A prospective study of suicidal deaths and its risk factors at a tertiary carelevel hospital of Ahmedabad a post-mortem study

Background and aims: Suicide is one of the significant causes of death. Suicidal deaths have increased in recent years due to various factors. Physical and mental illnesses, financial struggles, and interpersonal and family disputes contribute to suicidal deaths. The present study aims to assess the pattern of suicidal deaths and identify the contributing factors associated with suicidal death cases in a developing city like Ahmedabad. Material and methods: 552 post-mortem examinations were carried out at the mortuary from August 2020 - July 2021. The autopsy cases are accompanied by a requisition letter, "maranottar" form


INTRODUCTION
Suicide is a destructive act of self-harm with some indication of an intended death. 1 Suicide is the fourth chief cause of death among youths. Suicide rates vary substantially between regions. About 80% of all suicides occur in low and middle-income countries. 2 A significant fraction of people nowadays are affected by stress and worry; some might find solace in suicide. Due to its delicate nature and the stigma surrounding it, suicide is occasionally not acknowledged or recorded. 3 An increase in awareness is required in the general population about the severe negative repercussions of adolescent suicide tendencies, which include not only the direct loss of many young lives but also upsetting psychosocial disruptions and detrimental socioeconomic implications on a significant scale. Studies suggest that the most effective predictor of suicide attempts or death by suicide is a history of prior suicide attempts. 4,5 Identifying the contributing factors behind suicidal tendencies, particularly amongstthe young, is essential from the perspective of public mental health and its management through effective preventive measures. Therefore, it is essential to gain as much insight as possible into the different populations' risk factors contributing to suicidal behaviour.
The objective of the present study is to assess the pattern of suicidal deaths and to determine the factors for suicidal deaths amongst the population of Ahmedabad.

MATERIALSAND METHODS
The present study was a prospective descriptive study carried out at the VS General Hospital, Ahmedabad, Gujarat mortuary, including all the cases brought for autopsy from August 2020-July 2021. A total of 552 post-mortem examinations were included during the study period. The documents studied were the clinical case papers, requisition letter from police for conducting medico-legal post-mortem examination, "maranottar" (post-mortem) form, and copy of the inquest report. In all autopsy cases, a detailed case history was elicited from the police, close relatives cohabiting with the deceased and close friends. Prior informed consent was obtained from the next of kin to collect data.
Preliminary information about the deceased, including age, sex, occupation, socioeconomic status, etc., and history of circumstances before the incident, and details about the incident were noted in a pre-designed proforma.The history of any organic or psychiatric illness or any previous suicide attempt was also inquired about from the previous treatment papers (if any were anywhere available) and the interview of the relatives and friends. Details about the day to day of the victim were also inquired from close relatives and friends. The manner of the suicide was decided based on the history & circumstances of the incident, circumstantial evidence mentioned in the police papers, clinical history and progress of the case after admission, findings of the inter views of the police, close relatives and friends, and medicolegal autopsy.
The data were analyzed using Statistical Package for the Social Sciences version 16 and presented as frequencies and percentages.

RESULTS
Out of a total of 552 cases autopsied during the study period, 116(31.78%) cases were of suicidal manner, among whom 54.3% were male and 45.6% were females. Month-wise distribution of cases showed that the suicidal rates varied from 5.1% to 11.1%. Maximum suicidal death cases were observed in September, October and December 2020, while the least was observed during April-July 2021 ( Table 1). As seen from Table 2, the age-wise distribution of the cases showed that most of the suicide cases belonged to adolescents and adults, the majority from the age group of Table 2 Age-wise distribution of cases (n=116) 15-29 years (52.5%). Suicidal deaths were the least observed among children (5.4%) and older people (2.5%).
In 43.1 % of cases, the reason for suicide could not be elicited by questioning relatives and close friends. Family disputes and family factors contributed to 20.6 % of suicidal deaths. At the same time,love affairs (8.5%) and failure in the examination (8.5%) were the other significant contributors to suicide, particularly in the 15-29 age group.
Gender-wise distributions showed that family factors and disputes significantly contributed to male suicides, whereas drug abuse was surprisingly the most contributing factor in female suicidal deaths. Out of 53 female suicide cases, the reason for suicide was unknown in 30 cases ( Table 3).

DISCUSSION
Suicide is a serious public health issue that affects the entire world. Suicidal behaviour varies between genders, age groups, geographical locations, and socio-political contexts, and it also varies in its associations with various contributing factors. 1 The present prospective study was undertaken to evaluate the pattern of suicidal deaths and the contributing factors amongst the population of Ahmedabad.
Out of the 552 autopsies carried out during the study, 116 were due to suicide. The rate of suicidal death was almost similar in both sexes. Also, it was observed that the history of an attempt at previous suicide is more common in femalesthan males. Many studies find a strong link between previous suicide attempts or a history of self-harm and suicide. 6 Research has shown that men who have attempted suicide in the past are more likely to attempt it again than men who have never done so. Also,females with previous suicide attempts are at three times increased risk of suicide. 6 The age-specific distribution of the data showed that most of the suicide cases belonged to the 15-29 age group. Those under 30 years commit the majority of suicides (37.8%) in India. The fact that people under the age of 44 accounts for more than 70% of suicides in India places a tremendous social, emotional and financial strain on society. 7 Suicide is associated with impulsivity. 8 Although the suicidal process might take weeks, months, or even years, the tragic leap from suicidal ideation and suicide attempts to a completed suicide often occurs suddenly, unexpectedly, and impulsively, especially among adolescents. These young people are vulnerable to mental health transition, especially during adolescence. 9 This period in life is characterized by movement, changes, and transitions from one state to another in several domains simultaneously. Young people have to make decisions about critical concrete directions in life. They must also address new challenges about building their identity, developing selfesteem, acquiring increasing independence and responsibility, building new intimate relationships, etc. In the meantime, they are subject to ongoing, changing psychological and physical processes. And besides, they are often confronted with high expectations, sometimes too high, from significant relatives and peers. Such situations inevitably provoke helplessness, insecurity, stress, and a sense of losing control. 10 Several population-based psychological autopsy types of research on suicides have been carried out recently, involving key informant interviews, records review, as well as follow-up studies of individuals who have attempted suicide, providing crucial information regarding the risk factors for adolescent suicide.A multitude of circumstances can cause suicides, but ultimately each one is caused by a very unique, dynamic, and challenging confluence of genetic, biological, psychological, and social factors. 11,12 Although this is particularly significant in preventing such instances, it is also crucial to identify the various indicators linked to an elevated risk of youth suicide.
In the present study, in 43.1 % of cases, the reason for suicide could not be elicited by questioning the relatives and close friends in almost 43% of cases. Most importantly, out of 53 female suicide cases, the reason for suicide was unknown in 30 cases.There might be some defamation or underlying stigma that the respondents did not want to make public. In those situations, the facts were lost with the deceased.
For almost 20.6% of suicidal deaths, family factors and disputes were the key factors.The home environment in which young people live or have grown up is one of the most crucial sources of assistance for overcoming the numerous problems confronted by adolescents.Family structure and processes have been linked to suicidal behaviourin numerous studies. 13 Poor communication within the family is also found in many cases of suicide, not only with the child or about the child's problems, but in general between family members. Direct conflicts with parents have a significant impact, but so do the absence of communication and neglect of communication needs. 14,15 Furthermore, violence at home often seems to be found in the background history of young suicide cases, specifically against the child, but more as a way of dealing with problems between family members. The suicide of the affected children is only sporadically correlated with parental divorce as a whole. This correlation is likely intricated by the socioeconomic, financial, and practical implications of living in a singleparent household or by relational background factors connected to the divorce. 16 To reduce the factors contributing towards suicidality,integrated and multi-sector prevention initiatives, including population-based prevention strategies targeting high-risk subgroups or even focusing on individuals identified as suicidal, is essential. 17 study of psychiatric, psychosocial and personality-related risk factors.