Suicidal ideas during premenstrual phase

JOURNAL

EUEVIER

Journal

of Affective

Disorders

AFFECTIVE DISORDERS

34 (199.5) 193-199

Suicidal ideas during premenstrual Santosh

*, Prabha

K. Chaturvedi

OF

S. Chandra, G. Gururaj, M.B. Beena

phase

R. Dhanasekara

Pandian,

Department of Psychiatry, Department of Epidemiology, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India Received

6 May 1993; revised

13 February

1995; accepted

13 February

1995

Abstract The aim of the present study was to determine the frequency of suicidal ideas and death wish among 296 women from urban, rural, industrial and college populations. Suicidal ideas and/or death wish during premenstrual period were reported by 30 (10%) subjects, more so among college students and industrial working women and less among housewives. Premenstrual symptoms, like depression, irritability, mood swings, sense of losing control and water retention, were significantly more often reported by women who had suicidal ideas as compared with women without

suicidal ideas. Keywords: Suicidal idea; Premenstrual

syndrome; Depression;

1. Introduction

With the transition occurring in societies, suicides are becoming a major problem. The epidemiology of suicide and suicidal behaviour is a complex area of research and requires a greater and in-depth understanding of various aspects. Information available from the West indicates that the mean annual incidence rates of suicide in the 1544-year age group among women is 6.7/100,000/year (Youk, 1987). Studies of psychiatric illnesses, especially depressive disorders,

* Corresponding author. Address: No. 8, Type 4, NIMHANS Quarters, Byrasandra, Bangalore 560 011, India. Fax: (91) (80) 6631-830. 0165-0327/95/%09.50 0 1995 Elsevier SSDI 0165-0327(95)00017-8

Science

Premenstrual

distress

and completed suicide have shown a strong positive association through case control and followup studies as depression has been found to be present in 29.6% (Dorpat and Ripley, 1960), 47% (Robins, 1981) and 70% (Barraclough et al., 1974) of the subjects. These studies have shown a strong evidence that psychiatric illness, especially affective disorders, and suicidal thoughts or attempts are important risk factors for suicide. A variety of social risk factors, relevant to women, are also considered in the epidemiology of suicides (Venkoba Rao, 1984). Sainsbury (19861, after a correlational analysis of 15 social variables with suicide rates in 18 European countries, indicated that factors, like divorce, illegitimacy, unemployment, family factors, education, income and other factors indicating status of women, play a major role.

B.V. All rights reserved

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A special relationship is known to exist between premenstrual syndrome (PMS) and mood disorder (Dejong et al., 1985; Rubinow and Schmidt, 1987) in that women with PMS often have a greater lifetime prevalence of affective disorder (Mackenzie et al., 1986). Suicidal ideas and attempts are disconcerting features of affective disorder as well as of the PMS. The evidence in favour of significant association between attempted suicide and the menstrual cycle was derived from the studies of Dalton (1959) and Thin (1968). Suicide attempts in women with PMS and psychiatric disorder were noted by some studies in 15% (Stout et al., 1986) and 20% (Glare, 1983; Keye et al., 1986). Stout et al., (1986) studied the lifetime prevalence among 223 women attending the PMS clinic and observed that 63% reported suicidal ideation and 15% had made previous suicidal attempts. They also noted a discrepancy between low number of women meeting criteria for major depressive disorders and high number of women reporting suicidal ideation and attempts which suggested that women seeking treatment for PMS may be more likely than women in the community to experience shorter periods of depressive symptoms which may be intense and severe. Another explanation offered for this was that women seeking treatment for PMS may be reluctant to admit to more continuous depression because they view their depressive symptoms as associated with their menstrual cycles. In either case, the number of previous suicidal attempts in this group of women whose premenstrual symptoms are disruptive enough to cause them to seek treatment indicated that they constituted a high-risk group (Stout et al., 1986). Wetzel et al. (1971a) reported an increased proportion of female suicides and attempted suicides during the luteal and menstrual phases of the cycle. Mandell and Mandell (1967) found an increased number of women calling a suicide prevention centre in the late luteal and menstrual phases of their cycle. The number of women calling another suicide prevention centre was almost twice the expected frequency with significantly more callers being in their luteal and menstrual phases than follicular phase (Wetzel et al.,

1971a). Zacco et al. (1960) reported a significant positive relationship with women with PMS being more likely to attempt suicide premenstrually. Wetzel et al. (1971b) reported thoughts of suicide in 36% of callers as a premenstrual symptom. This study showed an association between reporting a high total number of premenstrual symptoms, self-reported seriousness of suicidal risk and the phase of menstrual cycle. Harrison et al. (1989) reported prior suicide attempts in 12% of women who were seeking treatment for premenstrual symptoms but who were not mentally ill and in 32% of those who were seeking treatment for PMS with coexisting mental disorder. Halbreich et al. (1982) reported suicidal ideations in 17% of women attending a PMS clinic of which 5% reported suicidal ideas to be of moderate or severe intensity. They also noted moderate to severe sadness (36%), anxiety (26%) and mood swings (30%) in their subjects. Devi and Rao (1972) analysed 115 cases of attempted suicide and reported that 64% had made their attempts when in the premenstrual period or early menstrual phase. On the contrary, some studies did not confirm the association between suicidal ideations or attempts and the premenstrual phase. Tonks et al. (1968) studied relationship between PMS and phase of menstrual cycle at the time of suicidal attempts and found a negative relationship. Women without PMS accounted for the premenstrual increase in suicidal attempts. Birtchnell and Floyd (1974) found no significant differences between observed and expected number of suicidal attempts during different menstrual phases. They also pointed out that emotional disturbance can affect menstrual function and that suicidal behaviour may be associated with the women knowing or fearing pregnancy. In another study, Birtchnell and Floyd (1975) compared 107 female suicide attempters with a control sample of 110 normal women matched for age. The proportion of the two groups who admitted to premenstrual emotional disturbances were comparable and the incidence of such disturbance was unrelated to taking an oral contraceptive. There was no evidence that suicide attempters had more irregular cycles or that the duration of cycles or of men-

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of Affecticle Disorders 34 (1995) 193-199

strual bleeding was longer. However, significantly higher proportions of suicide attempters were pregnant or beyond the date of their next expected menstrual period. There are many studies on suicide and parasuicide but very few on the occurrence of suicidal ideas. Sorensen (1993) reported that 13.6% of > 3000 Los Angeles residents had thought of suicide. Carstairs and Kapur (1976) reported occurrence of suicidal ideas in - 5% of general population. 9% of university students referred to a student counselling centre in India reported suicidal ideas (Wig et al., 1969). Further, though there are studies reporting the relationship between suicide, parasuicide and menstrual phase, there are no reports on the occurrence of suicidal ideas during premenstrual phase. In fact, most premenstrual assessment forms do not enquire about suicidal ideas or death wish. For the prevention of parasuicide and suicide, it is imperative to enquire about the occurrence of suicidal ideas. The present report deals mainly with occurrence of suicidal ideas among women in the reproductive age group with the objectives determine the frequency of suicidal ideas reported by women during their premenstrual phase and its relationship with other psychological symptoms of PMS, like depression, irritability, sense of loosing control, mood swings and water retention reported during the premenstrual period.

2. Methods 2.1. Study sample and area An important aspect of this epidemiological project on the prevalence of premenstrual experiences was to assess women from different strata of society and of different age groups and occupations. To get an adequate representation of women from Bangalore District, India, it was decided to recruit into the study women in the 1545year age group from four major areas. Urban and rural women were included from a middle-class locality, Shanthinagar, and a village, Bidriguppe, respectively. In view of the special

195

focus of occupation on premenstrual experience, the urban sample also consisted of women working in the industry, banks and offices. The fourth group included collegiate students selected from four different categories to give equal representation for age, education, socio-economic background and geographical distribution. To ensure this, students were included from government, private, professional and evening colleges. A list was made of all the colleges and industrial establishments and the sample selected by randomization (with the help of random numbers). With this method, women from 14 colleges and 14 industrial establishments, banks and offices were studied. Only those women who were residents of Bangalore District for at least 6 months and who could communicate in the local language were included. The urban locality selected was based on census records (for layout selection) and consisted of a house-to-house survey. The rural area selected was a village which had all the characteristics of a rural area and the women were included from households by serial numbering (Chandra et al., 1994). The subjects for this study on the premenstrual suicidal ideas were 296 randomly selected women from different populations, between the ages of 15-45 years who had regular menstrual periods, no known major physical, gynaecological or psychiatric illnesses and were not using any oral contraceptives. These women were selected by stratified random sampling method from an urban area (n = 56), rural area (n = 601, industrial establishment (n = 591, professional college (n = 55) and a nonprofessional arts college (n = 66) in Bangalore District. The details of randomization for selection of colleges, industries and other catchment areas are described above and more details are described elsewhere (Chandra et al., 1994). The refusal rate was very low, with most women co-operating for the survey. Informed consent was sought from the subjects and concerned authorities before data collection. Detailed instructions were given to the subjects regarding the rating and their doubts were clarified. For the purpose of the study, premenstrual period was defined as a period of 5 days before the onset of their periods.

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of Affective Disorders 34 (1995) 193-l 99

2.2. Instruments

The socio-demographic details, menstrual and gynaecological history were collected using a semistructured proforma. The premenstrual assessment form (PAF) was used to elicit distress during the premenstrual period. This was constructed, modified and standardized by the research team during the pilot phase and is described elsewhere (Chaturvedi et al., 1994). The test-retest and interrater reliability were also studied during the pilot phase (Chaturvedi et al., 1994). The PAF was found to be suitable and culturally relevant for assessing premenstrual distress for our Indian population and have been used in our previous studies (Chandra and Chaturvedi, 1989; Chaturvedi et al., 1993). The PAF is a 65item self-report inventory with different distress symptoms, like somatic, depressive, anxiety, organic (cognitive), water retention, hostility, impulsivity and other general stress and distress experiences. Suicidal ideas and death wish were enquired as depressive features in the inventory. For this study, suicidal ideas were elicited from the subjects response to the statement ‘At times, I think of ending my life’ and death wish was elicited in their response to the statement ‘At times, I wish I were dead’. The number of subjects who experienced either both suicidal ideas and death wish or any one were identified. These women formed the study group. An equal number of women who did not report suicidal ideas or death wish during the premenstrual period formed internal controls selected in a random method by including the next

consecutive case following the subject with suicidal ideas. The association between suicidal ideas and other key premenstrual symptoms, like depression, irritability, mood swings, sense of loosing control and water retention, were compared in the two groups. 2.3. Analysis The data analysis consisted of % frequency analysis of the key items. A comparison was made between subjects who had premenstrual suicidal ideas and those who did not report such ideas. The relationship between suicidal ideas and other key psychological symptoms was also computed.

3. Results Of the 296 women who were interviewed, 10% (n = 30) reported suicidal ideas and/or death wish during their premenstrual period. Among these 30 subjects (study group), 17 (57%) women experienced both suicidal ideas and death wish, 10 (33%) reported only suicidal ideas and 3 (10%) reported only death wish. Of the women who reported suicidal ideas (n = 30), 16 (53%) were students from an arts college, 8 (25%) were industrial working women, 3 (10%) were students of professional college, 2 (6%) were urban household women and 1 (3%) belonged to a rural area (Table 1). Suicidal ideas were significantly more often reported by nonprofessional arts college students (P < 0.001) and

Table 1 Frequency of suicidal ideas in different groups Area

Rural women Urban women Industrial working women Professional college women Arts college women Total

Subjects recruited

Subjects with suicidal ideas

n

n

%

60 56 59 55 66 296

1 2 8 3 16 30

1.7 3.6 13.6 5.4 24.2 10.1

(3.3) (6.6) (26.7) (10.0) (53.3) (100.0)

x2, P < 0.001. * Figures between parentheses are % or proportions derived from women with suicidal ideas, i.e., women from that area with suicidal ideas divided by total number of women with suicidal ideas.

SK

Chaturvedi et al. /Journal

of Affective Disorders 34 (1995) 193-199

Table 2 Frequency of depressive features and suicidal ideas in different groups Area

Rural women Urban women Industrial women

n

Subjects with Depression

Suicidal ideas

n

% *

n

% **

60 56

8 7

13 13

1 2

12.5 29

59

21

36

8

38

Similar data for college students could not be analysed. * % of women with premenstrual depression in respective group. * * % of women with premenstrual suicidal ideas from among those with premenstrual depression.

less frequently by household women both in rural and urban residential areas (Table 1). The women’s age was 17-45 years (mean = 25 years). They were mainly in the age group of 20-29 years (67%). 70% were unmarried and 30% were married. There were, however, no significant differences regarding any socio-demographic variable between the women with suicidal ideas and those of the control group. The comparative frequency of premenstrual symptoms in the two groups is given in Table 2. Of the 30 subjects who reported premenstrual suicidal ideas 70% reported irritability, 57% reported sense of loosing control, 50% each reported depressive and water-retention features and 47% reported mood swings during premenstrual period. 12 women (40%) reported that the distress experienced was intolerable. On the other hand, these symptoms were significantly less frequent in the control group and only 4 (13%) reported that the premenstrual distress experienced was intolerable. Thus, women reporting suicidal ideas during premenstrual phase significantly more often reported (P < 0.001) irritability, mood swings, sense of loosing control depression and water retention during premenstrual period (Table 2). Premenstrual depressive mood changes were noted among 21/59 (36%) women from industrial area, 7/56 (13%) women from urban area and in 8/60 (13%) women from rural area. Of these women with premenstrual depressive features, 1, 2 and 8 women had premenstrual suici-

197

dal ideas from rural, urban and industrial areas, respectively. In other words, 12.5, 29 and 38% of women with premenstrual depression reported premenstrual suicidal ideas from the rural, urban and industrial areas, respectively. Similar figures for the women from other areas have not been analysed.

4. Discussion Our data suggests that there is a high prevalence of suicidal ideas (10%) among noncomplaining women in the general popmation during premenstrual period with higher frequency reported by students from nonprofessional arts college and industrial working women and lower frequency among students from professional college and household women both in rural and urban areas. The possible reasons for high rates of suicidal ideas in nonprofessional college students could be increased stress since they were completing their study course and uncertainity about future as compared with women from professional colleges. It is Iikely that the above stresses increase psychiatric problems and suicidal ideas during vulnerable phases, such as the premenstruum. Similarly, higher rate among industrial women could be because of increased stress due to coping with their dual role in the household as well as industry. Our findings also suggest that psychiatric symptoms, like irritability, sense of loosing control, mood swings, water retention and depression, were significantly more often reported by women with suicidal ideas during the premenstrual period. In studies from the West, though rates of suicidal attempts during premenstrual period have been studied, frequency of suicidal ideas have not been mentioned. Our findings tend to support the observations of the studies which noted a significant association between premenstrual period and parasuicide (Clare, 1983; Stout et al., 1986; Mandell and Mandell, 1967; Wetzel et al., 1971a; Wetzel et al., 1971b; Halbreich et al., 1982; Devi and Rao, 1972). How frequently did the subjects in these studies experi-

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ence suicidal ideas is not known since most measures of premenstrual distress do not enquire about suicidal ideas. It is also difficult to speculate how many of the women with premenstrual suicidal ideas in our study had attempted suicide since this was not asked but certainly they seem to be an obvious high-risk group. The relationship with other premenstrual symptoms indicates its likely association with severe premenstrual distress or PMS, including physiological effects, like water retention. On the other hand, the significant differences in rates of suicidal ideas among women from different backgrounds indicates the definite influence of social factors and life stresses in influencing mood changes and causing suicidal ideas during premenstrual period. On re-analysing some of our data, it was observed that 29% (urban background) and 38% (industrial working women) of the women with premenstrual depression reported suicidal ideas, similar to the observations with nonmenstrual-related depressions (Robins, 1981; Dorpat and Ripley, 1960). InterestingIy, only l/8 women reporting premenstrual depression (12.5%) from the rural background reported premenstrual suicidal ideas. There are indications that not only premenstrual depressive symptoms are frequent among industrial working women (38%); many of them, i.e., 36% (of those with premenstrual depression), also reported premenstrual suicidal ideas or death wish. Nevertheless, these women with recurring suicidal ideas during their premenstrual period should be considered as high suicidal risk. The occurrence of suicidal ideas could be an indicator of brief severe depressive phases as observed by Stout et al. (1986). Our subjects perhaps did not seek help for their distress related to menstrual cycle due to absence of special PMS clinics and also it is likely that they were aware of the selflimiting nature of their distress and suicidal ideas. One important implication of this finding is that women in general should be educated about the nature of premenstrual psychiatric symptoms and the fact that suicidal ideas can occur. They should be re-assured that these ideas are usuahy fleeting and disappear as soon as the premenstrual phase is over.

One limitation of this study is its retrospective nature and a lack of prospective confirmation of our findings. Our observations, nevertheless, emphasize the importance of enquiring about suicidal ideas and death wish during the assessment of premenstrual symptoms. This would help prevent premenstrually occurring parasuicide and suicide. This high frequency of premenstrual suicidal ideas in noncomplaining women can caution us that the occurrence is likely to be much higher in those women suffering from premenstrual tension or PMS.

Acknowledgements

This study was conducted as a part of the NIMHANS Funded Project on Prevalence of Premenstrual Symptoms and Syndromes in Indian Women. The support and financial assistance from NIMHANS and its Director, Professor SM. Channabasavanna, is gratefully acknowledged. References Barraclough, B., Bunch, J. and Nelson, B. (1974) A hundred cases of suicide: clinical aspects. Br. J. Psychiatry 125, 355-373. Birtchnell, J. and Floyd, S. (1974) Attempted suicide and the menstrual cycle - a negative conclusion. J. Psychosom. Res. 18, 361-369. Birtchnell, J. and Floyd, S. (1975) Further menstrual characteristics ofsuicide attempters. J. Psychosom. Res. 19, 81-85. Carstairs, G.M. and Kapur, R.L. (1976) The Great Universe of Kota. Hogarth Press, London, UK, pp. 74-75. Chandra, P. and Chaturvedi, S.K. (1989) Cultural variations during premenstrual period. Int. J. Sot. Psychiatry 35, 343-349. Chandra, P., Chaturvedi, S.K. and Gururaj, G. (1994) Methodological issues in premenstrual research. NIMHANS J. 12, l-8. Chaturvedi, S.K., Chandra, P. and Isaac, M.K. (1993) Premenstrual experiences: the four profiles and factorial patterns. J. Psychosom. Obstet. Gynecol. 14, 223-235. Chaturvedi, SK., Chandra, P., Gururaj, G., Beena, M.B. and Pandian, D. (1994) Prevalence of premenstrual symptoms and syndromes: preliminary observations. NIMHANS J. 12, 9-14. Clare, A.W. (1983) Psychiatric and social aspects of premenstrual complaints. Psychol. Med. Monogr. Suppl. 4, Cambridge University Press, Cambridge, UK, pp. 5-49.

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