“To end or not to end, is the question!”: Content analysis of suicide-notes and thematic analysis of interviews in suicide survivors

BACKGROUND: India stands out as the ‘suicide-capital of South-east Asia’ with increasing suicide rates every year. Elderly population is twice more likely to act out on their suicidal ideations with multiple other vulnerabilities. As suicide attempts are much more than the completed suicides, it is fundamental to study the experiences of suicide survivors for prevention. OBJECTIVE: To understand the perspectives, unmet needs and protective factors in the elderly who have survived a suicide attempt. METHOD: Qualitative methodology was used with constructivist paradigm. Between 2014 to 2016, all elderly (age > 60 years) who attempted suicide in a tertiary care mental health institute by any means (not just self-harm) with an intention of dying, but survived the attempt, were enrolled with consent (M:40, F:11). Their suicide notes (if present) were obtained with permission and in-depth one-to-one interviews were conducted with them once they were medically and psychiatrically stable. The interviews were audio-recorded and transcribed verbatim. Thematic analysis of the interviews and content analysis of the suicide notes were done, based on Charmaz’s grounded theory approach. RESULTS AND DISCUSSION: Hanging and self-poisoning/medicating were the prominent methods. The suicide notes revealed themes of self-guilt and blame, apology, bereavement, hopelessness and advice/prayers for loved ones. Their unmet needs were mainly lack of audience, increased social demands, lack of awareness about mental-health resources, loneliness, somatic complaints and loss of self-autonomy. Complaints about cognitive decline and significant stigma about the ‘act of suicide’ were predominant post-survival. Almost all of them visited at least one medical practitioner within two weeks prior to the attempt, which was alarming. CONCLUSION: There is significant dearth of data on suicide-survivors, more so in elderly where the risk is double. Our study showed that awareness and structured assessment of the risk, early identification of cognitive complaints and decreasing stigma can be fundamental in reducing deaths in older people due to suicide. All classes of physicians need to be sensitive and aware about the same. Mixed method studies are further warranted.