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Original Article

DELIBERATE SELF HARM- TRENDS IN GERIATRIC POPULATION AND FACTORS RELATED TO IT

Rakesh Kumar Paswan1, Ravi Rana2 , Sanjay Gupta3

1 & 2. Lecturer, L.L.R.M.Medical college,Meerut, U.P. India 3. Professor (IMS Varanasi)

Abstract

Background: Old age is itself a major life stress adding a large burden and stress to life of every individual impairing his coping. This maladjustment of life cycle when coupled with some psychiatric disorder or life stress can produce suicidal ideations, which if neglected can lead to deliberate or fatal self harm.

Aim: The study was undertaken to study the Psychiatric co-morbidities in geriatric suicide attempters, preceding life event and stress in geriatric suicide attempters.

Methodology: Total 480 subjects with attempted suicide were evaluated. Only 63 subjects fulfilled the inclusion exclusion criteria & rest 417 subjects were excluded from the study. They were thoroughly evaluated on preformed Sociodemographic Performa and various scales after being declared physically fit.

Results & Conclusion: This study was an attempt to understand the complex phenomenon of geriatric suicide. In this study the prevalence of geriatric suicide out of total suicide was demonstrated to be 13.13%. About 34.9 % subjects were screened positive for common psychiatric disorders.

Key words: Suicide, stress.

 

Introduction

Suicide is a tragic situation for the individual, his or her family and friends, and the communities of which they are a part. At a population level suicide is also a major public health problem, accounting for over 0.1 million deaths each year in Indian subcontinent1 and an estimated one million or more worldwide. Despite this high official data suicidal events assumed to be more in number as recent data suggests that suicide rates in India are grossly underreported due to various legal and social causes 2,3,4,5.

According to the census 2011, the elderly (>65 years) made up 5.5% of total population6. As compared to prior data of censes, a trend of increased life span is observed adding more geriatric population. Old age is a stage of debilitated physical health as well as a stage with compromised psychological, social and family support. Person in this age group face maladjustment with their daily need due to their compromised physical or psychological state or due to lack of support they need. Sometime this general phenomenon of impaired adjustment of old age population is coupled with some stressful life situation or some psychiatric disorder and gives rise to morbid phenomenon of suicidal ideation. This suicidal ideation may lead to deliberate self harm or fatal self harm leading to loss of the life. Various studies demonstrate that geriatric suicide comprises 12-18% of total suicide7,8,9, which is increased as compared to past data. So it seems to be a target group because geriatric population which is only 5 % comprises about 15 % of suicide victims (3 times more).

Acknowledging the complexity and multi-determined nature of suicidal behavior in older adults10 need for providing a framework for its understanding and on which to base its prevention is urgently needed. There are various studies which had focused various markers of suicide and demonstrated that violent behavior (Conner K.R. et al 2001)11, substance use (Nordentoft M)12, Depression, Dementia (Andersson F 2002)13 and other psychiatric illness (Gupta SC 1981; Jain V et al 1999; Kung HC et al 2003)14,15,16, suicide rehearsal and Self absorbed behavior or isolation (Barraclough B)17 can be a preceding event in suicidal subjects. Elderly men seem especially vulnerable one study reports a relative risk for widowed men being over three times that of married elderly males, whereas widowed and married elderly women showed similar risk (Guohua, 1995)18.

Aims and Objectives

The study was undertaken with the following aims and objectives:-

To assess:

       Psychiatric co-morbidities in geriatric suicide attempters.

       Preceding life event and stress in geriatric suicide attempters.

       Psychosocial factors in deliberate self harm.

Methods and Material

The study was conducted in Sarojni Naidu Medical College, Agra for a period of 1 year from August 2011 to august 2012. It was a cross sectional study. All consecutive subjects of deliberate self harm with age >65 years coming to emergency department of S. N. medical college were enrolled. They were thoroughly evaluated on preformed Sociodemographic Performa and various scales after being declared physically fit. Corroboration of data given by patient was done by information gathered from accompanying informants.

Selection of cases

Total 480 subjects with attempted suicide were evaluated. Only 63 subjects fulfilled the inclusion exclusion criteria & rest 417 subjects were excluded from the study. Most common cause for exclusion was their age less than 65 years (98.56%).Written informed consent was taken from the subjects, maintaining confidentiality and anonymity.

Inclusion criterion

1.       Age ≥65 years.

2.       Subjects who were physically stable (stable vitals).

3.       Who gave written informed consent.

Exclusion criterion

1.       Age <65 years.

2.       Unwilling & uncooperative patients.

Following tools were used for the Assessment

1.       Preformed Performa with detailed sociodemographic evaluation, and evaluation of various aspects of suicidal event.

2.       Various scales-Presumptive Stressful Life Events Scale (PSLES), Standardized Assessment of Personality Abbreviated Scale-SAPAS; Mini mental status examination-MMSE; Hamilton Depression Rating Scale HAM-D; Hamilton Anxiety Rating Scale-HAM-A.

Result

Table-1 Sociodemographic distribution of study population

Variable

Denominator

Number of subjects

Percentage

Gender

Male

40

63.5%

Female

23

39.5%

Age

65-75

39

61.9%

76-85

21

33.3%

>85

3

4.8%

Religion

Hindu

44

69.8%

Muslim

17

27%

Others

2

3.2%

Marital status

Married

22

34.92%

Single

41

65.08%

Residence

Rural

38

60.3%

Urban

25

39.7%

Education

Illitrate

12

19%

Upto Primary

22

34.9%

Upto Highschool

15

23.8%

Upto Intermediate

8

12.7%

Graduate or above

6

9.5%

Occupation

Unemployed

37

58.7%

Unskilled

25

39.7%

Skilled

1

1.6%

 

*Single( Widow/ widower/ separated/ unmarried)

 

 

 

 

 

Table-2: Various Psychiatric co morbidities detected in the subjects by using various screening tools i.e. HAM-D, SAPAS, MMSE and HAM-A.

 

S.N.

Psychiatric Disorder

No. of Subjects

Percentage

1

Depression

22

34.20

2

Personality

2

3.17

3

Dementia

5

7.9

4

Anxiety

3

4.76

5

Total

32

50.79

 

 

Table 3-Mode of attempting suicide

S.N.

Mode of attempt

No. of subjects

Percentage

1

Poisoning

32

50.79%

2

Hanging

12

19.05%

3

Fall from height

2

3.17%

4

Burn

3

4.76%

5

Self mutilation

11

17.46%

6

Drowning

2

3.17%

7

Others (Rail)

1

1.59%

 

Table 4: Causes of suicide as stated by the subjects who attempted suicide

S.N.

Cause of suicide

No of subjects

Percentage

1

Conflicts marital/family

20

31.75%

2

Death of beloved

12

19.05%

3

Economic crisis

18

28.57%

4

Loneliness

3

4.76%

5

Other

10

15.87%

Discussion

Out of total 480 subjects only 63 subjects were evaluated (13.13%) and most of the subjects were excluded due to age less than 65 years. This data roughly represented the prevalence of geriatric suicide in total suicide subjects. This finding was in co-relation with the findings of other studies on suicide, which roughly demonstrated the prevalence of geriatric suicide in all suicide subjects to be 12-18%7,8,9.

On analyzing the sociodemographic data 63.5% subjects were males and rest were females. Maximum numbers of subjects of suicidal attempt were from 65 to 75 age group which is due to more population of this age group subjects. Religion wise most of the subjects were Hindu (69.8%), and residence wise mostly they were from rural background ( 60.3%) which roughly correlates the census data of 2011 (Indian census 2011) . Most of the subjects were educateed below high school. This finding was in correlation with the finding of other studies on geriatric suicide attempters, which showed that suicide is more common in old age males as compared to females (Guohua, 1995)18. Occupation wise 59% subjects were unemployed or retired and 39% were doing unskilled works.

On screening the subjects for psychiatric co morbidities 22 were depressed (34.20%), 2 have some personality traits (3.17%), 5 subjects have dementia (7.9%) and 3 were suffer from some kind of anxiety disorders (4.76%). Total 32 out of 63 subjects were screened positive for psychiatric disorders. 34.9 % of total were screened for substance use behavior. The study results were in correlation with some other studies who demonstrated that old age suicide is less due to impulsivity and more due to some physical or psychiatric illness. A study by Lawrence D8 et al in Australia in 2004 concluded that old age suicide is significantly associated with Psychiatric disorders. Highest risk of suicide was found in patients with diagnoses of affective psychoses, adjustment reaction or depressive disorder in that study. Batchelor & Napier (1953)19 diagnosed 10% of their attempted suicides aged 60 and over as having an organic dementia and 47% had depression.

On comparing various scales statistically p value (2-tailed) came to be o.ooo which signified that the evaluation was statistically significant but the measured outcome was sub syndrome except for PSLES which demonstrated high stress level in the subjects. On comparing gender wise difference in stress (PSLES) score was more for male subjects with P value 0.03, which was significant statistically. This provided a clue for more suicide rates in old males.

On comparing various mode of suicide, most of the subject used Poisoning (50.79%) rest attempted suicide by Hanging (19.05%), fall from height (3.17%), Burn (4.76%), Self mutilation (17.46%), Drowning (3.17%), and Others (1.59%). The study finding was in correlation with the study done by Khan MM (2002)1.On analyzing the suicidal events thoroughly, it was clear that Communicability was present in only 28.6 % cases, Impulsivity in 21.6% cares, Repent in 39.7 % cases and substance use in 34.9% case (including nicotine).

When we analyze the causes of suicide stated by the subjects, maximum number of subjects (31.75%) attempted suicide due to some short conflict (marital or family). Other causes of suicide were Death of beloved (19.05%), Economic crisis (28.57%), Loneliness (4.76%) and other (15.87%).

Conclusion

This study was an attempt to understand the complex phenomenon of geriatric suicide. In this study the prevalence of geriatric suicide out of total suicide was demonstrated to be 13.13%.

It seemed that old male that are single are more prone for suicidal behavior. Stress level was high in most of the subjects. About 34.9 subjects were screened positive for common psychiatric disorders. Maximum of them had depression. Poisoning and hanging were commonest methods used by the attempters.

Impulsivity proved less significant in geriatric suicidal events, and most of them were planned. Communicability was only 28.6% regarding. Other significant findings were prior suicidal events in 4% cases, impulsivity in 21.6% cases, repent or regret about the event in 39.7% cases, note of act in 18 % cases, knowing the consequences in 82% cases and substance use in 34.9% case (including nicotine).

If the findings are analyzed and accumulated it is clear that old age suicide is hard to forecast but when the awareness is there, it can be screened and by providing proper care and treatment lives can be saved.

References

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