Asian Immigrants with a History of R epeated Suicide A ttempts: Risk and Protective Factors

1. Asian Immigrants with a History of Repeated Suicide Attempts: Risk and Protective Factors Irene Chung, LCSW, PhD Associate Professor, Silberman School of Social Work at Hunter College

2. Literature Review • Individuals who have a history of two or more suicide attempts are at high risk of death by suicide (Beautrais, 2004; Gibb, Beautrais, & Fergusson, 2005; Chandrasekaran, R. & Gnanaselane, J. (2008). • These individuals’ cognitive, affective and behavioral schemas associated with suicidal behaviors become more easily accessible in memory after repetition of the behavior (Beck 1996). • These individuals tend to develop a higher physical pain tolerance, less of a fear of suicide, and an affinity for emotional relief through suicidal behavior (Joiner, 2005; Orbach, et al., 1997; Van Orden, et al., 2008).

3. Literature Review • These individuals are more likely to suffer from a pervasive sense of hopelessness and an overall low level of functioning due to psychiatric and personality disorders, substance abuse, socioeconomic stressors such as social isolation, unemployment, interpersonal conflicts, and a history of childhood sexual and physical abuse (Cedereke, M. & Ojehagen, A, 2005; Chandrasekaran & Gnanaselane, 2008; Forman, et al., 2006; Scoliers, et al., 2009; Wang & Mortensen, 2006).

4. Purpose of Study • Fill the gap in studies on suicidality among Asian Americans, specifically Asian immigrants. • Capture the clinical and psychosocial profiles of repeated suicide attempters among Asian immigrants in a sociocultural context; • Identify suicide risk and protective factors for this sample population that can be considered in assessment, treatment and suicide prevention. Study is funded by the New York State Office of Mental Health Suicide Prevention Initiatives and sponsored by the Office of Behavioral Health, New York City Dept. of Health and Mental Hygiene. Principal Investigator: Irene Chung, LCSW, PhD Co-PI: Marianne Badaracco, MD, Charles Barron, MD, Eric Caine, MD

5. Methodology Mixed method design: • 2011: Retroactive Chart Review of Asian inpatient immigrants, aged 18 and over. • 2012 – 2013: Semi-structured interviews with Asian immigrant patients (inpatient and outpatient units), aged 18 and over, their family members and mental health providers. Locations: • Bellevue Hospital Center • Elmhurst Hospital Center

6. Retroactive Chart Review Design • Randomly selected two-year period (2009 - 2010). • Asian immigrants were defined as those who migrated from countries in East Asia, South Asia, and South East Asia. • A total of 44 patients who had a history of two or more suicide attempts were selected from the combined sample of 608 Asian patient charts in the two hospitals. • A chart review instrument was used to gather preliminary data on these identified patients’ demographics, psychopathology, treatment history, psychosocial stressors and history of suicidal attempts. • For comparative analysis, another group (n = 29) from the same sample of Asian immigrant patients (n = 608) with no lifetime history of suicide attempts but were comparable in age, gender, Asian ethnicity, and psychiatric diagnosis of the repeated suicide attempters was selected.

7. Semi-Structured Interviews • A total of 12 Asian immigrant patients were recruited at the inpatient and outpatient units. With their permission, their mental health providers (n = 12) and family members (n=6) were also interviewed. • Each patient was interviewed for about 75 minutes in their native language. Their family members and providers were interviewed for 45 and 30 minutes respectively. • An interview guide was used to expand on the data gathered from the chart reviews, specifically the depth and complexities of the participants’ distress in a sociocultural and immigrant-specific context, including the nature of familial support toward the participants’ recovery. • Interviews were audiotaped, transcribed and translated for thematic analysis.

8. Demographics of Participants • Countries of origin: China (over 70%), Korea, the Philippines, India, Pakistan and Bangladesh. • Low socioeconomic background. • Higher percentage of females: 56% in Chart Review sample; 75%in Interview sample • Higher percentage of young adults in their 20s and 30s: 52%in Chart Review sample; 50%in Interview sample • Living alone or in shelters: 25% in Chart Review sample and 33% in Interview sample • Single, divorced or separated: 75% in Chart Review Sample and 83% in Interview sample • Varied immigration status and length of time in the U.S.

9. Findings High prevalence of suicide attempters • 24% (n = 608) of the Chart Review Sample had made one or more suicide attempts. Further screening showed 7.2 % (n = 608) were repeated suicide attempters. • The number of reported suicide attempts for each patient in chart review sample ranged from 2 – 5 (mean: 2.8), and 2 – 4 in interview sample (mean: 2.7).

10. Findings A history of a suicide attempt is a lifetime risk factor • Varied lapses of time between suicide attempts: within the same day, weeks, months, 5 years, 10 years and even 30 years. • Half of the interview sample acknowledged frequent suicidal ideations when they had to cope with stress: “When I am frustrated and can’t see a way out, I am not afraid of dying.” “Whenever I don’t have any money, I want to die.”

11. Comparative Analysis Between the sample of repeated suicide attempters and patients with no history of suicide attempts, there were no statistical significance in: • History of mental illness and treatment (diagnoses, length of mental illness, non-adherence to treatment) • Co-morbid issues (impulsivity and personality disorder diagnosis), a history of alcohol and substance abuse, family history of suicide attempts) • Life stressors (family conflicts, undocumented immigrant status, health problems, and living alone or in shelters) • Implications? Table 2

12. Diminished Psychological Well-Being as a Significant Suicide Risk Factor Major themes from the interviews: A pervasive sense of not feeling loved and accepted by family. • “Even when I was young, I had some suicidal thoughts. I somehow felt my mom did not really love me. Maybe because I was not obedient; I was too oppositional. She would hit me for little things that I did wrong. She would also put me outside in the cold for the entire evening when I was only 11 or 12 years old. I was thinking how could my mom be so heartless?” • “It was a shameful event for my family when I got divorced. So I decided to cut myself off from the family and raise my son on my own. I didn’t want any help from anyone. But then I ended up sending my son to live with my ex-husband in his home country. I kept thinking: “does my son still know me and love me? And then my father died and I did not have a chance to say good-bye. I felt like I lost everyone I loved. That was why I did not want to live anymore.”

13. Diminished Psychological Well-Being as a Significant Suicide Risk Factor Identity as Mentally Ill Patients: Self Blame Characterized themselves as “a failure”, “useless”, “disappointing”, and a “burden to others” in their life roles. Self Stigma “I have not wanted to live since I became ill. I don’t like myself. I don’t think I am smart. My mind is not sharp. I am not normal… In my next life, I want to be a real person: very disciplined, smart, does a good job on the job.” “I did not tell anyone about my illness. They would take advantage of me or look down at me if they knew.”

14. Diminished Psychological Well-Being as Significant Suicide Risk Factor Pressure from family to improve their level of functioning: “My family said how come I don't get better from my illness. If I get better, I can marry a good man." “My mom always complained when I do household chores and cook. She doesn’t understand my situation, and that I am trying my best. I feel very inferior in the family. When they talk to me, it’s always about whether I’ve taken my medication. That’s all they are concerned about.” “My family said I should make some money before I return to China.”

15. Poor coping and help-seeking behavior as significant suicide risk factor Difficulties reaching out to others in times of distress Most of the participants in the interview sample (80%, n = 12) were characterized by their family members or mental health providers as “reticent and keeping their worries to themselves”. Many of them (75%, n = 12) made a similar statement that they felt “no one can help” during times of distress. “It would be nice if people will show that they care about me, and I don’t have to be the one calling them when I need help.”

16. Poor coping and help-seeking behavior as significant suicide risk factor Difficulties with self-soothing and managing impulses in times of distress “I guess I bottled up my emotions. Even now I am never too keen on talking, especially about difficult subjects; it’s hard to do it. I guess I‘ll have to make myself feel again; that was very scary for me to have to deal with the pain before.” “My life has been destroyed… Yes, my entire life has been destroyed…I couldn’t think of any other way except suicide to reduce the pressures in my life. And I heard voices urging me to kill myself.” Varied methods of suicide attempt were used by the patients each time, sustaining various degrees of injuries and lethal potentiality. • Little planning in suicidal attempts. • No patterns of increasing lethality between the various attempts.

17. Existential Issues as Suicide Protective Factor A glimmer of hope and optimism among 6 participants in the interview sample who have shown improvement in their level of functioning and treatment adherence: A sense of competence in their life roles “I don’t have a lot of expectations for my life right now, but I realize that my younger brother may be dying (of cancer), and I need to take care of him and my parents. I have very limited income from the government, but I still give money to my brother’s children.” “My husband, he knows how to cook, but he wants me to do all the cooking. I just do something simple. My son comes home for dinner. I also clean and tidy the place every day so we can spend some family time together after dinner.”

18. Existential Issues as Suicide Protective Factor A newfound sense of acceptance and care by others “My husband is the one who is aware of my condition. He has been very worried. He is a good man, and he treats me well. He gives me emotional support, but not financially. You can never have everything.” “I think my pastor understands my feelings a little bit. He promised to help me find a job. Also my daughter has been able to earn some money in her home country these days so that I can save some money little by little to find myself another place and leave the homeless shelter.”

19. Discussion Challenges: • Incomplete information in chart notes: • Recruitment of interview participants; • Discussion of sensitive issues with participants. Limitations: • Sample immigrant population was predominantly of low socioeconomic background in an urban setting; • Major Asian ethnic groups were not adequately represented; • Small sample size of comparative and interview groups; • Subjective interpretation inherent in data mining and qualitative studies.

20. Discussion Similar risk factors identified among other population groups: Mental illness, social isolation, unemployment, impulsivity and poor coping mechanism, lack of support and acceptance from family, and pervasive sense of hopelessness – played out in immigrant-specific and Asian cultural context. Other common risk factors not fully reflected in the study samples: Personality disorder, substance abuse, childhood sexual abuse. Future studies: Comparative studies with first-time attempters and other ethnic groups; intervention studies with a focus on the psychological well-being of participants.

21. Discussion • Challenges for clinicians: • Focus beyond the patients’ immediate unmet clinical and concrete needs and develop treatment on the suicidality of the Asian immigrant patients. • Explore issues of psychological pains that are the root causes of suicidality, given the cultural taboo and shame on disclosing negative feelings toward one’s family and mental illness. • Develop strength-based and culturally relevant approaches in providing psychoeducation with family members? • Other treatment modalities?