A cross-cultural study of attitudes toward suicide among young people in India, Italy and Australia

Similar and different? A cross-cultural comparison of the prevalence, course of and factors associated with suicidal thoughts and behaviors in first-episode psychosis in Chennai, India and Montreal, Canada

BACKGROUND

Data from high-income countries (HICs) show a high risk of suicidal thoughts and behaviors (STBs) in first-episode psychosis (FEP). It is unknown, however, whether rates and associated factors differ in low- and middle-income countries (LMICs).

AIMS

We therefore aimed to compare the 2-year course of STBs and associated factors in persons with FEP treated in two similarly structured early intervention services in Chennai, India and Montreal, Canada.

METHOD

To ensure fit to the data that included persons without STBs and with varying STBs' severity, a hurdle model was conducted by site, including known predictors of STBs. The 2-year evolution of STBs was compared by site with mixed-effects ordered logistic regression.

RESULTS

The study included 333 FEP patients (168 in Chennai, 165 in Montreal). A significant decrease in STBs was observed at both sites (OR = 0.87; 95% CI [0.84, 0.90]), with the greatest decline in the first 2 months of follow-up. Although three Chennai women died by suicide in the first 4 months (none in Montreal), Chennai patients had a lower risk of STBs over follow-up (OR = 0.44; 95% CI [0.23, 0.81]). Some factors (depression, history of suicide attempts) were consistently associated with STBs across contexts, while others (gender, history of suicidal ideation, relationship status) were associated at only one of the two sites.

CONCLUSIONS

This is the first study to compare STBs in FEP between two distinct geo-sociocultural contexts (an HIC and an LMIC). At both sites, STBs reduced after treatment initiation, suggesting that early intervention reduces STBs across contexts. At both sites, for some patients, STBs persisted or first appeared during follow-up, indicating need for suicide prevention throughout follow-up. Our study demonstrates contextual variations in rates and factors associated with STBs. This has implications for tailoring suicide prevention and makes the case for more research on STBs in FEP in diverse contexts.

Indonesian Stakeholders' Perspectives on Warning Signs and Beliefs about Suicide

The suicide rate in Indonesia is considered low among Asian countries, but the underreporting rate is at a staggering 303%, and the latest reports suggest an increase in suicidal behaviour, particularly among young people. As a multicultural country, Indonesia has a complex system of beliefs about suicide. Thus, various aspects specific to Indonesia must be considered in understanding and preventing suicide. This paper explores Indonesian stakeholders' perspectives through semi-structured interviews and focus group discussions. A total of 9 participants were individually interviewed, and 42 were involved in focus group discussions. They were mainly people with lived experiences of suicide. The other stakeholders were Indonesian experts who have experience in dealing with suicidal behaviour, helping people with a lived experience of suicide, or were involved in suicide prevention. Indonesian stakeholders highlighted various general and contextualised aspects concerning suicide. These aspects included a wide range of cultural beliefs and culturally specific warning signs, which included "bingung" (confusion) and longing for deceased persons. Other cultural beliefs such as viewing suicide as infectious, unpreventable, and guided by ancient spirits, and as an honourable act in some circumstances, also emerged. These findings can inform suicide prevention programs, including suicide prevention guidelines for Indonesia.

Studying Scripts of Women, Men and Suicide: Qualitative-Method Development and Findings from Nepal

Information about suicidal behavior in Nepal is limited. According to official records, suicide rates were high until the year 2000 and declined thereafter. Official records are considered unreliable and a gross undercounting of suicide cases, particularly female cases. Suicide research in Nepal has been mostly epidemiologic and hospital-based. Little is known about how suicide is understood by Nepali people in general-including dominant suicide attitudes and beliefs in Nepal. Suicide attitudes and beliefs, which are elements of a culture's suicide scripts, predict actual suicidality. Drawing on suicide-script theory, we developed and used a semi-structured survey to explore Nepali beliefs about female and male suicide. The informants were adult (Mage = 28.4) university students (59% male). Female suicide was believed to be a response to the society-sanctioned oppression and abuse that women are subjected to, in their family and community. The prevention of female suicide was viewed as requiring dismantling ideologies, institutions, and customs (e.g., child marriage, dowry) that are oppressive to women, and ensuring that women are protected from violence and have equal social and economic rights and opportunities. Male suicide was believed to be a symptom of societal problems (e.g., unemployment) and of men's psychological problems (e.g., their difficulties in managing emotions). The prevention of male suicide was viewed as requiring both societal (e.g., employment opportunities) and individual remedies (e.g., psychological counseling). This study's findings suggest that a semi-structured survey can be a fruitful method to access the suicide scripts of cultures about which there is limited research.

Functional and molecular characterization of suicidality factors using phenotypic and genome-wide data

Genome-wide association studies (GWAS) of suicidal thoughts and behaviors support the existence of genetic contributions. Continuous measures of psychiatric disorder symptom severity can sometimes model polygenic risk better than binarized definitions. We compared two severity measures of suicidal thoughts and behaviors at the molecular and functional levels using genome-wide data. We used summary association data from GWAS of four traits analyzed in 122,935 individuals of European ancestry: thought life was not worth living (TLNWL), thoughts of self-harm, actual self-harm, and attempted suicide. A new trait for suicidal thoughts and behaviors was constructed first, phenotypically, by aggregating the previous four traits (termed "suicidality") and second, genetically, by using genomic structural equation modeling (gSEM; termed S-factor). Suicidality and S-factor were compared using SNP-heritability (h2) estimates, genetic correlation (rg), partitioned h2, effect size distribution, transcriptomic correlations (ρGE) in the brain, and cross-population polygenic scoring (PGS). The S-factor had good model fit (χ2 = 0.21, AIC = 16.21, CFI = 1.00, SRMR = 0.024). Suicidality (h2 = 7.6%) had higher h2 than the S-factor (h2 = 2.54, Pdiff = 4.78 × 10-13). Although the S-factor had a larger number of non-null susceptibility loci (πc = 0.010), these loci had small effect sizes compared to those influencing suicidality (πc = 0.005, Pdiff = 0.045). The h2 of both traits was enriched for conserved biological pathways. The rg and ρGE support highly overlapping genetic and transcriptomic features between suicidality and the S-factor. PGS using European-ancestry SNP effect sizes strongly associated with TLNWL in Admixed Americans: Nagelkerke's R2 = 8.56%, P = 0.009 (PGSsuicidality) and Nagelkerke's R2 = 7.48%, P = 0.045 (PGSS-factor). An aggregate suicidality phenotype was statistically more heritable than the S-factor across all analyses and may be more informative for future genetic study designs interested in common genetic factors among different suicide related phenotypes.

Evaluation of psychometric properties of the Persian version of the predicaments questionnaire, exploring social attitudes to suicide

Background

Due to the growing prevalence of suicide, assessing people's attitudes toward suicide is necessary. Therefore, this study aimed to examine the psychometric properties of the Persian version of the Predicaments Questionnaire (PQ), measuring social attitudes toward suicide.

Methods

This psychometrics study evaluated face validity, content validity, temporal stability, internal consistency, and construct validity. First, the questionnaire was translated into Persian by the translate-back-translate method. The Persian version was provided to 10 experts in psychiatry for further revision. Two indicators, CVR and CVI, were calculated to evaluate the content validity. To check the face validity, we prepared a form and gave it to 10 people outside the campus to submit their opinions. Temporal stability was investigated by the test-retest method, reporting Intraclass correlation (ICC). Internal consistency was assessed by reporting Cronbach's alpha and McDonald's Omega coefficients. Construct validity was assessed using the confirmatory factor analysis to determine the number of dimensions of the questionnaire.

Results

A total of 151 students were enrolled with a mean age of 25 (SD = 0.32). The Persian PQ was valid in terms of content validity and face validity. Furthermore, it was reliable as Cronbach's alpha, McDonald's Omega, and the ICC were 0.94, 0.943, and 0.998, respectively. In addition, the confirmatory factor analysis yielded one dimension. Finally, after reviewing the experts' comments, the final amendments were made, and only question 29 was removed from the final version.

Conclusion

Consequently, the Persian version of the PQ is acceptable in terms of content validity, face validity, temporal stability, and internal consistency.

Piloting of a suicide first aid gatekeeper training (online) for children and young people in conflict affected areas in Syria

Suicide among internally displaced people remains an under-researched public health issue especially in conflict affected countries. Given the limited and sometimes inaccessible mental health services, there is a need for scalable evidence-based suicide prevention programmes that could be delivered by trained and supervised non-specialists. The Suicide First Aid Guidelines approach aims to support humanitarian workers who deal directly with children and families with the appropriate knowledge and skills to identify and support those at risk of suicide until they can access further specialized support services or until the crisis passes.This paper presents the findings of an online pilot training of 56 humanitarian workers from different sectors (e.g. Child Protection, Nutrition and Mental Health and Psychosocial Support) in conflict affected areas in Syria. The quantitative and qualitative evaluations were based on pre- and post-training questionnaires and revision journals completed between training sessions. Suggestions and examples provided in the journals and during the trainings were incorporated into the succeeding trainings. This was to contextualize and modify the gatekeeper training to fit the Syrian context and provide adaptations for future research and suicide prevention guidelines. Overall, the evaluation indicated that the pilot training raised awareness and improved participants' knowledge on how to assist a suicidal person, including warning signs. It also contributed to a positive change in attitude or beliefs towards suicide. Although the pilot training was considered adequate for the Syrian context some improvements were suggested.

Risk factors for suicide in psychiatric emergency patients in Beijing, China: A large cross-sectional study

Psychiatric emergency patients constitute a population at high risk of suicidal thoughts and behaviors (STB). However, the risk factors for STB in this population have not been clearly defined. This study aimed to explore the risk factors for STB in psychiatric emergency patients in China. A cross-sectional analysis was conducted at the emergency department of psychiatry, Anding Hospital, Capital Medical University from 2015 to 2017. The Chinese suicide risk factors scale was used to test the STB of the patients. Multivariable logistic regression analysis was used to determine the risk factors of STB. A total of 12,345 patients were included. Their average age was 36 years. According to the suicide risk scale, 3436 cases (27.83%) were at risk of STB, mainly young adults. The multivariable analysis showed that urban residence, years of education, living in Beijing, ethnic Han, living alone, unemployment, poor relationship with parents, one or more siblings, visit time in the night, family history, disease course, total duration, the total number of psychiatric hospitalizations, a clear diagnosis, Brief Psychiatric Rating Scale total score ≥28.5, Hamilton Depression Rating Scale total score ≥20, and Young Mania Rating Scale total score ≥12 were independent risk factors for STB.

Stigma associated with mental health problems among young people in India: a systematic review of magnitude, manifestations and recommendations

BACKGROUND

Globally, 20% of young people experience mental disorders. In India, only 7.3% of its 365 million youth report such problems. Although public stigma associated with mental health problems particularly affects help-seeking among young people, the extent of stigma among young people in India is unknown. Describing and characterizing public stigma among young people will inform targeted interventions to address such stigma in India, and globally. Thus, we examined the magnitude and manifestations of public stigma, and synthesised evidence of recommendations to reduce mental-health-related stigma among young people in India.

METHOD

A systematic review and meta-analysis of observational studies was conducted. Nine electronic databases were searched and 30 studies (n = 6767) met inclusion criteria.

RESULTS

Most studies (66%) focused on youth training to become health professionals. One-third of young people display poor knowledge of mental health problems and negative attitudes towards people with mental health problems and one in five had actual/intended stigmatizing behavior (I2>=95%). Young people are unable to recognize causes and symptoms of mental health problems and believe that recovery is unlikely. People with mental health problems are perceived as dangerous and irresponsible, likely due to misinformation and misunderstanding of mental health problems as being solely comprised of severe mental disorders (e.g. schizophrenia). However, psychiatric labels are not commonly used/understood.

CONCLUSION

Public education may use symptomatic vignettes (through relatable language and visuals) instead of psychiatric labels to improve young people's understanding of the range of mental health problems. Recommended strategies to reduce public stigma include awareness campaigns integrated with educational institutions and content relevant to culture and age-appropriate social roles.