidemiological surveys on psychopathology and suicidal risk among late adolescents and young adults in India, using more representative samples and assessment of relevant psychosocial variables. Future research could also include a twostage assessment procedure including standardised clinical interviews. Mixed-method designs using qualitative methods could be useful to understand the stressors and difficulties encountered by this vulnerable segment of the population as well as explore the personal and structural barriers to helpseeking. The research findings underscore the imperative need for informed and targeted youth suicide prevention initiatives to address this public health issue. Funding: Research grant from St. John’s Medical College and Hospital Research Society. Acknowledgements: Ms. Rita Pledger for assistance in data entry. Dr. Uma Devi, Principal. Seshadripuram P.U. College and Dr. M.V. Ashok. St. John’s Medical College and Hospital, for their support. References Aaron, R., Joseph, A., Abraham, S., Muliyil, J., George, K., Prasad, J., Minz, S., Abraham, V., Bose, A., 2004. Suicides in young people in rural southern India. Lancet 363 (9415) 1117–1118. Andrews, J.A., Lewinsohn, P.M., 1992. Suicidal attempts among older adolescents: prevalence and co-occurrence with psychiatric disorders. J. Am. Acad. Child Adolesc. Psychiatry 31, 655–662. Arun, P., Chavan, B.S., 2009. Stress and suicidal ideas in adolescent students in Chandigarh. Indian J. Med. Sci. 63, 281–287. Bala´zs, J., Miklosi, M., Kereszteny, A., Hoven, C.W., Carli, V., Wasserman, C., Apter, A., Bobes, J., Buner, R., Cosmn, D., Cotter, P., Haring, C., Iosue, M., Kaes, M., Kahn, J.P., Keeky, H., Marusic, D., Posturan, V., Resch, F., Saiz, P.A., Sisak, M., Snir, A., Tubiana, A., Varnika, A., Sarchiapone, M., Wasserman, D., 2013. Adolescent subthreshold-depression and anxiety: psychopathology, functional impairment and increased suicide risk. J. Child Psychol. Psychiatry 54 (6) 670– 677, http://dx.doi.org/10.1111/jcpp.12016. Beautrais, A.L., 2002. Gender issues in youth suicidal behaviour. Emerg. Med. 14 (1) 35–42. Bharath Kumar Reddy, K.R., Biswas, A., Rao, H., 2011. Assessment of mental health of Indian adolescents studying in urban schools. Malaysian J. Paediatr. Child Health 17 (2) . Retrieved from http://mjpch.com/index.php/mjpch/article/ view/276/193 (accessed 25.9.13).

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