Clinical profile of non-fatal suicidal behaviour in adolescents

INTRODUCTION

Non-fatal suicidal behaviour (NFSB) is defined as intentional self-inflicted poisoning, injury or self-harm which may or may not have a fatal intent or outcome.^[1] The rise in NFSB among children is a growing concern in paediatrics. It is one of the major risk factors for completed suicide.^[2] Other risk factors include different sexual orientation, depression, bullying, impact of media, internet use and adoption^[3,4] These NFSB indicate serious emotional distress and often affect children at an age when they should be enjoying their childhood. This troubling trend urges us to understand the root causes, contributing factors and social and psychological consequences of NFSB in children. This study was done to understand the clinical profile of NFSB in our hospital.

MATERIAL AND METHODS

This observational, cross-sectional, prospective study was conducted in our hospital between September 2022 and March 2024 among children aged 8–17 years who were admitted for NFSB. Approval for the study was obtained from the Institutional Ethics Committee (KCGH/EC/1619/Inst/KA/2021). After obtaining consent from parents or guardians and assent from patients more than 12 years, children and adolescents aged 8–17 years admitted to KC General Hospital for NFSB were included in the study, which means self-harm and suicide attempts with the ability to comprehend and respond to the assessment tools. Patients with severe cognitive impairments or developmental disorders that hinder participation, acute medical conditions requiring immediate intensive care, unwilling to consent for participation in the study, and those undergoing treatment for chronic psychiatric conditions were excluded from the study. After clinical stabilisation, each patient underwent a comprehensive evaluation using the Columbia Suicide Severity Rating Scale (C-SSRS).^[5] This initial assessment included a detailed questionnaire about their suicidal ideation, behaviours, and the context of their actions. They were followed up, telephonically, monthly for 6 months, and the same scale was administered at the end of 6 months to assess the suicidal ideation during the study. The details of the same were entered into the pro forma, and adherence was ensured by calling the patient on a fixed date and time every month. The participant and guardian were counselled regarding the importance of follow-up. All participants were referred to the psychiatrist at admission and treated at his discretion.

Descriptive statistics were used to summarise the demographic and clinical characteristics of the participants. Frequencies and percentages were calculated for categorical variables, and Chi-square tests were used to assess the associations between different categorical variables. For paired categorical data, McNemar’s test was used to assess changes in suicidal ideation before and after psychotherapy. A p value < 0.05 was considered statistically significant for all tests.

RESULTS

The study included a total of 68 children admitted for NFSB. The age distribution of the study participants ranged from 11 to 17 years, with the majority aged 17 years (n = 41, 60%) and females (n = 44, 64.7%) outnumbering males. The common methods adopted for NFSB were consumption of chemicals and noxious substances, such as rat and cockroach poison and toilet cleaner (n = 36) and drugs and medicaments (n = 31). Only one patient was admitted for hanging. The most prevalent reason for the NFSB cited was being scolded by parents (n = 37). The other causes are listed in Figure 1. Only 17 patients reported having problems at home. The majority of the participants belonged to the upper-lower socioeconomic class according to the modified Kuppuswamy classification (n = 44). The lethality of the method used by the participants was evaluated, and it was found that 21 patients exhibited suicidal behaviour that was likely to result in death. Thirty-seven participants expressed intent to die, while the remaining 31 participants resorted to NFSB to vent out their anger on their parents or as an impulsive thought in rage. Seventeen (25%) participants had active suicidal thoughts. They were further questioned if they had any specific plan to commit suicide, and 7 participants complied with it. Twenty children had a history of NFSB, and notably, 16 of them had hesitation cuts on their left arm. Of the 20 participants with a history of NFSB, 18 reported an intent to die, suggesting that a clear intent to die is strongly associated with past suicidal behaviours (p value = 0.0001). Of the 21 participants who exhibited lethal behaviour, 18 had suicidal intent, indicating a statistically significant association between the intent to die and the lethality of the method used (p value = 001). Out of the 37 patients who wished to be dead, only 9 participants continued the fatal ideation at the end of 6 months (p value = 0.001), indicating a statistically significant reduction in suicidal ideation following psychiatric intervention as shown in Table 1. Only one participant in the study group was readmitted within the 6 months for NFSB.

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Figure 1:

Reasons for non-fatal suicidal behaviour.

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DISCUSSION

The various methods of assessment of suicidal behaviour include C-SSRS, Ask Suicide Screening Questionnaire,^[6] and Beck’s Scale for Suicidal ideation.^[7] A study by Posner et al. found that the C-SSRS had a high predictive validity for future suicidal behaviour and was superior to other commonly used scales.^[8] Through a comprehensive assessment using clinical interviews and C-SSRS, the study provides valuable insights into the severity of suicidal ideation and behaviour among the children in a district hospital, as well as the impact of psychiatric counselling and follow-up. Our study found that 60% of the patients engaging in NFSB were 17-years-old, consistent with the findings from Lingappa et al.,^[9] and Maciej Zygo et al.,^[10] who reported 60% and 58%, respectively. This suggests a critical period during late adolescence where targeted interventions might be most effective. The study found that 64% of the NFSB cases involved females, similar to a study by Maciej Zygo et al.^[10] and Zanus et al.,^[11] where females accounted for 55% and 64%, respectively. This highlights the need for gender-specific prevention and intervention strategies. 54.4% of children in our study cited getting scolded by a parent as the precipitating event for their NFSB, similar to Lingappa et al. (37.5%).^[9] According to the National Crime Records Bureau (NCRB), family problems, failure in examination and illness were the most common causes of suicides in children with male preponderance.^[12] This difference could be attributed to the fact that our study considered NFSB versus completed suicide. The majority of the participants (64.7%) were from the upper-lower socioeconomic class, similar to the study by Bridge et al.^[13] However, a study by Kumar et al. reported 31.2% belonged to the lower-middle class (Class 3).^[14] This difference could be because our hospital is a district hospital that caters mostly to the lower socioeconomic strata. In our study, 25% of children with NFSB came from problematic family backgrounds, such as single-parent or broken families, similar to the study by Kumar et al., which showed that 13.6% of DSH cases had poor relationships with family members.^[14] There was no significant association between family background and suicidal intent (p value = 0.823), which contrasts with findings from studies by Meza et al.^[15] and Brent et al.^[16] that have identified family dynamics as a crucial factor in suicidal behaviour. Fifty per cent of the patients consumed chemicals and noxious substances, similar to Grover et al. where 62% used chemicals for NFSB, implying a high prevalence of chemical ingestion among adolescents engaging in self-harm.^[17] The NCRB suicide report 2022 shows an increase in the number of deaths by hanging (49.8% in 2017 to 58.2% in 2022) and a decline in the number of suicides by poisoning (27.5% in 2017 to 24.5% in 2022).^[18] This undermines the need for preventive strategies focusing on reducing access to harmful substances and increasing awareness about the risks associated with them. In our study, 54.4% expressed intent to die, whereas in a study by Sreelatha et al., who used Beck’s suicidal intent scale, 25% of individuals with suicidal behaviour exhibited moderate-to-severe intentionality.^[19] The remaining participants did not have a clear intent to die, suggesting that their suicidal behaviour might have been impulsive, more of a cry for help or an expression of extreme stress rather than a genuine attempt to end their lives. It was found that 80% of the participants with intent to die had a history of NFSB, and the association was statistically significant (p value = 0.0001). 71% did not have a history of NFSB, similar to the results from Kumar et al. where 48.5% of patients exhibited impulsive behaviour, suggesting that their current suicidal behaviour may be an isolated impulsive incident triggered by anger or stress.^[14] In our study, 10.3% had suicidal thoughts with a specific method in mind, underscoring the need for thorough assessments to uncover detailed suicidal plans.

On regular follow-up after re-administration of C-SSR at 6 months, we found a significant reduction in the ‘wish to be dead’ and active suicidal thoughts (p value = 0.001 and p value = 003 respectively), similar to a study by Stanley et al.^[20] Preventive strategies are crucial in reducing the incidence of NFSB among children.

This was a cross-sectional study with a small sample size, which may limit the generalisability of our findings. The study was conducted at a single centre, which may not reflect the broader population. Another limitation is the reliance on self-reported data, which introduces bias. The short duration of the study limits the establishment of causality between the identified factors and suicidal behaviour.

CONCLUSION

This study contributes to the understanding of the clinicopsychological profile of children admitted for NFSB. It underscores the importance of early identification, comprehensive assessment and continuous support in managing these cases. Public awareness campaigns to destigmatise mental health issues and encourage help-seeking behaviour among children and adolescents, comprehensive mental health programs in schools that include education on coping strategies, resilience-building and mental health awareness, Improving access to mental health services, including psychiatric care, psychological counselling and crisis intervention, especially in underserved areas, will go a long way in reducing the incidence of NFSB and improving the mental health outcomes for at-risk children.