Epidemiological Risk Factors of Suicidal Behavior in Medical Students

After investigating the paper titled “Epidemiological Risk Factors of Suicidal Behavior and Effects of the Components of Coping Strategies on Suicidal Behavior in Medical Students: A North-Indian Institution-Based Cross-Sectional Study,”1 it was noted that the study aimed to evaluate the prevalence and risk factors of suicidal behavior in medical students; therefore, assessment of depression, suicidality, and coping skills could have been supplemented with associated risk factors to fulfill the objectives in a better way. Further suicidal behavior and depression have a complex bidirectional association, and therefore it becomes more difficult to interpret the results.2

We appreciate the stratified random sampling technique with probability proportionate to size; however, this has limited the exploration of the association of coping strategies with the academic year. Authors discussed their findings as “The second strongest predictor for suicidal behavior in medical students was depression.” Although it is an important finding, in a cross-sectional study, it is not possible to predict the “cause-effect relationship,” and therefore longitudinal follow-up studies are more relevant in this context.3 Even in the longitudinal studies, the risk factors associated with the outcome of interest are subjected to statistical analysis such as interaction, effect modification, or mediation analysis while predicting a change in a complex behavioral pattern such as suicidality.4 To add further, a few specific risk factors unique to this subgroup such as accessibility to medications, self-prescriptions, the area of specialty, staying away from home, ragging, etc. could influence the outcome of interest have not been discussed by authors.5 6 Reductionistic concepts of risk factors of suicidality, the cross-sectional design of the study, single-center responses, and response bias related to the coronavirus disease 2019 pandemic are important factors that one should keep in mind while interpreting the results of this study.