Comparative Study of Suicide Potential Among Pakistani and American Psychiatric Patients

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COMPARATIVE STUDYOFSUICIDE POTENTIAL AMONG

PAKISTANI ANDAMERICAN PSYCHIATRIC PATIENTS

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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



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





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



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



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



(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

25Suicide Potential



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

26 Y. N. Farooqi



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)

27Suicide Potential



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.

28 Y. N. Farooqi



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





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.

31Suicide Potential





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



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.

34 Y. N. Farooqi



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



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

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a g n o s i s


3

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a t i o n a l i t y 6

M a r i t a l S t a t u s


1

2 6 3 7 0 . 5 2

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1

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a t i o n a l i t y 6

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1

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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 .



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.

37Suicide Potential





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



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



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



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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Comparative Study of Suicide Potential Among Pakistani and American Psychiatric Patients

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