Stressful Life Events in Impulsive and Non-impulsive Suicide Attempters: A Cross-sectional Study

Abstract

Background:

Suicide is a significant public health issue, yet it can be avoided with prompt, evidence-based, and frequently inexpensive interventions. There are distinctions between the profiles of impulsive suicide attempters (ISA) and non-impulsive suicide attempters (NISA), and a significant number of suicide attempts are impulsive. A thorough multisectoral suicide prevention strategy is necessary for an effective national response.

Methods:

This observational cross-sectional study was conducted at a tertiary healthcare center in Karnataka. Sixty inpatients above the age of 18 years with an alleged history of suicide attempts were enrolled in the study. Their stressful life events in the past year were assessed using the Presumptive Stressful Life Events Scale (PSLES). Impulsive and non-impulsive attempters were considered based on the time gap between the suicidal ideation and the suicidal attempt with the presence or absence of plans regarding the act. They were compared using appropriate inferential statistical tests.

Results:

The majority of the suicide attempts were impulsive (63.3%). The ISA and NISA did not differ in socio-demographic characteristics except for age and family type, with impulsive attempters being more common at younger ages than the non-impulsive attempters (p = .02). The majority of ISA were from joint families (44.7%), while 72.7% of NISA were from nuclear households (p = .04). Compared to ISA, NISA recollected a higher number of stressors.

Conclusion:

The ISA and NISA differ in aspects of age, family type, and stressors. Characteristic distinctions between ISA and NISA should be recognized and understood in order to design policies for suicide prevention and minimize morbidity and mortality. Exploring and addressing the stressors and helping patients to overcome them through better coping skills helps in suicide prevention.

Keywords

suicide attempt impulsive non-impulsive stressor life events

Key Messages:

Life stressors are major risk factors for suicide attempts, more so with non-impulsive attempts.

There is a need for better handling of stressful situations and improving coping skills in the general population as a suicide prevention strategy.

Suicide is a mode of intentional death usually consequent to a complex and multifaceted behavioral pattern. It is seen typically as the fatal outcome of a long-term process molded by the interaction of several social, cultural, situational, psychological, and biological factors.¹ It is a shocking and very personal final act. Every suicide is a tragedy that impacts families, communities, and countries, as well as the suicide survivors.

According to Durkheim, an intent to die arises from enormous psychological and sociological upheavals, which have become more widespread in the twenty-first century, particularly among the younger population.² In India, for every suicidal death, there were more than 200 people with suicidal ideations and more than 15 suicide attempts.³

The causes of suicide and suicide attempts are complex and multifaceted. Socio-demographic characteristics, prior history, family history, concomitant medical condition, underlying psychiatric illness, stressful life events, personality factors, and coping strategies are just a few of the factors that contribute to suicide attempts.^4-6

Suicide is considered to be caused by an interaction of genes and psychological and environmental factors. Suicidal behaviors have a common diathesis, resulting in an interaction between stressors and susceptibility to suicidal behavior.^7,8

Psychiatric disease is the most frequently implicated risk factor for suicide, accounting for roughly 60% of cases.^5,7 However, the majority of individuals with psychiatric disorders never engage in suicide behavior, demonstrating the relevance of diathesis.⁷ Suicide, according to the stress–diathesis concept, is the result of an interplay between state-dependent (environmental) stressors and a trait-like diathesis or vulnerability to suicidal behavior, which is independent of psychiatric disorders.⁹

Even though research consistently demonstrates that a significant number of suicide attempts are impulsive and unplanned,^10-13 only a few studies have looked into how impulsive and non-impulsive suicide attempts vary.

There exists a significant association between the number of insolvable problems and suicidal intent. The most prevalent life events preceding suicide include job difficulties, family conflicts, somatic illness, financial hardship, unemployment, separation, and death or illness in the family.^3-5 Suicide is the result of a cascade of events that are far more significant than a single life event.¹³ In most situations, life events are not coincidental but rather are influenced by the individual’s actions and personality traits, including psychiatric illness.⁵

The relationship between the frequency of adverse life events and the type of suicide attempt has received mixed support, with most studies indicating a high frequency of adverse interpersonal life events prior to both impulsive and non-impulsive suicide attempts.^12,14 Few authors have linked stressful life events with impulsive suicide attempts,^12,15 along with higher impulsive behaviors in the past year, such as involvement in physical fights and quitting the job without an alternative job.¹¹

Rationale for the Study

This research is necessary because it is critical to understand the causes of suicide attempts, particularly among today’s youth and adults, and to understand the shifts in suicidal tendencies and the relationships between the biopsychosocial variables. We have made an effort to bridge the information gap about the traits and variables that lead to youth suicides as well as the ways that an expanding number of stressors directly affect mental health. However, studies done in India on the profile of impulsive and non-impulsive suicides are limited and focus mainly on planned attempts (non-impulsive suicide attempters [NISA]) secondary to depression and other psychotic illnesses.^12,14,15 Because the majority of the current suicide attempters are young in age,^4,5 and their attempts are usually unplanned (impulsive), more studies are needed to identify the characteristic traits and factors associated with these attempts and thereby determine the possibilities that may help sudden unplanned suicides and to plan effective intervention strategies.

The current study was done with the hypothesis that planned suicide attempters (impulsive suicide attempters [ISA]) have more psychiatric morbidity and stressful life events than NISA. We aimed to study the stressful life events and associated factors in ISA and NIA. The objectives were: (a) to determine the types of stressful life events that were associated with suicide attempts; and (b) to compare the socio-demographic characteristics, mode of attempt, stressful life events, and psychiatric morbidity between ISA and NISA.

Methods

The study lasted two years, from February 2021 to December 2023. Based on the formula $n = \frac{z_{1 *}^{2} p \times q}{d^{2}},$ the sample size of 60 was derived; here, z₁ represents the 95% confidence level, p represents the prevalence of suicide attempts, which is 5.7%,¹⁶ q represents the 100-prevalence, and d represents the absolute precision of 6% of prevalence. Sixty consecutive patients above the age of 18 years admitted after suicide attempts in the inpatient wards, who were medically stable and referred to the Department of Psychiatry and who were willing to participate in the study and gave informed consent were recruited for the study. Medically unstable and uncooperative patients; patients who had accidental self-harm, including inadvertent consumption of poison; patients with intellectual disability, organic mental disorders, major mental illnesses (such as bipolar affective disorders, schizophrenia, acute and transient psychotic disorders, and delusional disorders); and those without informants were excluded from the study.

The study received approval from the Institutional Ethics Committee. A written informed consent was sought, and a proforma was used to collect information regarding socio-demographic details, clinical details, and details related to the suicide attempt. The stressful life events in the past year in the attempters were assessed using the Presumptive Stressful Life Events Scale (PSLES) checklist,¹⁷ which is a yes/no self-rated scale developed and validated for the Indian population. The PSLES consists of 51 positive and negative life events relevant to the Indian culture and representative of the everyday life events experienced by the Indian population. Each life event has a different mean stress score. Further, these life events are divided into three categories: undesirable (31 events), desirable (10 events), and ambiguous (10 events). According to Singh et al.,¹⁷ Indians usually can experience two stressful life events in the past year without suffering any adverse physical or psychological disturbance. This yes/no self-rated scale takes about 5 minutes to complete. The number of life events and the weighted scores experienced by the patient in the past year were assessed using this scale. When life event data from each patient was compared to information provided by a relative, the results were determined to be adequate (with a good kappa value of 0.8). There is good concurrent validity and internal consistency in the scale. The PSLES has been validated by Singh et al.¹⁷ and shown to have adequate factor structure and good reliability. The presence of psychiatric disorders was ascertained by clinical interview, per the International Classification of Diseases, Tenth Revision (ICD-10) diagnostic criteria.¹⁸ In the event of detection of psychopathology, patients were treated accordingly by the psychiatrist.

Suicide attempts were classified as impulsive suicidal attempts and non-impulsive suicidal attempts as per the operational definitions.^19,20

The operational definition of an impulsive suicide attempt is a suicide attempt where

The time between the occurrence of the suicidal idea and the attempt was less than 30 minutes.

No plans about the act were made prior to the attempt.

The operational definition of non-impulsive suicide attempts is a suicide attempt where

The time between the occurrence of the suicidal idea and the attempt was more than 30 minutes.

Plans about the act were made prior to the attempt.

Approval for the study was obtained from the Institutional Ethical Review Board.

Statistical Analysis

Data was entered in Microsoft Excel and represented in descriptive statistics (percentages and frequencies for categorical variables and mean and standard deviation for continuous variables) with appropriate tables and graphs. Statistical Package for Social Sciences (SPSS) version 20 (IBM) was used for data analysis. The chi-square test was used for categorical variables, and the independent sample t-test was used for continuous variables.

Results

A total of 60 study participants were enrolled in the study; 38 (63.3%) were ISA, and 22 (36.7%) were NISA.

Socio-demographic Characteristics

The mean age of the sample was 31 years (SD 10.5). The ISA group (28.4 ± 8.4 years) was younger than the NISA group (35.5 ± 12.3 years), which was statistically significant (t = 2.63; p = .02) (Table 1). When the participants were divided into four age groups, the majority of those in the ISA group (47.4%) were under 25 years old, while the majority in the NISA group (36.4%) were 25–35 years old. Compared to the ISA group, the NISA group had more participants over 45 years of age (22.7% and 2.6%, respectively). The difference in age distribution was statistically significant (χ² = 7.93; p = .04).

Table 1.

Socio-demographic Variables Among Impulsive and Non-impulsive Suicide Attempters.

Variables		N = 60 n (%)	ISA N = 38 n (%)	NISA N = 22 n (%)	Statistical Analysis
Age (years)		31.0 ± 10.5	28.4 ± 8.4	35.5 ± 12.3	t =2.63 p = .02*
Gender	Male	27 (45%)	19 (50.0%)	8 (36.4%)	χ² = 1.04 p = .30
Gender	Female	33 (55%)	19 (50.0%)	14(63.6%)	χ² = 1.04 p = .30
Marital status	Unmarried	16 (26.7%)	12 (31.6%)	4 (18.2%)	χ² = 1.35 p = .50
	Married	42 (70.0%)	25 (65.8%)	17(77.3%)
	Widow(er)	2 (3.3%)	1 (2.6%)	1 (4.5%)
Socio-economic status	Low	21 (35.0%)	17 (44.7%)	4 (18.2%)	χ² = 5.60 p = .06
	Middle	38 (63.3 %)	21 (55.3%)	17(77.3%)
	High	1 (1.7%)	0 (0%)	1 (4.5%)
Family setup	Joint	22 (36.7%)	17 (44.7%)	5 (22.7%)	χ² = 6.33 p = .04^*
	Nuclear	31 (51.7%)	15 (39.5%)	16 (72.7%)
	Extended	7 (11.7%)	6 (15.8%)	1 (4.5%)

* represents the statistically significant values.

There were 27 men (45%) and 33 women (55%) in the study sample. Males were more likely to attempt suicide impulsively than non-impulsively (50% vs. 36.4%). The majority of the suicide attempters (n = 42, 70%) were married. Unmarried people were more likely to attempt suicide impulsively (31.6% vs. 18.2%); however, statistically, the variations in marital status were not significant. The majority of the participants were of middle socioeconomic status (63.3%). The majority of ISA were from joint families, while 72.7% of NISA were from nuclear households. This difference in the family structure was statistically significant (p = .04) (Table 1).

The Precipitant for Suicide Attempts

The most common precipitant for suicide attempts was marital conflict, followed closely by familial conflict and financial issues. In the ISA group, familial conflict was most common (23.7%), followed by financial issues and broken relationships (21.1% each). About 40.9% of the suicide attempts in the NISA group were attributed to marital conflicts (Table 2).

Methods Employed for Suicide Attempts

The most common method of suicide attempt among the study participants was poisoning (70%, n = 42). This included OP compound poisoning (40%, n = 24), insecticide, rodenticide, fungicide, fumigant, and disinfectant. It was followed by medication overdosage (21.7%, n = 13) and hanging (3.3%, n = 2) cases. Three of the suicide attempters employed a mix of methods to attempt suicide.

Poisoning was the most common method in both groups (73.7% and 63.7%). Medication overdosage was higher in the NISA group compared to the ISA group (27.3% vs. 18.1%). Two ISA attempted hanging (Table 2).

Table 2.

Precipitants of Suicide Attempt and Methods Employed for the Suicide Attempt in Impulsive and Non-impulsive Suicide Attempters.

Variables		N = 60 n (%)	ISA N = 38 n (%)	NISA N = 22 n (%)	Statistical Analysis
Precipitant for suicide attempt	Marital conflict	15 (25%)	6 (15.8%)	9 (40.9%)	χ² = 10.89 p = .14
	Familial conflict	13 (21.7%)	9 (23.7%)	4 (18.2%)
	Financial issues	12 (20%)	8 (21.1%)	4 (18.2%)
	Broken relationships	8 (13.3%)	8 (21.1%)	0
	Physical problems	2 (3.3%)	1 (2.6%)	1 (4.5%)
	Failure in examinations	2 (3.3%)	2 (5.3%)	0
	Separation/death of a dear person	3 (5%)	2 (5.3%)	1 (4.5%)
	Multiple reasons	5 (8.3%)	2 (5.3%)	3 (13.6%)
Methods employed for suicide attempt	Poisoning	42 (70%)	28 (73.7%)	14 (63.7%)	χ² = 9.664 p = .077
	Medication overdosage	13 (21.7%)	7 (18.4%)	6 (27.3%)
	Hanging	2 (3.3%)	2 (5.3%)	0
	Combination	3 (5%)	1 (2.6%)	2 (9.1%)

Psychiatric Morbidity

71.7% (n = 43) of the suicide attempters were diagnosed with psychiatric morbidity, with nine (15%) having more than one diagnosis. Depressive disorder was the most common psychiatric morbidity (49%, n = 21), followed by adjustment disorder (28%, n = 12). Alcohol and nicotine dependence contributed to 16% each (Table 3).

Psychiatric morbidity was present in 55.3% (n = 21) of ISA, with depressive disorder being the most prevalent diagnosis (33%), followed by adjustment disorder and alcohol dependence accounting for 28.6% each. All the NISA had psychiatric morbidity, with depressive disorder present in 63% and adjustment disorder in 27.3%. This variance was statistically very highly significant (χ² = 13.73; p < .001), and the difference in depressive disorder was statistically significant among the two groups (χ² = 10.88; p = .001) (Table 3).

Table 3.

Psychiatric Morbidity in Impulsive and Non-impulsive Suicide Attempters.

Variables (n = 60)	n (%)	ISA N = 38	NISA N = 22	Statistical Analysis
Absent	17 (28.3%)	17 (44.7%)	0.0%	χ² = 13.73 p < .001^***
Present	43 (71.7%)	21 (55.3%)	22 (100%)
Comorbidity/dual diagnosis	9 (15%)	6 (15.8%)	3 (13.6%)
MDD	21 (49%)	8 (38.1%)	14 (63.6%)	χ² = 10.88 p = .001^**
Adjustment disorder	12 (28%)	6 (28.6%)	6 (27.3%)	χ² = 1.14 p = .28
ADS	7 (16%)	6 (28.6%)	1 (4.5%)	χ² = 1.70 p = .19
NDS	7 (16%)	5 (23.8%)	2 (9.1%)	χ² = 0.22 p = .63
Dysthymia	4 (9%)	2 (9.5%)	2 (9.1%)	χ² = 0.32 p = .56

MDD: Major depressive disorder; ADS: Alcohol dependence syndrome; NDS: Nicotine dependence syndrome.

* represents the statistically significant values. Life Events

The suicide attempters in the study recalled a mean of 5.6 life events in the past year, majorly undesirable life events (mean 4.10). NISA had more undesirable life events than ISA, which was statistically significant. ISA had more desirable and ambiguous life events than NISA. However, it was not statistically significant. The mean undesirable event stress score and total mean stress scores were higher in NISA when compared to ISA. This was statistically significant (Table 4).

Table 4.

Life Events and Mean Stress Scores in the Past One Year Among Impulsive and Non-impulsive Suicide Attempters.

	N = 60	ISA	NISA	Statistical Analysis
Number of undesirable life events	4.10 ± 2.4	3.50 ± 2.12	5.14 ± 2.55	t = 2.67 p = .01^*
Number of desirable life events	1.05 ± 0.1	1.24 ± 1.05	0.73 ± 0.83	t = 1.94 p = .05
Number of ambiguous life events	0.45 ± 0.62	0.50 ± 0.65	0.36 ± 0.58	t = 0.81 p = .41
Total number of life events in the past 1 year	5.60 ± 2.46	5.24 ± 2.31	6.23 ± 2.64	t = 0.27 p = .13
Undesirable events stress scores	196.42 ± 113.58	165.32 ± 94.85	250.14 ± 124.96	t = 2.96 p = .004^*
Desirable events stress scores	39.45 ± 37.32	43.24 ± 37.20	32.91 ± 37.47	t = 1.03 p = .30
Ambiguous events stress scores	15.90 ± 23.34	17.79 ± 23.22	12.64 ± 23.72	t = 0.82 p = .41
Total mean stress score	251.77 ± 114.53	226.34 ± 99.10	295.68 ± 127.91	t = 2.34 p = .02^*

* represents the statistically significant values.

The most common stressor in both ISA and NISA was family conflict (34% and 50%, respectively), followed by financial issues (32% and 45%, respectively). The other everyday stressors in the ISA group included large loans (26%) and broken relationships (24%). Marital conflict (36%), major personal injury/illness (32%), and conflict with in-laws (32%) were the other stressors in the NISA group. Desirable events such as going on a pleasure trip or pilgrimage and gaining new family members were significantly higher among ISA. Undesirable events such as changes in eating habits, changes in social activities, major personal injury or illness, conflicts with in-laws (other than over dowry), marital conflict, and extramarital relations of spouses were significantly higher among NISA (Table 5).

Table 5.

Major Life Events in the Past One Year Among Impulsive and Non-impulsive Suicide Attempters.

Sl No.	Life Events in Past One Year	ISA		NISA		Total		Statistical Analysis
Sl No.	Life Events in Past One Year	N	%	N	%	N	%	χ²	p
1.	Family conflict (U)	13	34	11	50	24	40	1.447	.22
2.	Financial loss/problems (U)	12	32	10	45	22	37	1.155	.28
3.	Change in sleeping habits (U)	9	24	8	36	17	28	1.103	.29
4.	Change in eating habits (U)	6	16	10	45	16	27	6.270	.01*
5.	Large loan (U)	10	26	6	27	16	27	0.007	.93
6.	Going on pleasure trip or pilgrimage (D)	13	34	1	5	14	23	6.854	.009*
7.	Gain of new family members (D)	12	32	2	9	14	23	3.939	.04*
8.	Change in working conditions or transfer (D)	8	21	6	27	14	23	0.301	.58
9.	Change in social activities (U)	4	11	9	41	13	22	7.578	.006*
10.	Marital conflict (U)	5	13	8	36	13	22	4.421	.03*
11.	Broken engagement/love affair (U)	9	24	3	14	12	20	0.879	.34
12.	Getting married or engaged (D)	8	21	3	14	11	18	0.512	.47
13.	Unfulfilled commitments (U)	6	16	5	23	11	18	0.448	.50
14.	Major personal injury or illness (U)	3	8	7	32	10	17	5.742	.01*
15.	Conflict with in-laws (other than over dowry) (U)	3	8	7	32	10	17	5.742	.01*
16.	Illness of family member (U)	5	13	4	18	9	15	0.276	.59
17.	Trouble with neighbor (U)	6	16	1	5	7	12	1.709	.19
18.	Property or crops damaged (U)	5	13	2	9	7	12	0.224	.63
19.	Failure in examination (U)	5	13	1	5	6	10	1.148	.28
20.	Extramarital relations of spouse (U)	0	0	3	14	3	5	5.455	.02*

U: Undesirable; D: Desirable; A: Ambiguous.

* represents the statistically significant values.

Discussion

The present cross-sectional study attempted to find the differences in socio-demographic characteristics and the stressful life events among ISA and NISA.

About two-thirds of the study participants who attempted suicide did so impulsively rather than non-impulsively, indicating that ISA were more common. There were no statistically significant differences in the socio-demographic variables among the two groups, except for the age and family setup.

The suicide attempters in this study were, on average, 31 years old. The increasing suicide attempts among young people might be attributed to a sudden increase in obligations and role transitions, work-related stress, and marriage.²¹ ISA were younger than NISA, which could be implicated in young adults lacking impulse control.^22,23

ISA were more likely to belong to joint families (44.7%), whereas NISA were more likely to belong to nuclear families (72.7%). Previous studies revealed no difference between the groups, although recent studies by Indian authors have found increased suicide attempters hailing from nuclear families.^21,24 The dissolution of the joint family system, an ancient Indian social institution that had historically offered emotional support and stability, is also considered a significant cause of suicide. The impact of a lack of social cohesiveness in predisposing to suicidal conduct may be seen in the contribution of nuclear families to the incidence of suicide attempts.²⁵ However, in contradiction, the conflicts arising within the family structure and the marital household can be the stressors precipitating suicide.

Marital conflicts (25%), familial conflicts (21.7%), and financial conflicts (20%) were the most common precipitants for suicide attempts in the study, in agreement with previous authors.^3,21,24 Similar to earlier studies, there was no statistical difference found between the groups with respect to precipitants for suicide attempts.¹² However, familial conflicts, financial issues, broken relationships, failure in examinations, and separation/death of a dear person were more common among those who attempted suicide impulsively, while marital conflicts and physical illness were more common precipitants among those who attempted suicide non-impulsively.

Poisoning was the most prevalent technique used by both ISA and NISA in the current study, whereas medication overdosage was more common among NISA and hanging exclusively among ISA (5.3%); however, there was no statistically significant difference between the groups.

Factors influencing the choice of the suicide method are the availability, accessibility, and acceptability of a method.²⁵ Reducing access to pesticides using pesticide bans, sales restrictions, or regulations has the potential to reduce suicide (and attempts) by its ingestion.²⁶

Psychiatric morbidity was less common among ISA than among NISA (ISA: 53.3%, NISA: 100%). This is consistent with findings of a study by Wei et al. (ISA: 53.3%, NISA: 82.6%).²⁷ However, Kattimani et al. reported no difference in both groups (ISA: 43.7%, NISA: 38.8%).¹³ One author reported a higher lifetime history of psychiatric disorder in ISA than NISA (ISA: 59.7%, NISA: 72%).¹² These discrepancies can be ascribed to the diverse cultural backgrounds, diagnostic techniques, and varying operational definitions.

The low prevalence of depressive disorders among ISA could be evidence of the presence of a separate subgroup of suicidal people who do not follow the depression–hopelessness pathway to suicide. Trait aggression/impulsivity, for example, has been proposed as a viable endophenotype for suicide, and this might be especially significant for people who try suicide impulsively.^8,15

The current study found a higher prevalence of substance use disorders among the ISA compared to the NISA, though statistically, there was no difference.

Alcohol abuse and misuse are considered to be both distal and proximal risk factors for suicidal behavior. Alcohol use disorder may act as a distal risk factor for suicidal behavior by causing life stress and shattered relationships, whereas drinking alcohol prior to attempting suicide acts as a proximal risk factor by lowering inhibitions, increasing aggression, and focusing one’s attention on suicide.¹⁵

The suicide attempters in the current study recalled a mean of 5.6 life events in the past year, the majority of them being undesirable. This is consistent with previous studies,^24,27 which report that exposure to stressful life events in the recent past is a significant risk factor associated with suicide attempts. Childhood adversity and life stressors may affect the diathesis and increase the risk of mood disorders and subsequent suicide behavior. There have been studies indicating a biological pathway for suicide and the link between stress and suicide attempts.²⁸

The undesirable and total mean stress scores were significantly higher among NISA than ISA. The life stressors were significantly higher among NISA than ISA (3.5 ± 2.1 vs. 5.14 ± 2.6). A contradictory finding was reported by Kattimani et al. (3.5 ± 2.2 vs. 2.8 ± 2.0).¹³ The mean age of the sample in the study by Kattimani et al. was much lesser than the mean age of the current study subjects. The increase in life stressors as age advances could explain the above-found difference.

The most common stressors in the ISA group included family conflict (34%), financial issues (32%), large loans (26%), and broken relationships (24%). Kattimani et al. reported a similar finding: family conflicts (31.8%), financial issues (25.2%), and marital conflicts (23.2%) are the most common stressors in impulsive attempters.¹³ Panikkath et al. reported that interpersonal difficulties, such as marital discord and family conflicts, were the most stressful life events reported by impulsive suicide attempters, followed by failure in exams or interviews and failure in love.²⁹

Indian studies have frequently linked suicide attempts to traumatic life circumstances rather than psychiatric disorders.^13,30 Interpersonal ties are highly valued in socio-centric Indian society. Thus, it is found that marital conflict is the leading cause of suicide among women, whereas interpersonal conflict is the leading cause of suicide among men.²¹ Studies measuring stressful life events reported approximately 90% of suicide attempters having adverse life events and about 35% experiencing stressful life events in the previous six months.^25,31

Strengths of the Study

The sample size for the study was adequate. The tool used in the study has established reliability and validity with a rater-friendly, easy-to-administer system, causing no discomfort to the patients. Suicide attempters were all evaluated within a short duration from the time of attempt (mean of five days), thus possibly eliminating recall bias. This is one of the few studies that studies suicide attempters in terms of impulsive and non-impulsive suicide attempts and assesses its relationship with socio-demographics, clinical variables, and life events.

Limitations of the Study

The study participants were drawn from a private teaching medical college hospital, which may not have the same characteristics as the general population and hence cannot be generalized. The study involved a one-time cross-sectional assessment and lacked follow-up of the suicide attempters owing to time constraint. The recruitment of a convenient sample of subjects may lead to selection bias. The cases of hanging were excluded as cognitive deficits were foreseen in them. Accidental self-harm cases were excluded as there would be no definite intent to die. Suicide attempters who were medically unstable and those with no reliable informants were omitted, which may have resulted in the underrepresentation of more lethal attempters and those with poor familial and/or social support.

Conclusion

The present study concludes that a significant proportion (63.3%) of the individuals who attempt suicide do so impulsively. Given the increased prevalence of impulsive attempts in the young, we should not dismiss suicidal thoughts, regardless of intensity, in the young, as suicide is one of the leading causes of mortality among the economically productive population. The presence of psychiatric morbidity, specifically major depressive disorder, is a significant risk factor for NISA. These findings imply that there is a need for prompt early detection and timely treatment of psychiatric disorders by minimizing suicide attempts.

Compared to ISA, NISA recollected a more significant number of stressors. Therefore, the presence of stressful life events is a significant risk factor for planned suicide attempts. Suicide attempters are more vulnerable to difficult life situations and interpersonal challenges, which might be a risk factor for both psychiatric morbidity and suicide attempts, especially in the planned attempters, and the fact that these stressors are chronic and recurring poses a challenge to preventing the reattempt of suicide. Since most of these suicide attempts occur in the context of acute interpersonal stress, community awareness programs to enhance life skills such as conflict resolution, problem-solving skills, communication skills, and coping with stress and emotions, especially among youngsters, will help in preventing suicide attempts.

Supplemental Material

Supplemental material for this article is availabel online.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Declaration Regarding the Use of Generative AI

None used.

Ethical Approval and Informed Consent

The study received approval from the Institutional Ethics Committee. Participants who were willing to participate in the study and gave informed consent were recruited in the study.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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