Suicidal process, suicidal communication and psychosocial situation of young suicide attempters in a rural Vietnamese community

Over the last 45 years, mortality due to suicide has increased in some developed and developing countries, among both adults and young people 1–2. Depending on age, sex and location, suicide attempts are 10–40 times more frequent than completed suicides 3–5. The results of SUPRE-MISS (the World Health Organization's Multisite Intervention Study on Suicidal Behaviours, within the Suicide PREvention initiative) show that suicide attempts, plans and ideation varied by a factor of 10–14 among the study sites in the ten countries concerned, in five continents (5). The incidence ratios of suicide attempts to suicide plans and thoughts varied substantially. The authors concluded that the idea of the suicidal process as evolving continuously from thoughts to plans and attempts needs further investigation, and that the process appears to depend on the cultural setting (6). A study from China 6 found that younger individuals are more likely to attempt low or intermediate-planned acts than high-planned acts. The attempts were classified as “low-planned” when the time lag between the first reported suicidal thought and the suicide attempt itself was less than two hours. Those who attempted low-planned acts were found to be more likely to have experienced greater acute stress than those whose attempts were characterized as “high-planned” 6. The majority of low-planned suicides in the study were carried out with pesticides, which were readily available at home. The results from the SUPRE-MISS study showed that 71.6% of female and 61.5% of male attempters in China, compared with 33.8% of male and 23.8% of female attempters in India, used pesticides as a means of attempting suicide 7. Studies from China and India conclude that restriction of access to toxic means of suicide, safer storage and a reduction of the toxicity of agricultural chemicals and rat poisons are advisable. An evidence-based suicide-preventive strategy focusing on restriction of lethal means of suicide is widely advocated 8,9. Other suicide-preventive strategies include improved recognition of suicidal communication 10–13 and better risk recognition of depression and substance abuse, especially in schools 14 and by primary care physicians 15. Several investigations in Western countries show that 48–84% of people who committed suicide repeatedly communicated their suicidal intentions to their significant others and to more than one person. Significant others’ responses to the suicidal communications of distressed, suicidal persons and lack of support have an impact on the course of the suicidal process 13. Significant others often fail to recognize suicidal communication, owing to their lack of knowledge, but also because their own ambivalent attitudes and behaviour towards self-destructive persons come to the fore when they are confronted with suicidal communication. Suicidal communication can be divided into direct and indirect verbal communication, on the one hand, and direct and indirect non-verbal communication on the other. “Direct verbal suicidal communication” refers to clearly expressed suicidal intentions. verbal suicidal communication” means the expression, in various ways, of the feeling that one's situation is hopeless, that life has no meaning, that there is no solution to one's current problems and that it would be better to disappear or die. In “direct non-verbal communication”, a suicidal person undertakes various kinds of preparation for the suicide attempt, such as collecting drug prescriptions, buying pesticides or raticides, or writing a farewell letter. “Indirect non-verbal suicidal communication” refers to withdrawal, deliberate self-isolation, weakening or rupturing ties with family and friends and/or taking concrete steps to put personal affairs in order before committing suicide. The present study was based on a sample of young suicide attempters in a rural community in Hanoi, Vietnam. The aim of the study was to explore the suicidal process (from the onset of suicidal ideation to the appearance of suicide plans and attempted suicide), suicidal communication and the psychosocial situation of suicide attempters. The theoretical background of the study was the stress-vulnerability model and the notion of the developing suicidal process 16,17. All suicide attempters who were hospitalized from August 2001 to August 2003 in the Intensive Care Unit at the Socson District Hospital in Hanoi were studied. All 29 suicide attempters from rural areas aged 15–24 years were selected for in-depth interviews. Four respondents had moved from the catchment area at the time of the study, three gave incorrect addresses and three patients refused to participate, which resulted in a total of 19 interviews. Interviews were performed using a uniform procedure and method. The time interval between the suicide attempt and the interview was 5–6 months (range 1–11 months). The interviews lasted up to two hours and were performed by one of the authors (HT). The location was chosen by the participants. In 14 cases it was the participant's home, in three the community health centre and in two a rice field. Basic sociodemographic data were collected and semi-structured interviews then enabled the participants to describe the course of events freely. In each case, however, structured questions were posed covering the following areas: I. Family relations and psychosocial situation as risk or protective factors; II. Presence of suicidal communication before attempted suicide; and III. Development of the suicidal process from suicidal thoughts to suicide plans and suicide attempts. The detailed questions asked during the interview are presented in Table 1. The in-depth interview records were translated into English and then interpreted by five persons (MG, AN, HT, CW, and DW) independently. After careful revision of the interview records, coding was used, based on the theoretical concept of the developing suicidal process and on the types of suicidal communication used. A peer-review group of qualitative researchers from the Swedish National and Stockholm County Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) discussed both the coding scheme and coding decisions. Analysis was based both on the three selected themes listed above and on narrative descriptions of the cases. Results for each theme were identified in the interviews and afterwards pooled. Ten females and nine males participated in the interviews. The mean age of the subjects was 19.5 years (range 15–24 years). Five of the 19 subjects were married. Fifteen were primary or secondary school dropouts. The parents of 12 respondents had primary education, while seven respondents’ parents had attended secondary school. Most of the participants lacked hobbies, with the exception of one male who was interested in football. None of the subjects had previously attempted suicide. Eighteen of the subjects were given the diagnosis of X68 (intentional self-harm by exposure to pesticide or raticide), according to ICD-10, while one subject received the diagnosis of X83 (intentional self-harm by other specific means). None were given psychiatric diagnoses by doctors during their stay in hospital after their suicide attempt. Their hospital treatment lasted from one to three days. Personal conflict was the main motive of attempted suicide for 18 suicide attempters. Seven committed a suicidal act after being scolded by a parent, five after quarrelling with partners and two after quarrelling with other family members. In three cases, the act took place after a parent had interfered in the subject's love life; in one after a parent refused to give the subject money to buy a birthday present for a friend; and in one because the subject felt sad. “… I was very upset and depressed, and I did not want to suffer from my mother's blame any more. I thought that death could free me from my current terrible life …” (Participant 4, male). “…He still blamed me when he sobered up. I ran to my parents’ house and told them what had happened. My parents also beat me and chased me back. I did not have any friends to confide in. I thought of death as a solution…” (Participant 17, female). None of the suicide attempters sought advice, consultation or communicated with parents, relatives or community services concerning the difficulties in their lives during the year before their attempted suicide. Four of the participants had fathers 2 or husbands 2 who were alcohol abusers. One of them had an elder brother who had abused drugs. None of them had anyone in the family with mental health problems or who had attempted or committed suicide. Ten of the young suicide attempters were regularly beaten by their parents. It happened “all the time” and “without reason”. Two of the four young married female suicide attempters regularly suffered from domestic violence. Sixteen of the suicide attempters were psychologically abused by their families for at least one year before attempting suicide, incurring regular scolding, blame, and criticism, or being reproached in ways that made them feel guilty and sad. Fourteen participants wanted financial support from their parents and four received it. Sixteen reported that they had asked their parents and family for psychological and moral support, but none of them received it. “… I sometimes felt my life was meaningless, and I wanted to put an end to my life. I was the only son in my family, but most of my family members have hardly spoken to me. An only son is said to be treated beautifully, but it seemed to be the opposite in my case. Almost every day, I was blamed for various things during mealtimes. I was even treated worse than a dog …” (Participant 4, male). “… Every day, my husband gambled and his behaviour affected our family finances. I tried to tell him, but he did not change. On that day, my husband continued gambling. I felt angry. We had an argument, I felt that life was not worth living and I went out to buy raticide…” (Participant 15, female). “… I had to pay a tuition fee of 20,000 Vietnam Dong (that's about 1.5 US dollars). My father refused to give it to me. I didn't think it was that much money. At the time, my father drank a lot and scolded me all the time. I felt sad, so I attempted suicide…” (Participant 5, male). Three of the 19 respondents used direct verbal suicidal communication. Sixteen of the 19 respondents felt deep frustration with their life situations for at least six months before they attempted suicide, and ten of them for at least one year, but they were unable to express in words to their families not only their need for help, but also their fleeting, vague suicidal thoughts. Seven of the 19 respondents communicated with their friends or peers about their distress and their wish to disappear from life. However, they were afraid of self-exposure and negative repercussions. They also thought that it is “sick” to harbour suicidal thoughts and they felt that it was easier to acknowledge or to talk about feelings of unhappiness, despair and distress. There was a marked discrepancy between what those young people expressed verbally and the desperation they felt. They were ashamed and they felt that they should cope on their own without intervention from outside. They wanted to give the impression of being strong. Feelings of being strong alternated with feelings of being useless and worthless. Their feelings of anxiety and anguish were not expressed either. Ten youngsters expressed their distress in a non-verbal way by deviant behaviour and weakening or rupturing ties with their families. They also had time to buy raticide in a shop. Two of the 19 respondents wrote farewell letters before attempting suicide. For 12 suicide attempters, the first suicidal thoughts became overwhelming, very pressing and constant less than one day before the suicide attempt in question. In five cases, the suicidal thoughts became overwhelming one to three days before the suicide attempt. One male had had fairly pressing, but sporadic suicidal thoughts for approximately a year before the attempt. Al least six months before they attempted suicide, 16 of the 19 respondents were “very sad”, “wanted to cry”, felt “unpleasant”, “self-pitying” and thought that “life was meaningless” and not worth living. They wanted to disappear or take a break from life. Sometimes they thought that death might be a solution to their problems. They acknowledged vague and fleeting suicidal thoughts, which could disappear quickly and recur equally fast in response to new or renewed strains. Ten of the respondents had felt deeply distressed for at least one year before their suicide attempt. Only two believed that those vague and fleeting suicidal thoughts were serious or could lead to a suicidal act. Almost all of them thought that their suicide attempt was due to chance circumstances. The information concerning the suicidal process and the presence of suicidal thoughts was unclear for one participant. All the young persons studied hoped that their difficulties would pass without any active steps being taken by themselves or others, and that their lives would be better in the future. Five respondents had a suicide plan for one to three days before attempting suicide. “…I had planned suicide two days before I attempted it. That morning I bought six or seven ampoules of raticide. After finishing work on the field and in the house, I took the raticide at around 5 pm, because my husband was often drunk and frequently beat me…” (Participant 17, female). All the young interviewees thought it highly unlikely that their suicide attempt might be interrupted or that external intervention could save them. On the other hand, 14 subjects had someone nearby or present when they displayed their suicidal behaviour. “…During dinner my mother like always repeatedly blamed various things on me. Moreover, my older sister came home and backed my mother up in the way she was speaking to me. I became very upset because I thought I was right, yet I was seriously blamed by both my mother and sister. I was tired after a long day's work, and very irritable. I did not have any hope for a change in my life. I stopped eating, left the living room and went to my bedroom. This was a small room next to the living room, separated from it by a curtain. I poured a packet of pesticide into my mouth without hesitation …” (Participant 4, male). Pesticides were used by nine subjects, raticide was also used by nine, and one male used allergy medication in his suicide attempt. According to the young suicide attempters interviewed, raticides are cheap and pesticides easily available for purchase in rural areas. “…because raticide was cheap and easy to buy. First, we wanted to use an electric wire but way was (Participant feelings after the suicide attempt of the subjects felt were two had feelings of and and one was unclear about his “… I felt and my I that my parents were and I had (Participant male). “… I was very upset and and I did not want to suffer from my mother's blame any more. I thought that death could free me from my current terrible life. my was and I felt like a I was that I could not about my act and I suffer from it for the of my (Participant 4, male). The interviews were performed after hospital and in an respondents to express their which also and negative of their stay in the However, the respondents not have their in for two First, some of the subjects were months after their attempt and have some about the participants not have to be of the negative that to their suicide attempts, and have questions that were The of the 29 selected of the results of Suicide attempters who were not hospitalized were not in the Suicidal communication is a of personal a to for For suicide-preventive it be to various of suicidal communication, as as the subject's despair and for attempting suicide. In the present study, seven of the 19 respondents used indirect verbal of suicidal communication and three in direct verbal suicidal communication. Ten of the 19 patients felt they were in and experienced and distress for at least one year before their suicide attempt. Sixteen of the 19 had experienced an and constant as as fleeting, vague suicidal thoughts, and felt that “life is for one to six months to their suicide attempt. However, they were unable to with their parents or other family members about their to and in a with others about their distress and a need for psychological or financial support were in all the persons studied. The that vague and fleeting suicidal thoughts, which are on life are not taken seriously is also in patients from Western 12 of the 19 youngsters showed a time lag than one and five of the 19 had a time lag of between one to three days between their first pressing suicidal thought and their suicide attempt, they had experienced vague and suicidal thoughts in the months and of them had used some of suicidal communication. However, indirect communication can be for to and direct suicidal communication was by only three In investigation, only very constant and pressing thoughts on suicide before the suicide attempt were by respondents as suicidal thoughts. the presence of suicidal thoughts and of suicidal communication is from a of it a interview from study show that further of the and used, as as is Five of the 19 young people had some of suicide plan one to three days before the suicide attempt. Results from Western also show that young people have a suicidal process The time was used by young suicide attempters in for buying raticides or they had to or their distress had previously by significant others, they might have to to someone of buying It was from the narrative that the young people in our study displayed their distress in ways, often by deviant not only to their families but also to the The majority of youngsters felt a lack of in the and feeling their deviant behaviour and to of communication and is of suicide attempters in the Western countries as 13. 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However, the problems in suicidal families the parents’ is The of in which of problems is are of lack of communication between parents and suicidal young people is also in Western The young persons in the present study deeply and that they did not financial and psychological support when they felt Moreover, of the 19 young people were primary or secondary school dropouts. from the and the family were The on Mental Health by the in with the World Health and the for and and school the of at mental problems and suicide. out of school is one of the most significant of mental distress and mental of which suicide attempts and suicide are the suicide of suicidal communication and distress It is to much of intervention could suicide attempts among However, it to restriction of highly toxic and lethal means of suicide with some of psychosocial strategies that on young people at such as school and on families to about problems and can be young people to other people for a the family to give them support is on the stress-vulnerability suicidal behaviour when there is between risk and protective In our study, personal and lack of support were found to be the main for suicide attempts. 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The of in suicide risk has for the of suicide-preventive We would like to more qualitative focusing on the suicidal process and suicidal communication, and on and in suicidal behaviour. in the of school domestic communication and in distress should the suicide-preventive strategy of the of lethal means of suicide and attempted suicide, such as pesticides and