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Comparative Study of Suicide Potential Among Pakistani and American Psychiatric Patients
Comparative Study of Suicide Potential Among Pakistani and American Psychiatric Patients
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This study compared suicide potential and suicide attempts in 50 Pakistani and 50
American psychiatric patients all of whom reported a positive history of suicide attempts
during the past 175 years. It further explored the role of nationality, gender, diagnosis,
and marital status in respondents potential for suicide and suicide attempts. The
American sample reported a higher degree of suicide potential on the Firestone Assessment
of Self-Destructive Thoughts (FAST), more suicide attempts, and a larger number of
suicide precipitants (family conflicts, work pressure, wish for death, loneliness, financial
problems, and mental disorders/drug withdrawal) than did the Pakistani sample. For
suicide attempts, effects of 3-way interaction for gender, marital status and nationality
were found significant. However, these effects were non-significant for respondents
potentialforsuicide. In addition, the FASTwas found to have a significantly high correlation with suicide attempts.Thus, it may be inferred that the FASTcan be used as a valuable
screening instrument for the identification of patients at risk for suicide in diverse cultural
settings. However, more prospective validity studies are needed to enhance our crosscultural understanding of suicide; identification of psychiatric patients at risk for
suicide by the FAST; and for effective treatment and prevention programs for Eastern and
Western societies.
19
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Y. N. Farooqi
Suicide attempts arise from a variety of social, economic, and psychological factors (Bonger, 2002; Firestone, 1987, 1988, 1994, 1997a; Firestone
& Firestone, 1996, 1998; Shneidman, 2001). Of late, there has been a
steady increase in suicide rates in Western developed countries as well
as in Eastern developing countries such as Pakistan. Attempts to understand this anti-life phenomenon are of immense concern to helping professionals around the world.
Views regarding suicide have changed through the centuries, considering the complexity of this self-destructive process. Firestone and
Firestone (in press) proposed that understanding the causes and nature
of the self-destructive thought process of the suicidal individual is fundamental to developing psychotherapeutic interventions and preventive
mental health programs for potentially suicidal patients. Beck (1976,
1991), Ellis (1973), Kaufman and Raphael (1984), and Stillion,
McDowell, Smith, and McCoy (1986) have described negative thoughts
toward self and others, which lead to depression and self-defeating behavior. Firestone & Firestone argued that the suicidal individual is divided
within himself/herself . . . one part wants to live while the other part
wants to die. Therefore, it is our responsibility to appeal to and support
the part that wants to live because their right is not to commit suicide
but to have their need for psychological assistance met so that they may
enjoy a satisfying life among us (Leonard, 1967, p. 223).
There is sufficient clinical and empirical evidence that suggests that
the individuals who had made serious suicidal attempts manifest
extremevoice attacks (self-destructive thoughts) that may set the stage
for future fatal suicide attempts (Firestone, 1987, 1988, 1994, 1997a,
1997b; Firestone & Firestone, 1996, in press). Firestone and Firestone
(1996, in press) propose that there is a relationship between destructive
thought processes and self-destructive behavior and/or suicide. According to Firestones (1997a) SeparationTheory and Voice Concept, within
each individual there are tendencies to actualize the self (self-system)
and to destroy the self (anti-self system). He further argued that the
Firestone Assessment of Self-Destructive Thoughts (FAST) provides
valuable information regarding clients functioning level along an
11-level continuum beginning with self-critical thoughts of every day life
(Level 1) and progressing to injunctions to carry out the suicide plan
(Level 11).
Research has shown that a suicide crisis is the therapists worst fear,
often paralyzing clinicians emotionally and interfering with their sound
Suicide Potential
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Y. N. Farooqi
Suicide Potential
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Y. N. Farooqi
Suicide Potential
25
Method
For the present research, a retrospective ex post facto research design
was used. The sample was composed of 100 psychiatric patients (50
Pakistanis and 50 Americans). The inclusion criteria for both samples
were that the patients should be receiving some psychopharmacological
treatment in a hospital/clinic setting for the past 275 days; they must
not have experienced active suicidal ideation, threats, and/or attempts
within the past 1 month; but have a positive history of non-fatal suicide
attempts within the past 175 years; and they must voluntarily agree to
participate in this research project.
The American sample was randomly selected from data collected by
Firestone and Firestone (1996, 1998) for their validity studies of the
FAST. All the patients were selected from various outpatient and inpatient units of different hospitals and clinics in California. In an attempt
to make the Pakistani sample representative and comparable to the
American sample, the Pakistani psychiatric patients were also selected
from various outpatient and inpatient units of different hospitals and
clinics in Lahore, Pakistan. Only those patients were selected who
agreed to participate in this research, had been diagnosed by their treating psychiatrists on Axis 1 of DSM-IV (American Psychiatric Association, 1994) for depression/depressive illness, anxiety disorders,
schizophrenia, or substance-related disorders and met the abovementioned inclusion criteria like their American counterparts.
26
Y. N. Farooqi
Instrument
Suicidal potential was measured by the FAST, a self-report questionnaire consisting of 84-items drawn from eleven levels of progressively
self-destructive thought process that may lead to actual suicide. The
respondents were asked to endorse how frequently they experienced the
negative thoughts or voices toward themselves (in the second person)
on a 5-point Likert-type scale fromnever tomost of the time.
According to Firestone and Firestone (1996, 1998), factor analysis of
the FAST provided four factor-based composites: (a) self-defeating
composite (measure of feelings of low self-esteem), (b) an addictions
27
Suicide Potential
TABLE 1 Descriptive Characteristics of the Sample (N 100)
American Patients
(n 50)
Characteristics
Freq
Percent
Pakistani Patients
(n 50)
Freq
Percent
Gender
Males
Females
26
24
52%
48%
30
20
60%
40%
Marital Status
Single
Married
Separated
Widowed
Divorced
26
6
3
1
14
52%
12%
6%
2%
28%
29
19
2
0
0
58%
38%
4%
0
0
Education
Grade School
High School
173 Years of College
Bachelors Degree
Masters Degree
8
20
15
5
2
16%
40%
30%
10%
4%
17
16
11
6
0
34%
32%
22%
12%
0
Diagnosis
Depression
Anxiety Disorder
Schizophrenia
Substance-Related Disorders
20
10
10
10
40%
20%
20%
20%
20
10
12
8
40%
20%
24%
16%
Income
US Dollars Pak Rupees
$ 079,999 Rs 075,999
$10719,999 Rs 6711,999
$20729,999 Rs 12717,999
$30749,999 Rs 18723,999
$50 > Rs 24 >
31
8
8
2
1
62%
16%
16%
4%
2%
23
22
3
1
1
46%
44%
6%
2%
2%
5
2
4
3
2
5
3
10%
4%
8%
6%
4%
10%
6%
4
1
7
7
3
6
10
8%
2%
14%
14%
6%
12%
20%
Occupation
Professional
Manager
Clerical
Labor
Skilled Labor
Student
Homemaker
(Continued)
28
Y. N. Farooqi
TABLE 1 Continued
American Patients
(n 50)
Characteristics
Freq
Percent
Pakistani Patients
(n 50)
Freq
Percent
Disabled
Other
10
16
20%
32%
8
4
16%
8%
3
4
0
1
5
1
0
3
33
6%
8%
0%
2%
10%
2%
0%
6%
66%
18
14
2
2
5
1
2
1
5
36%
28%
4%
4%
10%
2%
4%
2%
10%
Age
Suicide Attempts
Range for reported or
recorded suicide attempt
R 18754 years
R 18745 years
R 1720
R 175
Note. $ US Dollars per month; Rs Pakistani Rupees per month; n Number of patients;
Freq Frequency; R Range.
Suicide Potential
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Procedure
The Pakistani patients were administered Urdu version of the FAST
(Farooqi, 1999) within the hospital settings by a research associate who
remained there along with this researcher to answer any questions or
communicate with those who might have become disturbed by feelings
aroused during the FAST testing. The patients responses on the FAST
were immediately scored so that their treating psychiatrists/psychologists could be informed if the scores were in the range of concern.
This was done to provide for the clients safety so that necessary interventions could be initiated. Furthermore, both therapists and patients
provided information on past suicide attempts through a structured
interview as was done in case of the American sample. In case of disparity between the patients and the therapists reported suicide attempts
the patients reported suicide attempts were considered. Moreover, a
structured interview was conducted by this researcher to obtain demographic information from the Pakistani sample on a separate sheet as
was done in case of the American sample.
Results
The data given in Tables 2 and 3 suggest that the American sample
reported more suicide attempts, a larger number of suicide precipitants,
and a higher degree of suicide potential as compared with the Pakistani
sample. In addition, the American participants in all diagnostic groups
reported more self-defeating, addictive, and self-annihilating voices
than the Pakistanis.
Figure 1 shows that within the American sample men reported more
suicide attempts, whereas in the Pakistani sample more women reported
suicide attempts.
Figures 2 and 3 suggest that the American patients suffering from
depression reported the highest rate of suicide attempts and greater
potential for suicide than all other diagnostic groups.This may be attributed to lack of socially acceptable ways to express anger and higher level
of social and economic competition and pressure for men in American
society. However, in the Pakistani sample, those suffering from substance-related disorders (mostly men) showed greater suicide potential
but reported a lower rate of actual suicide attempts than other diagnostic
30
59.65
83.10
150.85
251.45
1.80
3.40
Pakistani
American
Pakistani
American
Pakistani
American
Pakistani
American
Pakistani
American
Addictions
Composite
Self-Annihilating
Composite
Suicide Intent
Composite
Total FAST
Score
Suicide Attempts
Reported/Recorded
.79
4.31
51.35
66.31
26.01
29.11
33.06
37.57
4.93
8.95
22.07
27.74
SD
20
20
20
20
20
20
20
20
20
20
20
20
1.80
1.70
133.60
211.60
53.20
62.80
73.10
84.70
6.60
15.60
53.90
115.20
1.48
.95
53.04
78.81
28.79
31.54
40.38
40.19
4.38
7.29
20.43
31.84
SD
10
10
10
10
10
10
10
10
10
10
10
10
Anxiety-Disorders
75.40
113.05
9.35
20.20
66.70
118.20
Pakistani
American
Self-defeating
Composite
Nationality
FAST Factor-based
Composites/Suicide
Attempts
Depression
1.17
2.40
149.08
210.50
53.83
65.20
72.17
89.90
11.75
18.40
66.00
102.20
.39
1.51
63.53
77.35
30.83
28.92
40.56
40.23
6.92
9.86
25.47
37.42
SD
Schizophrenia
12
10
12
10
12
10
12
10
12
10
12
10
1.50
1.10
193.50
218.20
73.00
67.60
94.50
91.40
18.13
23.60
80.88
103.20
.76
.32
40.82
64.56
17.97
30.33
22.15
42.69
4.09
7.17
32.16
22.79
SD
Substance Abuse
Disorders
8
10
8
10
8
10
8
10
8
10
8
10
TABLE 2 Comparison of FAST Factor-based Composite Scores (Suicidal Potential) and Suicide Attempts Reported by the Pakistani and
American Psychiatric Patients byTheir Diagnosis
31
Suicide Potential
TABLE 3 Precipitant Events for Suicide Attempts Reported By the Pakistani and
American Patients
American Patients
Type of
Precipitant Events
Illness
Family Conflicts
Work Pressure
Wish for Death
and/or Loneliness
Grades/Study
Anxiety
Financial Problems
Interpersonal
Conflicts/Loss
Drug Withdrawal/
Mental Disorder
Multiple Events
Pakistani Patients
Freq
Percent
Freq
Percent
3
4
0
1
6%
8%
0
2%
18
14
2
2
36%
28%
4%
4%
10%
10%
1
0
2%
0
1
2
2%
4%
6%
2%
33
66%
10%
(Family Conflicts,Work
Pressure,Wish for Death
Financial Problems,
Mental Disorder)
Suicide Attempts
American Sample: Mean 2.40 (SD 2.94)
(n 50)
Range 1720
Pakistani Sample: Mean 1.62 (SD .92)
(n 50)
Range 175
Note. Freq Frequency.
32
Y. N. Farooqi
be inferred that the Total FAST Score could be used as a global assessment of patients suicidal potential for culturally diverse populations as
was done in this study.
MANOVA for two dependent variables (suicidal potential and suicide
attempts) and four fixed factors (nationality, gender, diagnosis, and marital status) was conducted to determine the effects of interaction. Table 6
suggests a trend toward a 3-way interaction for Nationality 6 Gender
6 Marital Status on patients suicide attempts (F 4.84, df 1, p < .05,
Suicide Potential
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34
Y. N. Farooqi
single and the separated. None were widowed and/or divorced in the
Pakistani sample. In contrast, the American widow (n 1) reported the
highest rate of suicide attempts, whereas the separated patients (mostly
men) showed higher degree of suicide potential than the single, the married, and the divorced.
35
Suicide Potential
Composite
Self-Defeating
Addicitions
Self-Annihilating
Suicide Intent
FAST Total Score
Suicide Attempts
.19
.15
.29**
.28**
.26**
.06
.15
.00**
.01**
.01**
.91**
.63**
.91*
.00**
.00**
.00**
.00**
1.00
TABLE 5 Relationship Between the Total FAST Score and Level/ Factor-based
Composite Scores
Levels/Composites
Level 1: Self-DepreciatingThoughts
Level 2: Thoughts Rationalizing
Self-Denial
Level 3: Cynical Attitudes Towards
Others
Level 4: Thoughts Influencing Isolation
Level 5: Self-Contempt: Vicious
Self-AbusiveThoughts
Level 6: Thoughts Supportive of Cycle
of Addiction
Level 7: Thoughts Contributing to
Hopelessness
Level 8: Giving Up on Oneself
Level 9: Injunctions to Inflict
Self-Harm
Level 10: Thoughts Planning Details
of Suicide
Level 11: Injunctions to Carry Out
Suicide Plans
Self-Defeating Composite
Addicitions Composite
Self-Annihilating Composite
Suicide Intent Composite
Note. r Correlation Coefficients; *p < .05. **p < .01.
.85**
.74**
.00*
.00*
.70**
.00*
.83**
.87**
.00*
.00*
.63**
.00*
.86**
.00*
.85**
.75**
.00*
.00*
.81**
.00*
.82**
.00*
.91**
.63**
.91**
.88**
.00*
.00*
.00*
.00*
36
1
1
1
Suicide Attempt
Total FAST Score
Suicide Attempt
22.69
7.89
4313.02
964.62
2.99
10858.32
9.95
16544.63
1.00
5449.14
8.27
11798.95
4.78
26370.52
Mean
Square
4.84
1.69
1.20
.27
.64
3.01*
2.12
4.59
.21
1.51
1.77
3.27*
1.02
7.32**
Note. All non-significant two-way and three-way interactions were omitted. *p < .05. **p < .01. df degrees of freedom.
Nationality6Gender6
Marital status
Nationality6
Marital Status
Diagnosis6Gender
Marital Status
Gender
Diagnosis
1
1
3
3
1
1
4
4
3
3
1
Nationality
df
Dependent Variable
Source
.03*
.20
.28
.61
.43
.04*
.11
.04*
.65
.21
.15
.03*
.39
.01**
.07
.03
.02
.00
.01
.13
.09
.07
.00
.09
.10
.14
.05
.10
Partial Eta
Squared
TABLE 6 The Role of Nationality, Diagnosis, Gender, Marital Status on Measure of Suicide Potential (FAST Total Score) and Reported
Suicide Attempts
Suicide Potential
37
Discussion
The main findings of this study are that the American sample reported
more suicide attempts, a series of multiple suicide precipitants and
38
Y. N. Farooqi
higher degree of suicide potential than the Pakistani sample. In addition, those suffering from depression reported more suicide attempts
and suicide potential in both samples. The Pakistani female patients
and the American men reported more suicide attempts. However, the
Pakistani men and the American women showed a higher degree of
suicide potential.
Suicide Potential
39
40
Y. N. Farooqi
potential in both samples. These results are consistent with the prior
international research data that suggest depression, schizophrenia, and
substance-related diagnostic groups pose a higher risk for suicide in the
Western and Eastern societies.
Contrary totheAmericanpatients suffering fromanxiety, the Pakistani
patients suffering from anxiety (mostly women) reported more suicide
attempts. In the Pakistani mental health system, anxiety, and depression
in women are perceived as relatively mild mental disorders, probably
because most of these women are expected to play limited roles within
the four walls of their houses. Moreover, in the male dominant Pakistani
society these disorders are perceived more feminine. In addition,
women suffering from depression and anxiety are often blamed by the
society, their family, and even professionals for not being strong and
good Muslims. Thus, under-diagnosis and under-treatment of these
disorders may further exacerbate the female patients state of emotional
distress, guilt, self-blame, shame, and self-hate. Consequently, in the
grip of this kind of crisis and lack of timely social7professional support,
the Pakistani women are quickly driven to suicide as a way out.
Depression and substance-related disorders are the most under-diagnosed and under-treated psychiatric disorders in men across the globe
especially in developed countries like the USA. Moreover, there are
other underlying factors associated with these disorders, such as family
discord, interpersonal conflicts, work-related pressures, financial problems, legal or disciplinary crisis (which often exacerbate feelings of
hopelessness), helplessness, and despair in such patients. Thus, it may be
inferred that a suicide attempt may be the patients way of communicating strong feelings of anger (voice attacks) and an overwhelming desire
to escape the psychological pain and unbearable circumstances as
reported by the American patients in this study.
In Pakistan, this situation could be further complicated because the
use of alcohol and other addictive chemical substances is considered a
sin and a crime mainly because of Islamic ideology. As a result, in the
Pakistani mental health system patients with substance-related problems do not receive the same kind of non-judgmental professional
attention as do the other diagnostic groups. Thus, when faced with
choice between two sinssuicide or drugsperhaps these patients
(mostly men) choose substance-abuse as a way of killing themselves to
escape the unbearable psychological pain of shame, guilt and embarrassment, and problems with law associated with actual suicide attempts
Suicide Potential
41
in Pakistani society. Nevertheless, our findings further suggest underlying strong feelings of despair and anger in these male patients, which
were communicated in their highTotal FAST Scores.
In the Pakistani sample, married women reported more suicide
attempts as compared with married men and single and separated
women.This finding is in contrast to the previous findings fromWestern
developed countries that suggest a lower rate of suicide attempts in the
married but higher rate among the singles, the widows, and the
divorced. It may be that in traditional and religious Pakistani society a
suicide attempt is perceived as a feminine behavior. Pakistani married
women in their passive-dependent roles receive relatively more sympathy when they attempt suicide than men despite the punitive laws and
religious sanctions against suicide in general. In contrast, any suicide
attempt by troubled Pakistani men is viewed as a violation of their traditional masculine sex-role message of strength, decisiveness, forbearance,
and inexpressiveness.This might have resulted in a higher rate of suicide
attempts in the Pakistani married women who are often overwhelmed
by feelings of helplessness and hopelessness, probably because of frequent and chronic conflicts with in-laws over dowry as compared with
the Pakistani men.
Furthermore, the patriarchal Pakistani society encourages a traditional complex joint family system, matching or mismatching of spouses
by mostly arranged marriages, an expensive dowry system, lack of equal
rights for divorce, chronic intergenerational family conflicts, passive
and chronic power struggles between spouses, severe economic hardships, unreported domestic violence/abuse, and hostile relationships
with in-laws. Moreover, Pakistani women are often economically and
physically dependent on their male counterparts. Divorce brings shame
and embarrassment and is neither an equal nor an easy choice for married Pakistani women who are rarely economically independent. Consequently, they end up feeling more helpless and hopeless if they fail to
fulfill their traditional roles as a wife and mother.
Problems in marital life multiplied with untreated psychiatric disorders may trigger more intense unresolved anger, feelings of helplessness
and hopelessness resulting in self-attacks/self-destructive behavior in
case of Pakistani married women. Perhaps the high rate of suicide
attempts among married Pakistani psychiatric female patients in this
study suggests their passive way of gaining attention or communicating
anger or love or to escape unbearable circumstances of marital life.
42
Y. N. Farooqi
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