Stigma of suicide

Sir,

The work of Nebhinani et al., 2013 which highlighted the attitude toward suicide of nursing students of North India is noteworthy.[1] As pointed out by the authors, suicide is a serious problem for India which requires consistent efforts to address the stigma towards suicide of the community as a whole.

The authors have chosen to use the Suicide Opinion Questionnaire, which although popular, has been criticized for having no consistent factor structure. The number of previously identified factors have poor internal consistence.[2] This possibly explains the reluctance of the authors to compare groups on individual items rather than factor scores. Citing the limitations of the study, the author states that ‘Attitude towards suicide prevention scale is not adapted for Indian population’, when the instrument is clearly not used by the investigators.[1]

When comparing the two institutes, the authors have pointed out significant statistical differences on 17 items of SOQ without attempting any possible reason for the same. Another fallacy is in considering certain scores as “uncertain” although summations of percentages suggests otherwise. For example, for the item ‘suicide happens without warning’ those agreeing add to 51.6% while those disagreeing amount to 31.8%. Clearly 68.2% of the sample is not in disagreement to the statement, which is a huge challenge for suicide epidemiologist and researchers. An average of 18.54% (range 4.5 to 35.1%) of responders are ‘uncertain’ for various statements, which hamper making a meaningful interpretation.

In contrast to ‘attitude’, assessment of stigmatizing attitudes of society towards those who attempt suicide or commit suicide provides more valuable insight into the problem. It must also be understood that negative views do not limit to those who suicide but also extends to the family and friends of those who suicide. The recently developed Stigma of Suicide Attempt (STOSA) and Stigma of Suicide and Suicide Survivor (STOSASS) Scales, provides a better picture of the challenge posed by this discrimination.[3] The scales capture behavioral responses which are practical indicator of the beliefs system of the individual. Responses in this self-administered instrument are reported as ‘strongly agree’, ‘agree’, ‘disagree’ and ‘strongly disagree’, thus removing the possibility of the ambivalent ‘not sure’ item. A composite stigma score on suicide (STOSA), attempted suicide (STOSASS- a subscale) and suicide survivor (STOSASS- b subscale), of 1 to 4 is generated, with a higher score denoting greater stigma. In experience of the author, both scales were easily administered to second year GNM nursing students of four nursing institutes of northern India (unpublished). The composite stigma score of 2.69 on STOSA, 2.47 on STOSASS-a and 2.46 on STOSASS subscale was observed.