Who dies and who survives? Investigating the difference between suicide decedents and suicide attempters

Suicide is the 15th leading cause of death contributing to the premature death of almost one million individuals each year (World Health Organization 2014). It causes over 50 billion USD medical and work loss cost (Florence et al. 2015). A recent meta-analysis illustrated a 16-fold increase in the risk of suicide among individuals with a previous suicide attempt (Yoshimasu et al. 2008). However, a previous literature hints that suicide decedents and suicide attempters belong to two distinct yet overlapping populations as only 10% of suicide attempters end their lives by suicide (Runeson et al. 2010) while 60% of suicide decedents are devoid of previous suicide attempt (DeJong et al. 2010). Research studies evaluating the difference between suicide and suicide attempt are limited to WHO American region (DeJong et al. 2010), WHO Western Pacific region (Fushimi et al. 2006; Zhang et al. 2015; Liu et al. 2016), and WHO European region (Giner et al. 2013; Uribe et al. 2013; Younes et al. 2015; Pompili et al. 2016) while there is a dearth of studies in the WHO Southeast Asian region which contributes 60% of worldwide suicide burden (Chen et al. 2011). Some cross-cultural variation in suicidal behavior exists between India and western countries in the domains of method of suicide such as agrochemicals usage; the presence of additional stressors, for instance, poverty, unemployment, domestic violence, and different vulnerable age groups such as married women reported among Indian populations.

Over the past three decades (1990–2016), India’s contribution to global suicide deaths has increased from 25.3 to 36.6% for women and 18.7 to 24.3% for men (Dandona et al. 2018). In Telangana state, the DALY (disability-adjusted life year) attributed to self-harm has increased from 2.6% in 1990 to 3.5% in 2016 (Telangana disease burden profile 1990 to 2016, n.d.). In the Indian context, there is a paucity of studies probing the difference between suicide attempters and suicide decedents. There is only one study reported from Kerala (Kumar 2004). In consideration of this, the present study aims to investigate the possible difference in sociodemographic and suicidal behavior characteristics between suicide decedents and suicide attempters in a rural population of Telangana.

In consensus with the gender paradox of suicidal behavior, a higher rate of male suicide while female suicide attempts were observed in the present study. Similar observations were also reported in previous epidemiological studies (Liu et al. 2016), hospital-based inpatients studies (DeJong et al. 2010; Zhang et al. 2015), and retrospective hospital record investigation of the difference between suicide attempters and decedents (Uribe et al. 2013; Joo et al. 2016). The high rate of male suicide than female suicide could possibly be attributed to the disparity in socially accepted coping methods for dealing with stress and difference in care-seeking behavior (Hamilton and Klimes-Dougan 2015). Women are more socially integrated with family and friends compared to men which guarantees support in difficult times while men are also exposed to cultural pressures to conceal feelings of weakness and vulnerability. Further. the higher rate of male suicide could be due to the higher suicide intent and exacerbated suicidal tendency under the influence of alcohol (Mergl et al. 2016). In the present cohort, suicide decedents died in the fourth decade of life (30–40 years) while the majority of suicide attempt occurred in the third decade of life (20–30 years), indicating a distinct vulnerable age for the suicide and suicide attempt.

Religion plays an important role in a person’s life and is also expected to influence suicidal behavior. Religious belief or religious prohibition against suicide deters a person from ending his life in a personal crisis. Further, the religious network provides social support and strong interpersonal relationships which lower suicide risk. Studies in this field have reported that religiosity measured by religious service attendance or self-reported religiosity is a protective factor for suicide, self-injurious thoughts, and behavior (Amit et al. 2014). In the present study, the proportion of suicide decedents was higher among the Hindus while suicide attempters were more likely to be Christians. Suicide is not accepted in Christianity and is displayed in the sixth Commandment “Thou Shall does not kill”, a Christian statement to prohibit suicide (Sisask et al. 2010). Hindu religious opposition towards suicide is evident from the negative outlook about suicide in Hindi mythological books such as Manu-Smriti, Yama-Smriti, Garuda Purana, and Arthasastra though occasional approval to suicide is seen in the case of Sati and Samadhi-Marana (Agoramoorthy and Hsu 2017). However, the role in religion as a protective or deterrent factor falls beyond the preview of the present paper and needs further exploration.

The WHO World Mental Health Survey (WMH) conducted from 2001 to 2007 suggested low income as a predictor of suicidal behavior (Borges et al. 2010). In the present study, suicide decedents had lower socioeconomic status than suicide attempters which is similar to the observation of past studies (Zhang et al. 2015; Liu et al. 2016). Alcohol is an important risk factor for suicidal behavior due to elevated impulsiveness and aggressiveness after alcohol consumption (Darvishi et al. 2015). In the present study, suicide decedents had a higher proportion of alcohol consumers than suicide attempters; this observation is in accordance with previous literature (Giner et al. 2013; Uribe et al. 2013; Joo et al. 2016). Previous literature indicates higher rates of marital dissolution individuals, i.e., widowed, separated, lower educational qualification, and living alone among suicide decedents compared to suicide attempters (Yoshimasu et al. 2008; Zhang et al. 2015; Giner et al. 2013; Uribe et al. 2013); however, these differences were absent in the present groups indicating an overlap of these sociodemographic parameters.

In the domain of suicidal behavior characteristics, it was observed that suicide decedents employed a more violent method in comparison to suicide attempters and the same was also observed in previous studies (Zhang et al. 2015; Liu et al. 2016; Uribe et al. 2013; Younes et al. 2015; Joo et al. 2016). This difference could be attributed due to the difference between suicide decedent and attempters in the realm of psychiatric diagnosis (Giner et al. 2013; Uribe et al. 2013), personality trait, i.e., impulsivity, hopelessness, and intense suicide ideation (Giner et al. 2013; Uribe et al. 2013; Younes et al. 2015; Joo et al. 2016; Liu et al. 2016), psychosocial parameters (Zhang et al. 2015; DeJong et al. 2010; Giner et al. 2013), and availability of suicide method (Zhang et al. 2015; Liu et al. 2016) as reported in past studies. Restriction of the violent method of suicide, psychological counseling, and rehabilitation of individuals with self-harm behavior could be initiated. Further seasonality of suicide, i.e., autumn peak, was observed decedents which are in consensus with previous studies (Coimbra et al. 2016); hence, screening of risk population and strengthening of current medical emergency interventions could be initiated around this hotspot time frame for self-harm patients. In the present study compared to suicide attempters, suicide decedents had less history of previous suicide attempt which coincides with the previous studies (DeJong et al. 2010; Younes et al. 2015; Joo et al. 2016), indicating that suicide decedents are successful in ending their lives in a single attempt due to either stronger intent or use of violent suicide method.

In the present study, economic distress was a trigger for suicide. This observation is in consensus with Indian studies (Manoranjitham et al. 2010) where the triggers for the suicide attempt were personal or social problems which have also been reported as Indian studies (Benjamin et al. 2018). Hence, for suicide decedents, the suicide prevention strategies could be invested in the betterment of economic status, while among suicide attempters, family counseling could be initiated.

The limitations of the present study are non-assessment psychiatric disorders, personality traits, and suicide intent among suicide decedent which could be diagnosed by only a psychiatric or mental health professional. Further, the proxy-based interview technique for suicide decedents could create recall bias and undermine the true picture of some of the study variables. In the limited sample size, the analysis based on sex stratification was not possible. To our knowledge, the present study is the first study to investigate the possible difference between suicide decedents and suicide attempters of the same geographical area in India having an enormous burden of suicidal behavior.

The present study found the difference between suicide decedents and suicide attempters in few sociodemographic and suicidal behavior characteristics, so better characterization could be valuable in implementing distinctive preventive policies.