Untitled Document

ORIGINAL ARTICLE

Year : 2020  |  Volume : 3 |  Issue : 1 |  Page : 22-31

DOI: https://doi.org/10.46319/RJMAHS.2020.v03i01.006

 

Exploring attitudes and perceptions regarding suicide in medical interns: A qualitative study
Swarna Buddha Nayok1*, Sathyanarayana M.T.2, Dhanashree Akshatha H.S.3
1 Junior Resident, 2 Professor and HOD, 3 Assistant Professor, Dept. of Psychiatry, Sri Siddhartha Medical College and Hospital, SSAHE, Tumakuru.
*Corresponding author:
Dr. Swarna Buddha Nayok, Junior Resident Dept. of Psychiatry, Sri Siddhartha Medical College and Hospital, Sri Siddhartha Academy of Higer Institution, Tumkur 572107, Karnataka. India.
E-mail: swarnabuddha_nayok@yahoo.co.in
Abstract
Background: Every doctor, and not just psychiatrists, should be competent enough to identify, assess and manage suicidal risk in any patient. Undergraduate medical training in India remains grossly deficit in this area and newly graduated doctors lack the essential skills required for suicide detection and management. To fill this lacuna, the prevailing perception of doctors towards suicide needs to be explored qualitatively. Aim: To explore the attitudes and perceptions of recently qualified doctors regarding suicide. Material and methods: A qualitative study with semi-structured audio-recorded in-depth interviews, with purposive sampling, involving six medical interns and analysed manually using Interpretive Phenomenological Analysis. Results: All viewed suicide to be increasing in the younger population.They believed “weak” and “trapped” people committed suicide, viewed society as “evil” and family as supportive. Although they were sensitive to suicidal issues, they lacked required professionalism and resorted towards informal ways like “being a friend” as the best immediate management. Creating awareness was opined to be effective to decrease suicidal attempts. Conclusion: Although all were sensitive towards suicide, there were conceptual gapsregarding causation and management of suicide in medical interns. This reflects the lack ofspecific training. Suicide causation, detection and related management should be more specifically and carefully incorporated in under-graduate medical curriculum.

Key words: Doctor, Suicide Prevention, Qualitative

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Introduction
Suicide rate in India was 11.4 per 100,000 population in 2010 and has increased to 18.5 suicide deaths per 1,00,000 population by 2016.[1,2] The trend is variable, but it is slowly rising over the last decade. It may be about 5.5% in students. Negative precipitating factors like failure in business or education and personal loss of loved ones and financial problems may be directly correlated to 30% of suicides in India. Suicide method in India is mainly consumption of poison and hanging, around 30% in each. Indian suicide attempting population also includes a significant proportion of farmers.[1–4]
                Quantitative studies have shown a poor attitude towards suicide in health care related professionals. In a study with 150 health care providers, which included about 50% post graduate resident doctors and about 30% interns, only about 60% had positive attitude, many not considering personal stressors as important factors. They also opined that most patients will not reveal their suicidal ideas.[5] This is a seriously flawed assumption as many indeed express suicidal ideas in some form or the other before attempting.[1,6] Out of 206 Greek doctors, more than 40% showed irritability and discomfort in view of attempted suicide in patients, showing an overall unfavourable attitude, as measured by Attitudes Towards Attempted Suicide–Questionnaire.[7]
                In an explorative study regarding attitudes towards suicide in medical students, only half of them had positive attitude toward working with suicidal patients and few had any practical exposure to management of suicidal patients.[8]  Qualitative study with community health workers and members of public found family problems were the most commonly mentioned cause of suicide whereas mainly depression, was the most important cause. But none thought this as a failure of the socio-political system in India.[9] Jones qualitatively assessed attitudes and beliefs of nurses regarding suicide and found that patient management is directly influenced by the nurse’s religious beliefs, giving importance to physical duties than psychological help and efficiency to provide psychological help was poor amongst them.[10] Jacob reviewed attitudes towards suicide and management available and found that those in distress often seek help from their doctors, may also visit emergency department and admitted to intensive care units. He points out that training among doctors regarding suicide management is below standards with lack of skill and confidence to recognize and manage suicidal risk.[11] In a narrative review of strategies to prevent suicide in general hospitals, Navin found educating the health care professionals was the best strategy for prevention along with environmental modification.[12]
                Role in prevention of suicide is not limited to psychiatrists, as each medical professional should be aware of the importance in detecting the risk of suicide in patients with any illnesses. This comes with a thorough understanding about not only suicidal behaviours cross-sectionally, but also the various factors that lead to such extreme step, individually for each patient.[13,14] One of the effective ways to prevent suicide is to spread awareness about it among common people.[12] This needs to be complemented by an adequate understanding of the same by health professionals. In order to detect suicide risk in the patient, a doctor first needs to be sensitive to the need and process of evaluation, and subsequent approaches if risk is detected.[8] However, medical under-graduate training lack in sensitizing young doctors regarding understanding, assessment and prevention of suicide.[5,8,12]
                The overall attitude towards suicide cannot be sufficiently explored by scales, need for a qualitative evaluation seems to be a better approach.[15] Only when we understand whether the attitude changes with training, and if so, in what ways, we can develop better modules to sensitize health professionals regarding suicide prevention. For this we need to study the perceptions about suicide in those who have finished under graduate medical training and are currently interns, as they are the next ones to deal with the community.[1,16] This will help us to understand their perspectives and plan academic and clinical interventions better at under-graduate level. Thus, the aim of this study was to qualitatively explore the beliefs, attitudes and perception regarding suicide in medical interns.
Materials and Methods
Setting and participants
The study was done at a private medical college attached to a private hospital. The department of psychiatry consists of four staff members and six post graduates. The department run out-patient services, catering to about 30-40 patients per day, with thirty beds as in-patient psychiatric facility. In the last one year, the department has made a 24-hour helpline mobile number available to the students and outside population too. This helpline is dedicated to manage crisis situation and the caller remains anonymous. The students have also been briefed about this facility. The interns are posted for 15 days in their compulsory rotational internship, during which they observe and at times participate in patient evaluation, including evaluation of suicidality. There are about 4-6 interns posted in the department for a period of 15 days. The interns have previously, in their undergraduate curriculum attended psychiatry theory classes, in their final year, once a week. They have also been posted in psychiatry department as their clinical postings three times in their entire five and half years of undergraduate training, each time for 15 days. During the clinical postings, they are taught psychiatric history taking and basic management. These trainings include brief discussion about depression and suicidality, approach and management towards a depressed patient. However, they are not explicitly taught to handle suicidal issues in their clinical postings. Six consenting interns were selected by purposive sampling. All of them were Indians by nationality, belonged to south Indian states, single, belonged to higher socio-economic status and had no history of suicide in family or such attempts by themselves in the past. Other relevant details are given in Table 1. We approached only six interns in total and all of them consented for the study.The interns were posted in the department of psychiatry, for about 3-5 days, after which they were approached to take part in the study.

Table 1: Relevant details of participants

 

Age

Gender

Branch preferred in future

Had been approached by someone with suicidal thought

Relationship with parents and siblings

Intern 1

24

Female

Surgery

Yes

Cordial

Intern 2

23

Male

Medicine

No

Cordial

Intern 3

24

Female

Medicine

Yes

Cordial

Intern 4

23

Female

Medicine

Yes

Cordial

Intern 5

24

Female

Obstetrics

Yes

Cordial

Intern 6

24

Male

Orthopaedics

Yes

Cordial

Tools
Direct Qualitative using face-to-face In-Depth Interviews (IDI) were scheduled by the Primary Investigator (PI)(SBN). Each IDI was of 45-60-minutes, face-to-face interview with the participants at an interview cubicle at psychiatry Out-Patient Department (OPD) within working hours of 9AM-4PM Indian Standard Time. No other person except from the participant and PI (SBN) were present during the process of interview. The interview schedule is given in Table 2 and the questions were asked in that particular order only. The interview was recorded with prior consent in the mobile phone of the PI and did not have the name of the participant to maintain anonymity. The participants were also not named during the interview. Only one IDI was conducted in one day and were held about one week after the interns had started their postings in psychiatry. Prompts were not provided throughout the interview.The interview schedule was pilot tested on two post graduates in the department of psychiatry. The recorded interviews were not further used to be commented on by the participants. The Institutional Ethics Committee approved the study(SSMC/Med/IEC-1/March-2020).

Table 2: Interview schedule

Sl. no.

Question

Domain

1.

“Tell me about suicides?”

“affected population, their qualities and stressors”

2.

“Who are the people who commit suicide?”

3.

“What makes them vulnerable?”

4.

“Who do you think are responsible for such decisions?”

“role of family and society”

5.

“What are the factors which lead to such an event?”

6.

“How does family and/or friends play a role in the decision or act?”

7.

“How does society affect suicides?”

8.

“How can we prevent suicide?”

“prevention and management”

9.

“What can specifically you do to prevent suicides?”

10.

“What will you say to a person who tells you that he/she is suicidal?”

Statistical analysis
Data was analysed manually using the method of Interpretative Phenomenological Analysis (IPA), where the PI went through the excerpts meticulously in order to find a set of themes, and if required classify superordinate and related sub-themes. The study and its reporting were retrospectively verified according to the Consolidated criteria for Reporting Qualitative research (COREQ) checklist and is given in Table 3.[17] Socio-demographic data was descriptive. Data saturation was not used. There were no themes identified beforehand.

Table 3: COREQ (COnsolidated criteria for REporting Qualitative research) Checklist

Topic

Item No.

Guide Questions/Description

Reported on
Page No.

Domain 1: Research teamand reflexivity

Personal characteristics

Interviewer/facilitator

1

Which author/s conducted the interview or focus group?

05

Credentials

2

What were the researcher’s credentials? E.g. PhD, MD

12

Occupation

3

What was their occupation at the time of the study?

12

Gender

4

Was the researcher male or female?

11

Experience and training

5

What experience or training did the researcher have?

12

Relationship with Participants:

Relationship established

6

Was a relationship established prior to study commencement?

12

Participant knowledge ofthe interviewer

7

What did the participants know about the researcher? e.g. personalgoals, reasons for doing the research

12

Interviewer characteristics

8

What characteristics were reported about the inter viewer/facilitator?e.g. Bias, assumptions, reasons and interests in the research topic

12

Domain 2: Study design

Theoretical framework

Methodological orientation and Theory

9

What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology,content analysis

06

Participant selection

Sampling

10

How were participants selected? e.g. purposive, convenience,consecutive, snowball

05,06

Method of approach

11

How were participants approached? e.g. face-to-face, telephone, mail,email

05,06

Sample size

12

How many participants were in the study?

05,06

Non-participation

13

How many people refused to participate or dropped out? Reasons?

05,06

Setting

Setting of data collection

14

Where was the data collected? e.g. home, clinic, workplace

05,06

Presence of non-
Participants

15

Was anyone else present besides the participants and researchers?

05,06

Description of sample

16

What are the important characteristics of the sample? e.g. demographicdata, date

05,06, Table 1

Data collection

Interview guide

17

Were questions, prompts, guides provided by the authors? Was it pilottested?

05,06

Repeat interviews

18

Were repeat inter views carried out? If yes, how many?

05,06

Audio/visual recording

19

Did the research use audio or visual recording to collect the data?

05,06

Field notes

20

Were field notes made during and/or after the interview or focus group?

05,06

Duration

21

What was the duration of the inter views or focus group?

05,06

Data saturation

22

Was data saturation discussed?

05,06

Transcripts returned

23

Were transcripts returned to participants for comment and/or correction?

05,06

Domain 3: analysis and findings

Data analysis

Number of data coders

24

How many data coders coded the data?

05,06

Description of the coding Tree

25

Did authors provide a description of the coding tree?

05,06

Derivation of themes

26

Were themes identified in advance or derived from the data?

05,06

Software

27

What software, if applicable, was used to manage the data?

05,06

Participant checking

28

Did participants provide feedback on the findings?

05,06

Reporting

Quotations presented

29

Were participant quotations presented to illustrate the themes/findings?
Was each quotation identified? e.g. participant number

07,08,09

Data and findings consistent

30

Was there consistency between the data presented and the findings?

 --

Clarity of major themes

31

Were major themes clearly presented in the findings?

 --

Clarity of minor themes

32

Is there a description of diverse cases or discussion of minor themes?

 --

Results
We used IPA to evaluate the interviews. Coding and analyses were done simultaneously by the PI. The evaluation was prepared according to the context of the questions. Answers to questions 1,2,3 were generalised to understand the participants’ views regarding affected population, their qualities and stressors. Questions 4,5,6,7 were grouped to explore the role of family and society in suicide. Questions 8,9,10 were formed to understand their approach to prevention and management. Themes were not identified, instead the question domains were used for further analysis.
Regarding “affected population, their qualities and stressors”:
Interns collectively had adequate knowledge about the growing incidence of suicide and that it is increasing in young generation. They pointed out that it was mainly the student population who were at risk, although recognising that anyone can commit suicide. However, they thought that there were certain vulnerable traits in those who attempt suicide. These traits were of negative valence, as described below:
Intern 1: “all very shy people and who don't come out of their own world”
Intern 2: “people who thought that this is an escape”
Intern 3: “personality who like take each and everything to their heart there are more sensitive to any situation or a problem next”
Intern 4: “If the person is weak, means he has less confidence or if he is hit hard by the situation that time it might be risk of double kind”
Intern 5: “sometimes it depends on the personality like a person has very weak or emotional labile they are not that much able to handle the situation”
Intern 6: “who break easily those people they don't have the self-confidence to live their life”

Regarding “role of family and society”
The interns found that “pressurized” circumstances lead to suicide. The pressure was mainly academic and coming from parents. Although all held the person committing suicide as the one who is ultimately responsible to end his or her life, they found society as “evil”. Although they reported parental pressure as a stressor, they did not feel that family was responsible. They found family and friends helpful and instead society as harmful. This contradiction remained evident throughout the interviews, although not in all.
Intern 1:

  1. Society: “They will be like what is wrong with you…. And say I will be talking things like that, this is not right like you can't be depressed. If everything is good in your life and you can't be depressed because of a small thing. So, you are judged basically about any small thing so when you don't have anything so that's what you do in the end”
  2. Family: “family try so hard to understand what is going on but eventually you have to talk to them….they will always ask but it doesn't matter how much effort they put, you have to ultimately come forward and say something to them”

Intern 2:

  1. Society: “Society making it even worse. To make them commit suicide, like if some person is failing again and again, society should be saying “ok exams are not the only thing in your life there are some other things”. But it is not telling that. Society is telling if you pass exams then your life will be OK”
  2. Family: “family love their children very deeply, they support them….they are the first one to go and help them to come out of that situation”

Intern 3:

  1. Society: “….society like randomly judging, everyone does it”
  2. Family: “I don't think parents really know that mental diseases exist. I had a friend whose brother was in depression. She brought out his depression to the parents and the parents ended up saying “He is doing drama nothing has happened to him he's just not studying because he doesn't want to study”. So they have no idea about it”

Intern 4:

  1. Society: “There are a lot of cases where we have seen that because of the society, the person has a lot of impact and that might also lead to take this drastic step. It might be the caste it might be the things like failures. The society doesn't take failure persons in jobs also anywhere”
  2. Family: “….very big role…. giving him a confidence or advise or something like that it's ok you can you can come out of this”

Intern 5:

  1. Society: “The person feels like I have some drawbacks I have some negative things. Society is pointing towards those things they will feel trapped”
  2. Family: “Actually friend and family play a major role in a person's life. Most of the time the person is staying either with the family, so they know the person much better. They should you know motivate him towards the situation or towards their problem”

Intern 6:

  1. Society: “Society helps with the decision. When you see a person who is like in a little weak, society, like doesn't care anything. I think like you should create an environment around them so that they feel safe so at least like the can open up a little bit. Maybe they feel my problems are small and not worthy to say out loud in the society”

Regarding “prevention and management”:
All reported that increasing social awareness about suicide was the best way to reduce suicide. They opined for more interactive sessions by the psychiatrists for students and more camps specifically for suicide awareness for rural populations. They found suicide prevention helplines to be useful, but people should be made more aware of their existence.
They all approached a “friend”-like manner with a personal approach to solve a crisis related to suicide. They all lined out the steps as to “calm the person down”, “listen to their problems”, “try to help them to solve the problems”, even if that meant informing parents and the significant ones. They mentioned about bringing up hope and that in case they cannot help, they will advise them to visit a psychiatrist.
Intern 1: “I will suggest their friends and family to be more supportive and understanding”
Intern 2: “I will hear them more and ask them like from when have you been having these ideas and try to change the reasons there will be reasons…. for this there will be a reason if I'll try to see if I can change the reason”
Intern 3: “first you should like what I try to do make them feel like they can talk first…trust me as a friend….I can talk about the problem whatever the problem is there and try to solve it up ”
Intern 4: “If my friend is doing that I will go stop her anyhow. Anything I will do, I'll go and stop. I will make sure that family members know. I will make them think that this is not the one thing in the world, the world is very big, you can love anyone and you can have so many people surrounding you, that failure is not only thing. Like that I will counsel them”
Intern 5: “I'll make them happy somehow, I'll take out them and take out off everything”
Intern 6: “ok first I will ask ok the person to like just come down and I will ask him asking the normal questions like general things as if nothing has happened like a friend I’ll talk….you reach the problem and then try to make out and solve as much as possible”
Discussion
This qualitative study qualitatively explored the perceptions and attitudes of six medical interns regarding suicide.There remains a differential understanding of the causation of suicide. When there are stressors, evident ones especially, then the “blame” of suicide seems to shift towards the one who attempted it. Or else, the society was blamed and suicide was viewed as an understandable reaction to “pressure” and being “trapped”. This disposes a person, who seemingly has no evident understandable stressor, as “weak”. Although on a positive note, interns understand the rising concern for suicide and the need for prevention, they still lack empathy. Instead, their understanding seems to be sympathetic, which is again quantifiable as per the stressor(s). Family was seen as supportive which is a positive understanding. This is reflected in their management style, like involvement of family members, although there maybe boundary violations.All the participants themselves had cordial relationships with their own families and this may be one reason to why all of them found family to be supportive.All did understand that hope can be used to prevent the immediate crisis and are aware enough to detect and approach suicidality in a non-judgemental way initially. However, their approach remains personal and not professional.
Manoranjitham used a similar set of questions in focussed group discussion regarding suicide in community health workers. They opined marital problems as the main causative factor. Although interns in our study mentioned family matters as a reason for suicidal attempts, their major focus was on the younger generation and student. This is the population that they have interacted within in their medical teaching. Interns were better informed about the ways to prevent suicide including helplines, which is also a given according to their profession. We see from this that our own socio-demographic background plays a major role in making our attitudes regarding suicide.[9]
In a review of qualitative studies in suicide involving community participants, the triggers for a suicide attempt were seeminglydependent upon emotions and family and personal influences. This is similar to our study, where family is seen as a protective factor and society as evil. The review mentions a study by Fullagar, where service providers like health workers and teachers. The constructs of suicide were different as per age and profession, youth understanding it from the peer interaction more while elders having a negative evaluation of suicide through reports and experiences. This is also reflected in our study, where, sympathy regarding suicide is peer generated. [18,19]
South Korean college students found suicidal ideations were increased by social concerns and influenced by culture. We find a similar view in this study regarding societal pressure and failure to support leading to suicidality.[20]Even in in-patients suicide care, the nurses, who are often the first responders may have a nihilistic view towards protection of suicide, that it is difficult to prevent and the skills to prevent them was not adequate. Shock and guilt are frequent in them after in-patient suicide attempts, including frustration. [10,20]
From the patients’ point of view, their expectations may revolve around the main themes of an effective therapy, which should preferably be ward based and that the therapy should address their personal specific issues related to suicide. So, it is not a generalized management plan, but a tailored one for each individual. In order to at least provide some of the basic reliefs, the doctor should be aware of this differential approach.[11,21,22]
Medical profession is affected by suicide of patients even on personal grounds. This is evident in psychiatrists, who despitebeing adequately trained in suicide management, feel shame and guilt when they fail to protect their patients from suicide. They may often require a short course of supportive therapy themselves. If this can happen to trained psychiatrists, it certainly will happen to many of the doctors of other specialities too. So, suicides in patients have a personal significance too.[13–15]
This study brings out perspectives a qualitative study may offer in contrast to a quantitative study. For example, if Attitude towards Suicide Prevention Scale was used, as used in a previous study, questions from the scale such as “I resent being asked to do more
about suicide”, “Suicide prevention is not my responsibility”, “If a person survives a suicide
attempt, then this was a play for attention” would obviously be disagreed to by our participants, as seen from their excerpts.[5] This would show an increased positive attitude towards suicide overall. However, when evaluated qualitatively, the same respondents show flaws in understanding causality of suicide.
Regarding the methodology, IPA was chosen as we considered the role of a doctor in suicide management and prevention inherent with a humanistic view, but different due to the requirements of professionalism. The phenomenon of interest here was regarding the approach to suicidality as a doctor. Further we followed hermeneutic phenomenology regarding the transcripts, and did not consider an event (such as being approached with suicidality) necessary to occur. We considered the training of being a doctor and reaching its final stage as an intern as the event or experience preferred in IPA. We deliberated over using Discourse Analysis, as it also deals with conversations, but did not approach it as we did not wasn’t to make deep social “meaning” out of the conversations. We also consider IPA as better analysis tool the Thematic Analysis. We did not try to find themes, as analysis was according to the groups of questions we asked. Previous studies have used Grounded Theory and Thematic Analysis, as well as IPA.[6,8,18,22]IPA was used in evaluation of nurses, which closely matches to our study.[10]We were unsure of using double hermeneutics, as the PI is partly from the same occupational community, as explained below.
As the study involves IPA analysis, two further considerations are taken into account:

  1. PI’s personal view: The PI is a male. He conducted the interviews and views that the “justification” of suicide leads to an inadequate understanding of the phenomenon. Often, suicide seems understandable in relation to personal or social stressors. However, this may not be the case for many, and the lack of an “understandable stressor” should not make the person who attempted suicide as “weak” and “had no reason/small reason”.
  2. PI’s relationship with the participants:The PI is a final year post graduate pursuing MD in psychiatry in the department of psychiatry and had no previous personal or social contact with the participants. He has completed Diploma in Psychological Medicine (DPM).He has not participated in, conducted or evaluated independently in any qualitative study before. He has been an observer (passive) in Focus Group Discussions before, but not in IDI. The PI was not trained in using computer software for data analysing, and thus chose a manual method, although without adequate expertise for the same. However, the PI has attended online course “Qualitative Research Methods and Research Writing” online course of 12 weeks (28 Jan 2019 - 19 Apr 2019) by IIT Kharagpur,National Programme on Technology Enhanced Learning (NPTEL).[24]
  3. The participants were also explained that they could say anything, and need not hide any thoughts for the fear of being “judged”. The participants were explained about the study in detail along with the reasons for doing the research and personal goals.

This is a unique qualitative study exploring medical interns about their attitudes and perception towards suicide, with a view to calibrate under graduate medical training in India. While the participants showed positive responses overall towards detections and management of suicidality, there remains flaws in understanding causation of suicide and professionalism in treatment approach.This may reflect towards lack of specific training. Suicide causation, detection and related management should be more specific and carefully incorporated in under-graduate curriculum.Although, a more specific question to evaluate this aspect would have been better, such as “When you start working as a doctor, what will you say to a person who tells you that he/she is suicidal?” This is reflected in the transcripts of interns 4 and 5 under section 3.3, where they probably assumed that their friends had approached them with suicidal thoughts, instead of placing themselves as professional and practising doctors and being approached by a patient.
Limitations:
Limitations include a need for a more extensive stepwise IDI, including self-perspectives and approaches towards stigma.The interns were evaluated after being posted in psychiatry, which may cause a bias, as they would have been involved in evaluation and discussion of patients with suicide attempts or risk. This may have contributed to an alteration in their perspective, may be through modelling.They had also not been given the opportunity to review their transcripts and given a chance to modify, explain or refute any interpretation, especially about society and family in section 3.2. A sample size of six is less, as we did not reach data saturation. The study done here required two batches of interns and thus a month, after which the PI was unavailable in OPD due to study leave.However, a low sample size is also justified in qualitative research. [24]As with qualitative study, we do not assume the views to be generalised, we instead assume that peer relations along with family dynamics play a significant role in development of such attitudes. Future studies should assess doctors working at various levels, especially interns and post graduates or residents and at various setups. The assessments should also include their self-perspectives, stigma, responsibilities and duties regarding care giving. This would help in creating better training modules, reflecting the professional approaches and causative factors of suicide in order have a more positive outlook and attitude.
Conclusion
Although all were sensitive towards suicide, there were conceptual gapsregarding causation and management of suicide in medical interns. This reflects the lack ofspecific training.Suicide causationand related management should be more specifically incorporated in under-graduate medical curriculum.
Acknowledgements:Nil
Financial support and sponsorship:Nil
Conflict of interest:Nil
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Research Journal of Medical and Allied Health Sciences is a medium for the advancement of scientific knowledge in all the branches of Medicine and Allied Sciences and publication of scientific research in these fields. The scope of the journal covers basic medical sciences, medicine and allied specialities, surgery and allied specialities, dentistry, nursing, pharmacy, biotechnology, public health and other branches of the allied health sciences. This journal is indexed with Advanced Science Index(ASI), National Science Library and Open J Gate.





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