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8/10/2019 Comparative Study of Suicide Potential Among Pakistani and American Psychiatric Patients
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????????????????????????????????????????????????????
COMPARATIVE STUDYOFSUICIDE POTENTIAL AMONG
PAKISTANI ANDAMERICAN PSYCHIATRIC PATIENTS
????????????????????????????????????????????????????
YASMIN NILOFERFAROOQI
University of California, Santa Barbara, California, USA
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 higherdegree ofsuicide 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 fordeath, 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 respondent’s
potential forsuicide. In addition, the FASTwas found to have a significantlyhigh correla-
tion withsuicide attempts.Thus, it maybe inferred thatthe FASTcanbeused as a valuable
screeninginstrument for the identification ofpatients at riskforsuicide in diverse cultural
settings. However, more prospective validity studies are needed to enhance our cross-
cultural 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.
Received 24 April 2001; accepted 4 June 2003.
Yasmin Nilofer Farooqi, PhD is now Professor at the Department of Applied Psychology,
University of the Punjab, Lahore, Pakistan.
This research project was funded by the Fulbright Scholar’s Program, U.S. Department of
States, Bureau of Educational and Cultural Affairs and the Council for International Exchange
of Scholars,Washington, DC. Moreover, Dr. Daphne Bugental of University of California, Santa
Barbara and Drs. Lisa Firestone and Robert Firestone of the Glendon Association provided tech-nical assistance in data collection and analysis.
Address correspondence to Yasmin Nilofer Farooqi, Department of Applied Psychology,
Death Studies, 28: 19746, 2004
Copyright#Taylor & Francis Inc.
ISSN: 0748-1187 print / 1091-7683 online
DOI: 10.1080/0748118049 0249247
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Suicide attempts arise from a variety of social, economic, and psycholo-
gical 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 under-
stand this anti-life phenomenon are of immense concern to helping pro-
fessionals around the world.
Views regarding suicide have changed through the centuries, consid-
ering 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 funda-
mental to developing psychotherapeutic interventions and preventivemental 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 beha-
vior. 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 suicidebut 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
extreme‘‘voice 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. Accord-
ing to Firestone’s (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 client’s 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 therapist’s worst fear,
20 Y. N. Farooqi
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and economic depression at a national level. Unfortunately, there has
been very little scientific or clinical research done in Pakistan to assess
suicide potential among psychiatric patients so that better interventions
and preventive measures could be introduced for those who pose a high
risk for self-destructive behavior or fatal suicide attempt. Currently,
there is no scale or measurement tool available in the Pakistani mental
health system to assess elements of suicidal ideation and intention, and
to predict/prevent suicidal behavior. However, Farooqi and Hussain
(2001) found a significant positive relationship (r ¼.56, p< .05) between
suicide potential (measured by the UrduVersion of the FAST1, Farooqi,
1999) and history of suicide attempts (reported/recorded) in the
Pakistani samples. Thus, the FAST may prove a valuable tool forassessing suicide risk and be especially useful to Pakistani pro-
fessionals who need a quick and simple scale to gain information about
their clients’ suicidality.
Much of the international research in this area has focused on suicide
and certain psychiatric diagnostic categories, such as depression and
substance abuse, probably because these groups pose a high risk for sui-
cide (Appleby, 1992; Apter et al., 1995; Brent et al., 1993,1994; Goldring
& Fieve, 1984; Rossow & Lauritzen, 1999; Singh, Nigman, Gahlaut, &Sinha, 1987; Strakowski, McElroy, Keck & West, 1996; Weissman,
Klerman, Markowitz, & Ouellette, 1989). Goldenberg (1995) and
Maier and Falkai (1999) noted that depression, generalized anxiety dis-
order and somatoform disorder show an excess of co-morbidity both in
general population and psychiatric patients. Tsai, Lee, and Chen (1999)
and Shah and Ganesvaran (1999) stated that bipolar disorders with sub-
stance abuse and/or previous suicide attempts and schizophrenia among
psychiatric in-patients are strong predictors of suicide.
Bakish (1999) mentioned co-morbidity of anxiety with major depres-
sion, which generally occurs more often than either diagnosis separately
(Isometsa et al., 1996). This type of diagnosis is associated with more
severe symptoms, a chronic and poorer outcome, and higher incidence
of suicide.
The main purpose of the current research project is to compare
the suicide potential among Pakistani (predominantly Muslim) and
1Firestone Assessmentof Self-DestructiveThoughts. Copyright#1999 by R.W. Firestoneand
L. Firestone. Translated and reproduced byYasmin Nilofer Farooqi, PhD with permission of the
22 Y. N. Farooqi
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American (predominantly Christian) psychiatric patients using the
FAST. It can be inferred from previous research findings and clinical
studies that high scores on the FAST would identify those individuals
with past history of suicide attempts (Firestone & Firestone, 1996,
and Farooqi & Hussain, 2001). The study will further explore the rela-
tionship between internalized self-destructive voice attacks (measured
by the Total FAST Score) and self-destructive behavior patterns (mea-
sured by the number of past suicidal attempts) of the Pakistani and
American samples. Finally, the study investigates gender differences
in suicide potential, suicide attempts, and suicide precipitants for both
samples.
Canetto (19927
1993) and Langhinrichsen-Rohling et al. (1998) sug-gested that suicidal behavior among women is typically non-fatal with
women outnumbering men at a rate of 2:1 in all industrialized countries
except Poland and India. Canetto (1994, 1997) and Canetto and Lester
(1995, 1998) noted that socioeconomic disadvantage, unemployment,
hostile relationships, and history of suicidal behavior among family and
friends are associated with non-fatal suicidal behavior in women.
Dahlen and Canetto (2002), Canetto and Feldman (1993), and
Hirschberger, Florian, and Mikulincer (2002) argued that gender playsa role in the risk for suicidal behavior as well as in how suicidal behavior
is evaluated in a specific cultural setting. Brent (1998) found suicide
completion rate four times higher in American men than women,
whereas the rate of suicide attempts is two to three times higher in
females than males. Moreover, the most common method for completed
suicide in American men is firearms, followed by hanging, carbon mon-
oxide and jumping.
McIntosh (1999, 2000) reported that out of the total suicide deaths
occurring in the United States in 1996, 81% were males. It may be
argued that in the USA, non-fatal suicidal behavior is both more socially
acceptable and common in women, probably because suicidal behavior
in American females receives greater sympathy than the same behavior
in males. There is sufficient empirical data that suggest that in the
United States, women become suicidal because of relationship
problems, and men in response to social and economic crises (Crosby,
Cheltenham, & Sacks, 1999; Marks, 198871989; Stillion, White,
Edwards, & McDowell,1989). Dahlen and Canetto (2002) argued thatsuicidal decisions following a physical illness would be viewed as more
23Suicide Potential
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achievement in American men. Wellman and Wellman (1986) and
Miller (1994, as cited in Stillion & Stillion, 199871999) reported that
American men are more likely to agree that people should have the right
to kill themselves and that such actions can be justified and rational.
Farooqi and Hussain (2001) found higher suicide attempts and sui-
cide potential among Pakistani men than Pakistani women. It may be
argued that in Pakistan the legal system, social stigma, and religious
sanctions bring relatively more shame, embarrassment, and guilt for
the female suicide attempters than do the male attempters. As a result,
reported suicidal deaths are more common in Pakistani men than in
Pakistani women. Another reason may be that suicide is a socially
tabooed, legally prohibited, and religiously condemned act. Thus, itmay be that the underreporting of suicide for the Muslim Pakistani
women might contribute to the apparently higher suicide rate among
men (Khan & Reza, 1998b). Another reason may be that Pakistani
men in their roles as the ‘‘bread winner’’ of the family are hit hard by
the current economic depression faced by the entire country in the
wake of being declared a nuclear state and as a result of the influx of
refugees after the Afghan war.
It has been further noted that economic crisis, achievement loss, andhealth crises are the precipitant events for suicide in Pakistani men,
whereas debilitating illness, interpersonal losses and overwhelming
family conflicts are more prevalent precipitating factors for Pakistani
women (Farooqi & Hussain, 2001). Furthermore, Pakistani women are
economically and physically dependent on their male counterparts
(fathers, brothers, sons, uncles, etc.). Consequently, they end up feeling
more helpless and hopeless if they fail to fulfill their traditional roles as
an obedient daughter, wife, sister, or mother.
Nevertheless, the reported suicidal deaths are more common in
Pakistani men than in women, perhaps because they tend to use more
lethal methods of suicide (such as shooting or running in front of a train
or jumping from a high building), whereas Pakistani women usually
access less lethal methods such as overdose on prescription drugs dis-
pensed by a licensed doctor. The same pattern was found for the male
suicide deaths in the United States though the suicide precipitants were
different for men and women in the two countries.
Specific cultural scripts of femininity and masculinity could influencewhich suicidal behavior women and men will exhibit under what kind
24 Y. N. Farooqi
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(Canetto, 1997).Thus, it is quite logical to expect gender and nationality
to influence self-destructive thought processes and final judgments about
suicidal behavior. Therefore, this researcher explored effects of gender
on number of suicide attempts (reported/recorded), suicide precipitants,and degree of suicide potential (measured by the Total FAST Score)
among Pakistani and American psychiatric patients. I hope that the
findings of this study would enhance our understanding of the complex
and multifaceted phenomenon of suicide from diverse cultural perspec-
tive. In addition, it may further validate the diagnostic value of the
FAST for timely assessment/prediction of suicide risk in the psychiatric
patients from diverse cultural backgrounds. Consequently, more effec-
tive treatment and prevention strategies could be introduced for thosewho pose a high risk for suicide across the globe.
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 inpati-ent 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 treat-
ing psychiatrists on Axis 1 of DSM-IV (American Psychiatric Asso-
ciation, 1994) for depression/depressive illness, anxiety disorders,schizophrenia, or substance-related disorders and met the above-
i d i l i i i lik h i A i
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It is worth mentioning here that instead of interrupting the ongoing
psychopharmacological treatment of the Pakistani patients, I requested
the treating psychiatrists to conduct the mental status examination of
each of the Pakistani patients prior to the administration of the FAST
to rule out the possibility of any confounding impact of medications on
the cognitive-perceptual processes of the patients that might have inter-
fered with their‘‘inner voices’’on the FAST, which was used as a measure
of suicide potential.
Participants
The majority of the American subjects (n¼ 50) were men ranging in agefrom 18754 years with high school education and monthly income
between $5,99979,999. However, majority of the Pakistani participants
(n¼ 50) were women in the age range of 18745 years and none were
divorced or widowed. The Pakistani participants had an average
monthly income less than $80 and their education was below high
school.These differences between Pakistani and American participants
may be attributed to low literacy rate and unstable political-economic
situation of Pakistani society. All the Pakistani patients like theAmerican patients had been diagnosed by their treating psychiatrist on
Axis 1 of DSM-IV (American Psychiatric Association, 1994) for
depression/depressive illness, anxiety disorders, schizophrenia, or
substance-related disorders. The percentage of each sample suffering
from various psychiatric disorders was similar. Further details about
demographic characteristics of both samples can be found inTable 1.
Instrument
Suicidal potential was measured by the FAST, a self-report question-
naire 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 from‘‘never’’ to‘‘most of the time’’.
According to Firestone and Firestone (1996, 1998), factor analysis of the FAST provided four factor-based composites: (a) self-defeating
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TABLE 1 Descriptive Characteristics of the Sample (N¼100)
American Patients
(n¼ 50)
Pakistani Patients
(n¼ 50)
Characteristics Freq Percent Freq Percent
Gender
Males 26 52% 30 60%
Females 24 48% 20 40%
Marital Status
Single 26 52% 29 58%
Married 6 12% 19 38%
Separated 3 6% 2 4%Widowed 1 2% 0 0
Divorced 14 28% 0 0
Education
Grade School 8 16% 17 34%
High School 20 40% 16 32%
173 Years of College 15 30% 11 22%
Bachelors Degree 5 10% 6 12%
Masters Degree 2 4% 0 0
DiagnosisDepression 20 40% 20 40%
Anxiety Disorder 10 20% 10 20%
Schizophrenia 10 20% 12 24%
Substance-Related Disorders 10 20% 8 16%
Income
US Dollars Pak Rupees
$ 079,999 Rs 075,999 31 62% 23 46%
$10719,999 Rs 6711,999 8 16% 22 44%
$207
29,999 Rs 127
17,999 8 16% 3 6%$30749,999 Rs 18723,999 2 4% 1 2%
$50 > Rs 24 > 1 2% 1 2%
Occupation
Professional 5 10% 4 8%
Manager 2 4% 1 2%
Clerical 4 8% 7 14%
Labor 3 6% 7 14%
Skilled Labor 2 4% 3 6%
Student 5 10% 6 12%
Homemaker 3 6% 10 20%
(C i d)
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composite (measure of cycle of addictions), (c) a self-annihilating
composite (measure of loss of feeling for self and depersonalization),
and (d) a suicide intent composite (measure of active suicide ideation
and planning). Each composite consists of different items from the 11
levels of the FAST. In addition, the FAST provides an overall global
measure of suicidal potential or self-destructive behavior, called the
Total FAST Score, which represents the sum of the scores obtained on
all levels. The internal consistency and test7retest reliability estimates
for the FAST meet or exceed acceptable reliability standards. The
validity of the FAST (examined through content-related, construct-
related and criterion-related methods) was also found very high as
reported by the Firestones (1996, 1998) and Farooqi and Hussain
(2001). Thus, it may be argued that the FAST is a reliable and validmeasure of suicide potential for clients with a wide range of diagnoses
TABLE 1 Continued
American Patients
(n¼ 50)
Pakistani Patients
(n¼ 50)
Characteristics Freq Percent Freq Percent
Disabled 10 20% 8 16%
Other 16 32% 4 8%
Precipitants for Suicide
Illness 3 6% 18 36%
Family Conflicts 4 8% 14 28%
Work Pressure 0 0% 2 4%
Wish for Death/Loneliness 1 2% 2 4%Grades/Study Anxiety 5 10% 5 10%
Financial Problems 1 2% 1 2%
Interpersonal Conflicts/loss 0 0% 2 4%
Mental Disorder/Drugs 3 6% 1 2%
Multiple Events from above 33 66% 5 10%
Age R¼18754 years R¼18745 years
Suicide Attempts
Range for reported or R¼1720 R¼175
recorded suicide attempt
Note. $¼US Dollars per month; Rs¼Pakistani Rupees per month; n¼Number of patients;
Freq¼Frequency; R¼Range.
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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 whoremained 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/psycholo-
gists could be informed if the scores were in the range of concern.
This was done to provide for the client’s safety so that necessary inter-
ventions could be initiated. Furthermore, both therapists and patients
provided information on past suicide attempts through a structuredinterview as was done in case of the American sample. In case of dispar-
ity between the patient’s and the therapist’s reported suicide attempts
the patient’s reported suicide attempts were considered. Moreover, a
structured interview was conducted by this researcher to obtain demo-
graphic 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 moresuicide 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 attrib-
uted 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 sub-stance-related disorders (mostly men) showed greater suicide potential
b d l f l i id h h di i
29Suicide Potential
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groups. Instead, the Pakistani patients suffering from depression and
anxiety (mostly women) reported a higher rate of suicide than schizo-
phrenics and substance-related disorders.
Table 4 shows that a statistically significant correlation was obtained
between the Total FAST Score and suicide attempts (r ¼ .26, p< .05).
Moreover, the self-annihilating composite (a measure of loss of feelings
for self and depersonalization) and the suicide intent composite (a mea-
sure of suicide ideation and planning) were found to have higher correla-
tions with suicide attempts (r ¼ .29, p < .05; r ¼ .28, p < .05, respectively)
and the Total FAST as the dependent variables (r ¼ .91, p< .05; and
r ¼ .88, p< .05, respectively).Table 5 further suggests that the Total FAST was highly correlated
TABLE 3 Precipitant Events for Suicide Attempts Reported By the Pakistani and
American Patients
Type of
Precipitant Events
American Patients Pakistani Patients
Freq Percent Freq Percent
Illness 3 6% 18 36%
Family Conflicts 4 8% 14 28%
Work Pressure 0 0 2 4%
Wish for Death
and/or Loneliness
1 2% 2 4%
Grades/Study
Anxiety
5 10% 5 10%
Financial Problems 1 2% 1 2%
Interpersonal
Conflicts/Loss
0 0 2 4%
DrugWithdrawal/
Mental Disorder
3 6% 1 2%
Multiple Events 33 66% 5 10%(Family Conflicts, Work
Pressure,Wish for DeathFinancial Problems,Mental Disorder)
Suicide AttemptsAmerican Sample: Mean¼ 2.40 (SD¼ 2.94)
(n¼ 50) Range¼1720
Pakistani Sample: Mean¼1.62 (SD¼.92)
(n¼ 50) Range¼175
Note. Freq¼Frequency.
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Z2¼ :07). However, these effects were nonsignificant on patients’suicide
potential though significant for two-way interaction for Diagnosis 6
Gender (F ¼3.27, df ¼3, p < .05, Z2¼ :14) and Nationality 6 Marital
Status (F ¼7.32, df ¼ 1, p< .05,Z2 ¼ :10).Figures 4 and 5 suggest that the married Pakistani patients reported
FIGURE 2. Suicide attempts reported by Pakistani and American patients by
diagnosis.
33Suicide Potential
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single and the separated. None were widowed and/or divorced in the
Pakistani sample. In contrast, the American widow (n¼1) reported the
highest rate of suicide attempts, whereas the separated patients (mostlymen) showed higher degree of suicide potential than the single, the mar-
FIGURE 3. Suicidal potential among Pakistani and American patients by diagnosis.
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TABLE 4 Relationship Between Suicide Attempts and FAST Factor-based
Composite Scores
Composite
Suicide Attempts Total Fast Score
r p r p
Self-Defeating .19 .06 .91** .00**
Addicitions .15 .15 .63** .00**
Self-Annihilating .29** .00** .91* .00**
Suicide Intent .28** .01** .00**
FAST Total Score .26** .01** 1.00
Note. r¼Correlation Coefficients; *p< .05. **p< .01.
TABLE 5 Relationship Between t he Total FAST Score and Level/ Factor-based
Composite Scores
Levels/Composites r p
Level 1: Self-DepreciatingThoughts .85** .00*
Level 2: Thoughts Rationalizing
Self-Denial
.74** .00*
Level 3: Cynical AttitudesTowards
Others
.70** .00*
Level 4: Thoughts Influencing Isolation .83** .00*
Level 5: Self-Contempt:Vicious
Self-AbusiveThoughts
.87** .00*
Level 6: Thoughts Supportive of Cycle
of Addiction
.63** .00*
Level 7: Thoughts Contributing to
Hopelessness
.86** .00*
Level 8: Giving Up on Oneself .85** .00*
Level 9: Injunctions to Inflict
Self-Harm
.75** .00*
Level 10: Thoughts Planning Details
of Suicide
.81** .00*
Level 11: Injunctions to Carry Out
Suicide Plans
.82** .00*
Self-Defeating Composite .91** .00*
Addicitions Composite .63** .00*
Self-Annihilating Composite .91** .00*Suicide Intent Composite .88** .00*
35Suicide Potential
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A B L E
6
T h e R o l e o f N a t i o n a l i t y , D i a g n o s i s , G e n d e r , M a r i t a l S t a t u s o n M e a s u r e o f S u i c i d e P o t e n t i a l ( F A S T T o t a l S c o r e ) a n d
R e p o r t e d
i c i d e A
t t e m p t s
u r c e
D e
p e n d e n t V a r i a b l e
d f
M e a n
S q u a r e
F
P
P
a r t i a l E t a
S q u a r e d
a t i o n a l i t y
T o t a l F A S T S c o r e
1
9 6 4 . 6 2
. 2 7
. 6 1
. 0 0
S
u i c i d e A t t e m p t
1
2 . 9 9
. 6 4
. 4 3
. 0 1
a g n o s i s
T o t a l F A S T S c o r e
3
1 0 8 5 8 . 3 2
3 . 0 1 *
. 0 4 *
. 1 3
S
u i c i d e A t t e m p t
3
9 . 9 5
2 . 1 2
. 1 1
. 0 9
e n d e r
T o t a l F A S T S c o r e
1
1 6 5 4 4 . 6 3
4 . 5 9
. 0 4 *
. 0 7
S
u i c i d e A t t e m p t
1
1 . 0 0
. 2 1
. 6 5
. 0 0
a r i t a l S t a t u s
T o t a l F A S T S c o r e
4
5 4 4 9 . 1 4
1 . 5 1
. 2 1
. 0 9
S
u i c i d e A t t e m p t
4
8 . 2 7
1 . 7 7
. 1 5
. 1 0
a g n o s i s 6
G e n d e r
T o t a l F A S T S c o r e
3
1 1 7 9 8 . 9 5
3 . 2 7 *
. 0 3 *
. 1 4
S
u i c i d e A t t e m p t
3
4 . 7 8
1 . 0 2
. 3 9
. 0 5
a t i o n a l i t y 6
M a r i t a l S t a t u s
T o t a l F A S T S c o r e
1
2 6 3 7 0 . 5 2
7 . 3 2 * *
. 0 1 * *
. 1 0
S
u i c i d e A t t e m p t
1
7 . 8 9
1 . 6 9
. 2 0
. 0 3
a t i o n a l i t y 6
G e n d e r 6
M a r i t a l s t a t u s
T o t a l F A S T S c o r e
1
4 3 1 3 . 0 2
1 . 2 0
. 2 8
. 0 2
S
u i c i d e A t t e m p t
1
2 2 . 6 9
4 . 8 4
. 0 3 *
. 0 7
N o t e . A l l n o n - s i g n i f i c a n t t w o - w a y a n d t h r e e - w a y i n t e r a c t i o n s w e r e o m i t t e d
. * p <
. 0 5 . * * p <
. 0 1 . d f ¼ d e g r e e s o f f r e e d o m .
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Discussion
The main findings of this study are that the American sample reported
FIGURE 4. Suicide attempts reported by Pakistani and American patients by
marital status.
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The high level of self-destructiveness in the American sample may be
attributedto complex psychosocial andeconomic pressures.There is suffi-
cient research data to suggest that killing oneself is considered more
appropriate in the American society (especially in case of American
men) when faced with a series of multiple crises, such as illness, family
and relationship conflicts, work pressure, financial problems, wish for
death, loneliness, drug withdrawal, and mental disorders. Our findings
confirmed these trends from the past studies. In contrast, the relatively
low rate of suicide attempts in the Pakistani sample may be attributed to
the underreporting of suicide, social taboos, religious sanctions and puni-
tive laws against fatalandnon-fatal suicide attemptsinthispredominantly
Muslim society.These findingsareconsistent with the prior research workof Alem, Kebede, Jacobson and Kulgren (1999).They foundthat Muslims
reported relatively fewer life-time attempts (2.9%) than Christians
(3.9%), probably to avoid social, religious, and legal repercussions.
Underreporting of suicide by the Pakistani mental health profes-
sionals, perhaps to avoid involvement with a complex legal system or as
a result of pressures and/or pleas from the relatives of the suicidal
patients, could be a confounding variable that might have contributed
to the apparently lower rate of suicide attempts and suicide potential inthe Pakistani sample. Another reason may be unavailability of sound
assessment tools and an acute shortage of trained professionals in the
Pakistani mental health system. Consequently, it is very difficult to read-
ily assess, report, treat, and prevent suicide in Pakistan.
Some striking differences between the two samples were noted as a
result of the interaction between gender and diagnosis of the respon-
dents. In the Pakistani sample those suffering from substance-related
disorders (mostly men) reported higher suicide potential but a lower rate
of actual suicide attempts. In contrast, the American males with sub-
stance-related disorders reported more suicide attempts and lower
degree of suicide potential. There is sufficient empirical evidence that
suggests that in industrialized countries like the United States, the pro-
blem of substance abuse in men often results in financial problems, poor
health, diminished mental status, family conflicts, interpersonal losses,
violence, and problems with law and job. Consequently, such male
patients often end up feeling so hopeless and helpless that they end up
killing themselves in a grip of despair.Our findings further suggest that those with schizophrenia and
39Suicide Potential
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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.ContrarytotheAmericanpatients suffering from anxiety, thePakistani
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 thesociety, 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 patient’s 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-diag-
nosed 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 pro-
blems, 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 patient’s way of communicat-
ing 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 pro-
blems do not receive the same kind of non-judgmental professional
attention as do the other diagnostic groups. Thus, when faced with
choice between two ‘‘sins’’suicide or drugsperhaps these patients
(mostly men) choose substance-abuse as a way of killing themselves toescape the unbearable psychological pain of shame, guilt and embar-
d bl i h l i d i h l i id
40 Y. N. Farooqi
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in Pakistani society. Nevertheless, our findings further suggest underly-
ing 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 sympa-
thy when they attempt suicide than men despite the punitive laws andreligious sanctions against suicide in general. In contrast, any suicide
attempt by troubled Pakistani men is viewed as a violation of their tradi-
tional 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 fre-
quent and chronic conflicts with in-laws over dowry as compared with
the Pakistani men.Furthermore, the patriarchal Pakistani society encourages a tradi-
tional 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 hard-
ships, 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 mar-
ried Pakistani women who are rarely economically independent. Conse-
quently, 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 disor-
ders 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 thisstudy suggests their passive way of gaining attention or communicating
41Suicide Potential
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Another finding of this research is that the most of the Pakistani
women reported illness, family conflicts, and interpersonal losses as sui-
cide precipitants, whereas Pakistani men reported more of financial pro-
blems, mental disorders, work stress, and study pressure. In contrast, it
was noted that the American women reported more relationship pro-
blems whereas men reported more of the social, economic, illness, and
multiple stressors as suicide precipitants. These findings are consistent
with the prior research data.
Our findings suggest that the FASTcan be used as a valuable and reli-
able screening test to evaluate the imminence of risk for suicide in cultu-
rally diverse psychiatric populations. These findings were consistent
with those of Farooqi and Hussain (2001) that suggest the FASTcouldsuccessfully discriminate between the suicidal and non-suicidal subjects
in a Pakistani Muslim sample. Nevertheless, prospective validity studies
are still needed in which an assessment is made of the relationship
between the Total FAST Score and future suicide attempts.
These findings suggest that issues of hopelessness, helplessness, and
giving up must be readily addressed in cases of those suffering from
depression, schizophrenia, anxiety, and substance-related disorders to
prevent an outburst of self-destructive behavior and self-limiting cycleof addiction, the extreme end of which is suicide. R.W. Firestone (1997)
proposes voice therapy as an effective treatment strategy to combat
self-destructive voice attacks and to prevent suicidal behavior in cultu-
rally diverse psychiatric patients who pose high risk for suicide but actu-
ally do not want to die.
Despite limitations of this comparative study, the implication of our
findings are significant for the cross-cultural understanding of suicide,
identification of patients at risk for suicide, and treatment and preven-
tion programs for suicidal patients.
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