This study consisted of two parts; one was descriptive, aimed at identifying the risk factors associated with suicidal behavior and the other a comparative study on the focused area of this article. The study was based on a suburban hospital in Sri Lanka, and the Base Hospital at Homagama, in Colombo District, was selected. Hospitals that already had existing psychiatric units/wards were excluded, as deliberate self-harm (DSH) patients admitted to these hospitals were subjected to specific assessments and treatment including counseling, making it difficult to design this study as a case control study. Ethical clearance for the study was obtained from the Ethical Review Committee of the Faculty of Medical Sciences of the University of Sri Jayewardenepura. A pilot study was carried out with ten patients with DSH, admitted to the same hospital, in order to determine the acceptability of the questionnaires.
Patients who were engaged in DSH, as recorded by the medical officers in the medical records, between the age group of 15 and 24 years, who had given consent in writing to participate in the study after verbal and written explanation, and were not diagnosed as having a major psychiatric disorder, and who were categorized as medium- and low-intent cases on the suicide intent scale,[13
] were recruited for the study. These patients were assessed by the main researcher within 48 hours of admission. The study period was 15 months.
The tools used were a Semi Structured Questionnaire to obtain the sociodemographic characteristics; the Mental State Examination to identify the psychiatric disorders; the Suicide Intent Scale to measure suicide intent; and the Individual Visual Analog Scale to measure the ability to solve problems on different dimensions. In the initial assessment, the suicide intent of the patient was measured by a clinical interview, using the Suicide Intent Scale developed by Pierce.[13
] The purpose of applying the Suicide Intent Scale was to quantitatively determine the suicide intent of the subjects and to refer those with high-intent for further psychiatric intervention. The scale dealt with the circumstances related to the suicide attempts, self-reporting items, and items dealing with the medical risk of self-injury. Subjects who were graded as medium- and low-intent were recruited to the study and those who graded as high-intent were referred for psychiatric assessment to the Teaching Hospital of Colombo South, situated 10 km away from the Base Hospital of Homagama.
Individual Visual Analog Scale (IVAS) was used as an independent tool to assess the effectiveness of problem-solving counseling. IVAS was constructed using the Likert scale,[14
] with ten statements giving five response categories, to measure the effectiveness of counseling. These statements were designed to assess the subject's capability of understanding more about one's own feelings, thoughts, and behaviors, ability to build up a relationship with others, ability to identify real problems, ability to find alternative solutions, capability of understanding the importance of setting goals, seeking help and support when necessary, ability to change, helping own self, ability to cope with life's circumstances, and confidence when approaching future problems. This scale has been in use as an evaluation tool for assessment of effectiveness of counseling offered to DSH patients at the university Psychiatry Unit of the Colombo South Teaching Hospital. In order to make a comparison, the IVAS was administered to both the experimental and control groups at the initial assessment, as a baseline assessment and subsequently six months after, to measure the difference between the groups, if any. During the 15-month period, a total of 371 patients were admitted to the hospital with suicidal behavior. Of them, 124 subjects who satisfied the inclusion criteria were recruited to the study, considering the dropout rate of 32.8 percent.[15
] All eligible patients were allocated to the experimental and control groups one by one during the study period, until the desired numbers were reached.
Those patients recruited to the study were informed of the purpose of the study, their involvement, interaction procedure, and expected level of participation. Written consent was obtained prior to the initial assessment. Confidentiality of the information disclosed by the patient was assured. In patients who were below 18 years their parents/guardians were also contacted to obtain their consent. The working model adopted was problem-solving. Literature on problem-solving counseling revealed that experts had promoted different approaches describing four to seven steps.[16
]In this study the six-step approach suggested by Andrews and Hunt[18
] was adopted. The six steps were: identification of the problem, listing out all possible solutions, assessing each possible solution, selecting the suitable or most practical solution, planning how to carry out the best solution, and reviewing the progress.
Each subject allocated to the experimental group was offered four one-hour sessions of problem-solving counseling by the same therapist. The six steps of the problem-solving techniques discussed earlier were applied and each counseling session was pre-determined. The first session was offered to each subject after the initial assessment. Subsequent sessions were offered one week, two weeks, and one month after the first session. The second, third, and fourth sessions were offered at the residences of the subjects and those who did not wish to continue sessions at their residences were given the opportunity at the Base Hospital, Homagama.
Patients who did not improve after four sessions were guided to the Psychiatric Unit of the Teaching Hospital of Colombo South, for further assessment. The control group received routine services: referral to a medical officer, psychiatric referral, and referrals to other agencies. Therefore, the control group too did not remain as an untreated group.