Suicide is the second most common cause of mortality worldwide among individuals aged 15 to 29, regardless of gender, following road accidents, according to the reports of the World Health Organization. Furthermore, it ranks as the second main cause of death for teenage girls (aged 15–19 years) following maternal conditions and the third greatest cause for teenage boys (aged 15–19 years) after road accidents and violence. Approximately 79% of suicides occur in low- and middle-income countries. Less than twenty-five percent of suicide cases occur in high-income nations overall. Notwithstanding the significant advancements of human cultures in the 21st century, an individual succumbs to suicide every 40 seconds.¹

Suicide constitutes a worldwide public health concern impacting individuals of all ages, genders, and geographical locations. Each statistic represents a life lost to suicide, and each loss is too many.²

Statistics from the World Health Organization indicate that 8,000,000 individuals succumb to suicide annually, equating to one person every 40 seconds. Studies demonstrate that suicide rates in the United States and Australia are comparable to those in India.³ Suicide rates in India are one of the highest globally and account for 26.6% of global suicide deaths. The National Crime Records Bureau (NCRB) released the suicide deaths for 2020 in 2021, showing a rate of 11.3 per lakh population, with the actual figure amounting to 153,052 deaths. According to the National Crime Record Bureau, an official agency in charge of compiling suicide statistics in India, Kerala, a state in South India, possesses the highest suicide rate among Indian states.⁴

Many factors, including biological, socio-cultural, and personality traits, can modify this complex behavior.⁵ Decades of suicide research have predominantly concentrated on risk factors for suicidal behavior while overlooking protective characteristics, such as resilience, that could contribute to mitigating this significant public health concern.⁶

Resilience is linked to psychological factors including positive emotions, optimism, emotional regulation, and cognitive flexibility. Resilience encompasses the capacity to cognitively reframe adversity positively, a history of overcoming challenges, dedication to a significant cause or purpose, the capacity to extract meaning from unfavorable circumstances, and elevated self-efficacy in coping. Resilience correlates with the presence of nurturing caregivers, substantial social support, assistance from religion and spirituality, and a focus on physical health. Studies have linked a heightened prevalence of suicidal behavior to reduced resilience.⁶ Studies indicated that resilience represents an intermediate between suicide risk factors and suicidality, and it may mitigate the adverse effect of suicide risk factors. Furthermore, individuals exhibiting low resilience were associated with an elevated risk of lifelong suicidal behaviors.⁷

Suicidal intent, characterized by the severity or intensity of an individual's desire to end their life, has been observed to be a predictor of completed suicide in the majority of studies, though it is not universally applicable in all research. Hopelessness, characterized as a condition of adverse expectancies, seems to be an additional predictor of suicide. Additional characteristics associated with increased suicide risk following an attempted suicide include male gender, advancing age, psychiatric disorders, previous psychiatric treatment, prolonged use of hypnotics, poor physical health, solitary living, and a "wish to die" as a motive for the initial attempt.⁸

Coping behavior is defined as the responses to external life stress that serve to avoid, prevent, reduce, or control emotional distress and stress. Existing researchers have examined various coping strategies affecting suicidal behaviors⁹ and analyzed gender-specific coping mechanisms related to suicidal ideation in students.¹⁰ It can be categorized as either positive, such as regulating emotions, actively seeking social support, and engaging in positive problem-solving, or negative, including denial, avoidance, or self-blame. Various studies have demonstrated a significant negative correlation between positive coping mechanisms and suicidal ideation. Individuals who adopt positive coping styles such as active planning, instrumental support, positive reframing, humor, acceptance, and seeking emotion and social support generally exhibit low suicidal ideation. Conversely, negative coping styles (e.g., avoidance and emotional coping styles) exhibit a significant positive association with suicidal ideation, suggesting that those who use negative strategies may be at an increased risk of suicidal behavior.¹¹ Various studies have reported that ineffective coping styles, along with stress and negative emotions in young adults, contribute to higher risk of suicidality.^5,12–14

In India, and specifically in Kerala, the incidence of suicide has been a growing area of concern, drawing attention to the need for effective intervention strategies. Resilience plays an important role in how individuals cope with distressing life events. Coping styles, or the methods people use to manage stress and adversity, are integral to understanding how resilience can be fostered and utilized effectively.

This study investigated the complex relationship between resilience, coping styles, and suicidal intent among individuals who have attempted suicide within the context of a tertiary care center in Kerala. By examining how different coping mechanisms correlate with suicidal intent, this study seeks to uncover potential pathways for enhancing psychological support and intervention strategies tailored to individuals at high risk of suicide.

MATERIALS AND METHODS

TYPE OF STUDY: Cross-sectional study

PLACE OF STUDY: Psychiatry ward and other wards consulting psychiatry in GMC Kannur

DURATION OF STUDY: 1 year after getting ethical clearance

STUDY POPULATION: Patients admitted with a suicidal attempt in Government Medical College, Kannur

INCLUSION CRITERIA

1) Age 18-65 years.

EXCLUSION CRITERIA

1)           Patients who are not giving consent.

2)           Poor physical condition interferes with a formal assessment of mental status.

3)           Intellectually disabled subjects have cognitive impairments.

SAMPLING METHOD: Consecutive Sampling

SAMPLE SIZE: 97 patients were selected to form a sample by using the formula zpq/d², with a prevalence of 70 percent as given in a study by JAISWAL et al.¹⁵, relative precision 13% Calculation was based on the formula. Z2pq/d2. p was taken as 70%, q as 30%, relative precision (d) is 13% of p, taken as 9.1%, and the sample size is rounded to 100.

STUDY TOOLS

1)           SELF-PREPARED SOCIO-DEMOGRAPHIC PROFORMA

2)           BRIEF RESILIENCE SCALE

3)           WAYS OF COPING QUESTIONNAIRE-REVISED (WCQ-R) SCALE

4)           BECK’S SUICIDAL INTENT SCALE

Sociodemographic and clinical information was gathered using the self-made sociodemographic proforma.

BRIEF RESILIENCE SCALE: A six-item scale used to assess the resilience developed by Smith et al. Responses for each item in the scale range from strongly disagree to strongly agree. For each item, the respondent gets a score of 1 for strongly disagreeing and 5 for strongly agreeing. The total score can be calculated by summing the scores of each item and then dividing the total score by six. The scores thus obtained can be categorized into low (1–2.99), normal (3–4.30), or high (4.31–5). The scale has adequate reliability (α = 0.83, intraclass coefficient = 0.69) and adequate convergent, concurrent, and predictive.¹⁶

WAYS OF COPING QUESTIONNAIRE-REVISED (WCQ-R) SCALE – The coping

styles of the participants were assessed using the Ways of Coping Questionnaire-Revised (WCQ-R) Scale34. This instrument consisted of 66 items, where each item has a brief description of a cognitive and behavioral strategy for coping with stressful events. The 66 items are grouped into eight coping subscales, which include confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape avoidance, planful problem solving, and positive reappraisal. There were two methods of scoring the questionnaire: raw and relative. Raw score describes the coping effort for each one of the eight types of coping, whereas relative score describes the proportion of effort represented by each type of coping. In both methods of scoring, individuals respond to each item on a 4-point Likert scale (“1” indicates “used somewhat,” “2” indicates “used quite a bit,” and “3” indicates “used a great deal”). In raw scoring, the scores are the sum of the individual’s responses to the items that comprise a given type of coping that was used in a particular encounter. A Cronbach α-value of 0.79 was calculated for the RWCQ.^17,18

BECK’S SUICIDAL INTENT SCALE: Beck's Suicide Intent Scale was employed to evaluate the degree of suicidal intent. It is a semi-structured, interviewer-administered evaluation scale exhibiting strong internal consistency (Cronbach’s α=0.90), reliability, and validity. Each item is evaluated using three alternative statements rated on a scale from 0 to 2 based on intensity. The scoring criteria are as follows: A total score below 10 signifies low intent, a score between 10 and 15 suggests medium intent, and a score over 15 represents high intent.¹⁹

Study Procedure

After the institution's Ethics Committee approved the study, all patients admitted with a history of attempting suicide and who met the inclusion and exclusion criteria were included.

Every patient admitted to various departments at GMC Kannur after an attempted suicide was typically referred for a psychiatry consultation. Individuals fulfilling the inclusion and exclusion criteria were included as a part of the study. The nature of the study was explained to the patients as well as to the caregivers. Informed consent was obtained from each willing patient. After collecting details of the socio-demographic profile using the proforma, resilience was assessed using the Brief Resilience Scale, and the Suicide Intent Scale was used to assess intent. The coping styles of the participants were assessed using the Ways of Coping Questionnaire-Revised (WCQ-R) Scale.

Statistical Analysis

The data collected was entered in Excel and analyzed using SPSS statistical version 24 software. Descriptive statistic tools were used to assess mean, median, standard deviation, percentage, interquartile range, and frequency. Inferential statistics were analyzed using the chi-square test. A p-value < 0.05 was considered clinically significant. Pearson’s correlation analysis was carried out to explore the association between resilience and suicidal intent. The mean scores of different coping strategies across low, medium, and high suicidal intent groups were compared using one-way ANOVA. Pearson’s correlation analysis was conducted to examine the relationship between coping styles on the Ways of Coping Questionnaire–Revised (WCQ-R) and the severity of suicidal intent.

Results

Table 1: Demographic and Clinical Characteristics of the study population

The study population comprised 100 suicide attempters. The majority (45%) were aged 21-39 years, followed by those over 40 (33%). There was a slight male predominance (52%). Most participants had attained a secondary school education (52%), and nearly equal proportions were employed (51%) and unemployed (49%). The sample was predominantly Hindu (79%). The marital status distribution was nearly equal between married (45%) and unmarried (42%) individuals. Notably, over a quarter of participants (27%) had a past history of suicide attempt.

Table 2: Distribution of Resilience and Suicidal Intent

Assessment of resilience revealed that nearly half of the participants (49%) exhibited low resilience, while 46% had normal resilience and only 5% demonstrated high resilience. Regarding suicidal intent, 40% of the sample showed low intent, 31% medium intent, and 29% high intent.

Table 3: ASSOCIATION OF WAYS OF COPING QUESTIONNAIRE – REVISED SCORE WITH SEVERITY OF SUICIDAL INTENT BY ONE-WAY ANOVA TEST

Analysis of coping styles across different levels of suicidal intent revealed significant associations. Specifically, maladaptive coping strategies like confrontive coping and distancing were used significantly more by those with high suicidal intent (means of 7.90 and 8.10, respectively) compared to those with low intent (means of 2.48 and 3.73). In contrast, adaptive strategies such as seeking social support, accepting responsibility, planful problem-solving, and positive reappraisal were used more by participants with low suicidal intent. The use of planful problem-solving was notably lower in the high intent group (mean 3.10) compared to the low intent group (mean 6.10). Self-controlling and escape-avoidance did not differ significantly across intent groups.

Table 4: CORRELATION OF WAYS OF COPING QUESTIONNAIRE – REVISED SCORE WITH SEVERITY OF SUICIDAL INTENT

Pearson's correlation analysis confirmed significant relationships between specific coping styles and suicidal intent. Confrontive coping (r=0.510) and distancing (r=0.534) showed significant positive correlations, meaning higher use of these strategies was associated with greater suicidal intent. Conversely, significant negative correlations were found for adaptive strategies: seeking social support (r=-0.239), accepting responsibility (r=-0.362), planful problem-solving (r=-0.539), and positive reappraisal (r=-0.274), indicating that greater use of these coping styles was associated with lower suicidal intent. The overall raw score of the WCQ-R showed no significant correlation with intent.

DISCUSSION

This study was aimed at understanding the association between resilience, coping styles, and suicidal intent using the BRS, WCQ-R, and Beck's suicidal intent scale in a sample of 100 suicide attempters at a tertiary care center in Kerala. The majority of participants in this study (45%) were between the ages of 21 and 39, with those over 40 coming in second (33%). This suggests that young and middle-aged adults were more likely to attempt suicide. In contrast, Madhavan et al. reported that the median age of suicide was 42 years for males and 34 years for females, suggesting that suicidal behavior extends into early middle age, particularly among men.²⁰

While Soman et al. found a higher suicide rate with a male-to-female ratio of 1.74, the present study also demonstrated a slight male predominance (52%), supporting the pattern of higher suicide risk among males. This consistency may reflect similar gender-related vulnerabilities, such as greater exposure to occupational and financial stress, social expectations, and lower likelihood of seeking psychological help. This finding differs from Jaiswal et al., who reported a female preponderance of 66%.¹⁵ This divergence could be attributed to differences in help-seeking behavior, methods of suicide attempts, or gender roles influencing stress response and coping styles in different populations. Together, these findings demonstrate the value of addressing gender- and age-specific factors in suicide prevention strategies.

The current study indicated that the distribution of marital status was nearly equal, with 45% of participants married and 42% unmarried. This indicates that both categories are vulnerable to suicidal behavior, though possibly due to different psychosocial stressors. Married individuals may experience interpersonal conflicts, financial strain, or family responsibilities that contribute to emotional distress, while unmarried individuals may face loneliness, lack of social support, or uncertainty about the future. Conversely, the research conducted by Naess et al. indicated that marital disruption, encompassing divorce and widowhood, was significantly correlated with an elevated risk of suicide. This indicates that instability or loss in intimate relationships can act as a major precipitating factor for suicidal behavior.²¹

In this study, over half of the participants had attained secondary school education (52%), aligning with the findings of Madhavan et al., who noted a prevalence of lower educational levels among individuals who attempted suicide.²⁰ This might suggest that a lack of education could contribute to poor coping skills and lower problem-solving abilities, increasing vulnerability to suicidal behavior. The employment status in the present study was almost evenly divided, with 51% employed and 49% unemployed, akin to the results of Madhavan et al., which indicated no significant correlation between occupational status and suicidal intent²⁰, implying that factors beyond employment—such as interpersonal conflicts or psychological distress—may be more pivotal.

 27% of participants reported having attempted suicide in the past. The finding emphasizes the importance of continuous monitoring and follow-up for individuals with a history of past attempts.

Resilience scores revealed that nearly half of the sample (49%) had low resilience, while only 5% demonstrated high resilience. Importantly, resilience was negatively correlated with suicidal intent (r = –0.306, p = 0.002), suggesting that higher resilience protects against suicidal ideation and behavior. This finding supports earlier work by Roy et al. in 2007 highlighting resilience as a buffer against stress and hopelessness.²² Interventions like resilience training and cognitive-behavioral methods may lower the risk of suicide by making coping resources stronger. Possible explanations include the ability of resilient individuals to manage stress more effectively, maintain hope, and utilize adaptive coping mechanisms during crises. These results reinforce the concept of resilience as a buffer against psychological distress and suicidal behavior.

The coping profile indicated that seeking social support was the most frequently used strategy (15%), followed by confrontive coping, distancing, and self-controlling (13% each). Confrontive coping and distancing were significantly higher among participants with high suicidal intent, and both correlated positively with intent. These strategies are considered maladaptive, as they involve aggression, avoidance, or withdrawal rather than constructive engagement. Similar associations between maladaptive coping and suicidality have been reported in an earlier study by Werbart Törnblom et al. in the year 2021.²³

Participants with low suicidal intent more frequently used adaptive strategies such as planned problem solving, accepting responsibility, positive reappraisal, and seeking social support. Planned problem solving showed the strongest protective correlation (r= –0.539, p < 0.001). Previous literature by Stanley et al. in the year 2021 also emphasizes that adaptive, problem-focused coping is associated with lower psychological distress and suicidal ideation.²⁴ This aligns with earlier findings in the study by Rajappa et al., 2012, where problem-focused and adaptive coping mechanisms are linked to lower psychological distress, higher resilience, and better emotional adjustment.⁷

In this study, self-controlling and escape-avoidance coping strategies did not exhibit a significant correlation with suicidal intent. Elbogen et al. (2020) found escape-avoidance to be a significant risk factor for suicide attempts, which is in contrast to this finding.²⁵ The absence of a notable correlation between self-control and escape-avoidance coping regarding suicidal intent in our study may stem from cultural variations in coping expression and the impact of additional protective factors such as resilience and social support.

CONCLUSION

The findings of this study reveal that resilience and coping style are critical factors that determine suicidal intent. A significant inverse relationship was observed between resilience, as measured by the Brief Resilience Scale, and suicidal intent, indicating that higher resilience is associated with lower intent. Concurrently, maladaptive coping strategies—specifically confrontive coping and distancing—were positively correlated with suicidal intent, while adaptive strategies such as planful problem-solving, positive reappraisal, accepting responsibility, and seeking social support were negatively correlated with intent. These results suggest that interventions aiming to increase resilience and foster adaptive coping may be instrumental in mitigating suicidal intent in this high-risk group.

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