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Family Conflict – the Major Underlying Influence in Suicide Attempts in Northern Bihar, India

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Family Conflict – the Major Underlying Influence in Suicide Attempts in Northern Bihar, India ORIGINAL ARTICLE Family Conflict – The Major Underlying Influence in Suicide Attempts in Northern Bihar, India. Sangeeta Naira, Lois Joy Armstrongb, Philip Finnyc a Clinical Psychologist, Department of Medicine, Duncan Hospital, A unit of Emmanuel Hospital Association b Research Co-ordinator, Epidemiology and Research Dept, Duncan Hospital, A unit of Emmanuel Hospital Asso- ciation c Consultant Physician/Endocrinologist, Duncan Hospital, A unit of Emmanuel Hospital Association Abstract Suicide attempts in North India are generally underreported but have been considered to be rising. The number of admissions due to attempted suicide at Duncan Hospital, North Bihar, rose from 82 in 2007 to 419 in 2011. A structured interview and the WHO (World Health Organization) Major (ICD-10) Depression Inventory were completed by 157 suicide-attempt survivors. Immediate relatives were also interviewed. Only 23% of patients came from India; 77% of patients came from Nepal. The highest incidence was in the age group 16- 20 years. Females have higher rates in the 21-30 year age group (p=0.012), but af- ter 30 years of age, the number of males becomes higher than the females (p=0.048); 81.5% of the respondents were below the age of 30 years. Pesticide poisoning was the major mode of attempted suicide (94.3%). Us- ing the WHO Major (ICD-10) Depression Inventory, 28 of the participants suffered from depression (17.7%). Ninety people (56.9%) admitted to previous thoughts of suicide, and nine (5.7%) people had attempted suicide previously. Hindus made up 84.0% of the respondents. Almost 50% of respondents only carried out their religious rituals on an occasional basis or not at all. 70.2% had not completed education beyond primary school, and 49.7% earned less than Rs10,000 per month (US$200). Eighty percent of the participants stated conflicts with family members led to the attempted suicide. Relatives did not expect the attempted suicide in 97.4% of cases. Knowledge of the suicide of a neighbour, friends, or relative influenced 77.0% of the participants to attempt suicide. Efforts to prevent suicide attempts and deaths need to be multifaceted. Banning the most poisonous pesticides and improving poison storage in the com- munity must be encouraged. Prevention, early intervention and treatment all are required in a suicide prevention plan. The lack of psychiatrists necessitates that other professionals and trained non-professionals be utilised in the mental health team. Holistic care should include cultural aspects like shame as well as physical, psychosocial, and spiritual issues. Special interventions need to be aimed at train- ing adolescents in stress management and conflict resolution and mentoring ado- lescents to become part of strong, caring families. April 2015. Christian Journal for Global Health, 2(1): 23-34. 24 Nair, Armstrong & Finny Introduction In general, health facilities in Bihar are 6,7 Suicide is a worldwide phenomenon, and severely under resourced. The number of whether it is a fatal or non-fatal suicide attempt, psychiatrists per 100,000 population has been it has repercussions on the family, the extended studied, and, overall, India has a 77% deficit in family, and wider community. India is no the number of psychiatrists. Bihar is the third most badly serviced state with a deficit of exception. Shame has always been associated 8 with suicide, but in cultures where shame and 96.62%. At the time of the study, there were no honour play a larger cultural role than in the psychiatrists in the District of East Champaran Western world, suicide has its own unique (5 million people) and no evidence of a District characteristics. It leads to the problem of suicide Mental Health Plan. being hidden and underestimated. This is In India, there are many reports of rising especially so in the teeming millions of North suicides and particularly high rates reported in India. the affluent states of India such as Kerala and 9-11 The state of Bihar had a population of 104 Tamil Nadu. In Maharashtra and Andhra Pradesh, farmer suicides are a particular problem million in the 2011 census and a population 12 density of 1100 people per square kilometre.1 and frequently relate to financial crises. In With the current 25% growth rate, this is now North India, especially Bihar, there is little data, much higher.1 Bihar is on the fertile Gangetic and lack of reporting may be influencing the 13 plain and has an 89% rural population, reported low rates in these regions. predominantly farmers.1 Although productive Around the world, there are many reports farming land, it is prone to flooding because of of rural suicide rates being higher than urban. the many rivers running down from Nepal, Some of the reasons given are the instability of across the plain, and into the Ganges River. The farming income due to climate change and natu- religion figures from the 2011 census are not yet ral disasters, increased access to pesticides and available, but in the 2001 census, Hindus made firearms, social isolation, higher population of up 79% of the population of Bihar followed by indigenous communities, and decreased access 16.5% Muslims and 0.064% Christians.2 to health care and, specifically, psychiatric 14-16 In rural Bihar, the literacy rate is 59.78% care. with female literacy lagging behind at 44.3%.1 In India, Radhakrishnan reports urban sui- The figure for the timely completion of primary cides to be higher than rural, using National school education for the state is 23%.3 Only Crime Records Bureau (NCRB) data, with the 21% of primary school teachers had completed reasons given being social isolation and over- 17 tenth standard of education. 3 Bihar follows crowding. In the Million Death Study, rural Uttar Pradesh in being the state with the second suicides are reported to be higher than urban largest number of people below the poverty line. with the reasons suggested to be higher avail- However, as a percentage of the population, ability of pesticides and poorer access to medical 18 Bihar is the highest.4 In East Champaran care. The discrepancy between these two In- District where Duncan Hospital is located, dian reports may be that there are poorer report- 21.3% of people have access to electricity, ing systems in rural India. 93.5% use firewood/crop residue/cow dung as Duncan Hospital is a 230 bed hospital and fuel for cooking, 61.2% have a phone/mobile community health facility at Raxaul, East phone, and 8.8% possess a computer. 5 It is Champaran District, Bihar. It began in 1930 on these types of figures, along with a history of the Indo-Nepal border to serve patients from poor administration and law enforcement, which both India and Nepal. It is a secondary level have given Bihar the reputation of being the referral centre with basic specialities and is part most backward state in the country. of the larger Non-Governmental Organisation, May 2015. Christian Journal for Global Health, 2(1): 23-34. 25 Nair, Armstrong & Finny Emmanuel Hospital Association. At the time of early or against medical advice were unable to the study, there were two physicians who took a be interviewed. One or two close relatives of special interest in mental health and a clinical the patient were also interviewed. At the time of psychologist. the interview, the psychologist also provided Duncan Hospital recorded 82, 126 and counselling for the patient and their relatives. 202 admissions due to attempted suicide in the Patient and close relative interviews were years 2007, 2008, and 2009. Of these 410 done using a questionnaire looking at patients, 403 patients ingested poisons demographic and socio-economic factors and a (predominantly pesticides), and seven attempted series of questions related to social factors and hanging (Unpublished hospital data). An audit reasons for suicide. The WHO Major (ICD-10) of poisoning cases was carried out from 1 Depression inventory was also completed to February 2011 to 31 January 2012 that included assess for depression among the attempted 418 attempted suicides by poisoning and one suicide cases.19 The Beck Depression Inventory attempted hanging. These poisoning cases was pilot tested, but was found to be too difficult constituted 9.5% of all the medical inpatients. to be used due to the complexity of ideas and Of those who took poisons, 9.5% died due to words used. fatal complications. The age group with the The data from the questionnaire was highest frequency was 16-20 years, and there coded and put in MS Excel and analyzed. were slightly more females than males (52.1%: Vassarstats Online was used for obtaining p 47.9). (Unpublished hospital data) values for differences of proportions and for After collecting a year of clinical data, confidence intervals.20 95% two-tailed expanded understanding of the psychological measurements were applied. Approval for this and sociological issues involved in attempted study was obtained from Emmanuel Hospital suicide in this region was needed. Current Association Research and Ethics Committee literature seems to have variation across the (Proposal Number 80). country regarding influencing factors, and as there was no published literature from this Results region, we hoped to determine what factors were relevant for North Bihar. The aim of this was to Between 16 May 2012 and 13 March help us develop relevant hospital and 2013, there were 372 suicide attempts (368 community services with appropriate personnel poisonings and 4 hangings) of which 32 persons to treat mental health issues and prevent died in hospital. One hundred and fifty-eight of suicides. these suicide-attempt survivors were approached for interview. One interview was not completed Materials and Methods due to problems with language.
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