This was a hospital-based cross-sectional study. The study was conducted at a teaching hospital located in a semi-urban area from August 2016 to January 2017. Approval for the study was obtained from the Institutional Ethics Committee bearing approval no 038/2016. The patients who attempted suicide were referred to Psychiatry Outpatient Department (OPD) for psychiatric assessment and necessary intervention from the medical facility after their physical condition improved. All the attempted suicide patients who attended Psychiatry OPD within the study period, from ages 15-65 years were evaluated in detail with a reliable informant. Written informed consent was obtained for the study from both the patients and their primary caregivers. Total patients initially considered for the study were 85 of which 13 were excluded, as they suffered from comorbid medical and psychiatric illnesses (such as patients with mental retardation, Organic mental disorders, illicit drug use other than nicotine and alcohol and personality disorders) making the final study sample of 72 patients. All patients entered into the study were accounted for. If some were not accounted for, the missing data would not seriously impair the interpretation of the study as the objective was to find impulsivity factor in the attempters which may or may not be present in the missing sample. The specific age groups were considered because: (i) It is uncommon to see suicide cases under the age of 15 years in regular practice. Also, mental retardation was considered in the exclusion criteria; (ii) Patients above the age of 65 years were excluded on basis of their primary physical and mental condition. Majority of patients above 65 years of age suffered from comorbid medical conditions. The above factors were considered as exclusion criteria not to affect the study as we included patients with no current psychiatric and medical illnesses.

Socio-demographic and clinical profile sheet were completed to record variables including age, gender, locality, level of education, employment status, type of family, socio-economic status, marital status, family history of suicide attempts and substance use. Beck’s SIS was used to assess the severity of the intent in the patient. The scale consists of 15 questions which are scaled from 0-2, which take into account both the logistics of the suicide attempt as well as the intent. The scale has high reliability and validity. Total score of 15-19 was regarded as low intent, score range of 20-28 as medium intent and a score >29 was considered as high intent [17]. Barratt Impulsiveness Scale (BIS-11) is a 30 item self-report scale used to measure the personality construct of impulsiveness [18]. It contains a total of 30 items, each of which was answered on a 4-point Likert scale (rarely/never=1, occasionally=2, often=3, almost always/always=4), and this yields a total score. The scale had three second order factors representing the multi-dimensional nature of impulsiveness namely attention/cognition impulsiveness, motor impulsiveness, and non-planning impulsiveness. Attention impulsiveness assessed task at hand, thought insertions, and racing thoughts (8 items); motor impulsiveness assesses acting on the spur of the moment and perseverance (11 items); and non-planning impulsiveness assessed planning and thinking carefully, and enjoyment of challenging mental tasks (11 items). Some of the items were reverse scored as 4,3,2,1 (items=1,7,8,9,10,12,13,15,20,29,30). A level of impulsiveness was calculated by summing up the scores for each item. The minimum score is 30 and maximum score is 120. Higher score means higher degree of impulsivity. While many scholarly manuscripts report only the total score, it was the recommended that at least the second order factors should be reported to account for their individual contribution to the relationship being tested. In the present study, the average of the total score of each patient for the three respective subscales of BIS-11 (Attention, Motor, Non Planning) was calculated and the patients were designated to four groups such as Never one, occasionally two, Often three, Always four for each of the three sub scales (Attention, Motor, Non Planning), to find a relation (if any) between suicidal intent and the three categories of Barratt Impulsiveness Scale.

The statistical analysis was carried out using SPSS (version 20). The demographic and clinical characteristics were represented using descriptive statistics including mean, standard deviations, frequencies, and percentages. The scale and sub-scale scores were calculated for various instruments as per scoring instructions. Chi-square tests (cross tabulation analyses) and t-tests were used to compare the significant difference on categorical and continuous variables across groups. All tests were two-tailed and a p-value of <0.05 was considered statistically significant.

[Table/Fig-1] depicts the distribution of the sample according to the various socio demographic variables. If was found that majority were illiterate 30 (42%) and males 38 (52.8%) were marginally more than the females. Majority of the study population was in the age group of 15-25 years 30 (42%) hailing from a rural background 61 (84.7%) who were mostly farmers 39 (54.2%). The primary reason stated for the attempt was family problems 43 (59.7%) and prominent method adopted was ingestion of poison 51 (70.8%).

Distribution of study population according to suicide intent score (n=72): High Suicide intent score was present in majority of the patients 35 (48.6%), followed by 23 (31.9%) having medium intent, and 14 (19.5%) patients had low suicide intent score.

Association of suicide intent scores with different socio demographic variables: When Suicide Intent score was compared with different factors, we found a significant association (p<0.05) with age, gender, joint/nuclear type of family, education, marital status, reasons for suicide, and history of alcohol use at the time of the attempt. Low suicide intent was found in females 12 (35.3%), who were unmarried 9 (32.2%) having family/inter personal problems 14 (32.5%) and poisoning 14 (27.4%) was the mode of suicide attempt.

The [Table/Fig-2] shows the mean scores of suicide intent corresponding to Attention, Motor, and non-planning impulsivity scores. Viewing the mean scores with standard deviations, the scores are gradually decreasing as the intent is increasing (from low to high) in both domains of attention (15.6 SD 1.94) and non-planning (31.5 SD 2.65) with highest score in the low intent group whereas in motor impulsivity, the mean score was highest in medium intent (24.82 SD 5.53). Also, non-planning domain of impulsivity had the highest mean scores in all three intent groups, low intent (31.5 SD 2.65), medium intent (29.17 SD 4.37), and high intent (27.6 SD 5.24).

In [Table/Fig-3a], there was no significant difference found between attention impulsivity (never, occasionally, often and always) and suicide intent groups. Majority of the patients 56 (77.8%) who complained of having occasional (2) attention impulsivity had the highest suicide intent 28 (50%). Lowest intent 14 (25%) was found having occasional (2) attention impulsivity. The calculated significance value was p=0.077 at α=5% level of significance (2-tailed) which is insignificant; but at 10% level of significance, it may be accepted as a significant difference.

[Table/Fig-3b] There was no significant difference found between motor impulsivity (never, occasionally, often and always) and suicide intent groups. Majority of the patients 54 (75%) who complained of having occasional (2) motor impulsivity had the highest suicide intent 28 (51.9%). Lowest intent 12 (22.2%) was found having occasional (2) motor impulsivity. The calculated significance value was p=0.166 at α=5% level of significance (2-tailed) which was insignificant.

[Table/Fig-3c] There was no significant difference found between non-planning impulsivity (never, occasionally, often and always) and suicide intent groups. Majority of the patients 41 (56.9%) complained of having often (3) non-planning impulsivity. But the highest suicide intent 18 (60%) was found in the occasional (2) group rather than that of the often (3) group. The Lowest intent 11 (26.8%) was found having often (3) non planning impulsivity. The calculated significance value was p=0.262 at α=5% level of significance (2-tailed) which was insignificant.

T-test was used to find significant differences in impulsiveness rates within each level of intent. There was no significant difference found between impulsivity of attention and motor sub scales within low intent (p=0.45, t=0.762, df=35), between attention and non-planning in low intent (p=0.428, t=0.799, df=47), and also between motor and non-planning impulsivity in low intent (p=0.937, t=-0.79, df=56) [Table/Fig-4].

There was significant difference between impulsivity of motor and non-planning sub scales within medium intent (p=0.043) which was less than 0.05 at α=5% level of significance (t=2.063 at df=56). No significance was found between attention and motor impulsivity in medium intent (p=0.711, t=-0.373, df=35). No significance was found also between attention and non-planning impulsivity in medium intent (p=0.121, t=1.579, df=47) [Table/Fig-5].

There is significance difference between impulsivity of attention and non-planning sub scales within high intent (p=0.012) which is less than 0.05 at α=5% level of significance, (t=2.618 at df=47). No significance was found between attention and motor impulsivity in high intent (p=0.082, t=1.793, df=35). No significance was found between motor and non-planning impulsivity in high intent (p=0.247, t=1.169, df=56) [Table/Fig-6].

This study was conducted to ascertain the relationship of trait impulsivity to the degree of intent in patients who attempted suicide. The association between gender and suicide intent was found to be significant (p=0.05) and highest intent to be present in males and low intent was found in 12 (35.3%) females. Men commonly use more lethal modes and planned the act more meticulously to avoid detection. In contrast, women use less lethal modes, are more impulsive, less well planned, and more likely to be found and rescued. The intent score was also found to be highest in people who were married 28 (66.66%), and low intent was present in 9 (32.2%) of the unmarried population and the relationship between marital status and suicide intent was found to be statistically significant (p<0.001). Regarding reasons for attempting suicide, low intent was present in 14 (32.5%) patients who had family problems/interpersonal issues. And as for the mode of the attempt, low intent was present in 14 (27.4%) patients who consumed pesticides.

As suggested by Mann JJ et al., impulsivity is an important component of suicidal behaviour [5]. In the present study, the mean impulsivity scores were gradually decreasing as the intent was increasing (from low to high) in all the sub scales of attention, motor and non-planning with highest score in the low intent group. Also non-planning second order factor of impulsivity had the highest mean scores in all three intent groups (low, medium, high), thus showing that people with low intent were more prone to the impulsive traits and as intent increases the impulsivity decreases. Similar findings were found in the study done by Baca-Garcia E et al., [19]. Individual BIS-11 sub scales were compared in relation to intent scores based on the four scoring divisions, and we found patients with low intent occasionally (score 2) complained of having both attention/cognitive and motor impulsivity at the time of the attempt. However, non-planning factor was complained more often (score 3) by patients having low intent at the time of the attempt. When we looked into the differences in impulsive rates within intent groups using t-test, and we found a statistical difference (p=0.043) between motor and non-planning sub scales within the medium intent group. And within the high intent group a statistical difference was also found (p=0.012) between attention and non-planning sub scales. There was no statistical significance (p=0.45, p=0.428, p=0.937) found between the second order factors in the low intent group. Similar findings were found in a study done by Baca-Garcia E et al., who also noted a trend for “motor” impulsiveness to be associated with impulsive attempts [19].

From the above findings, we see that as the intent increases the impulsivity decreases in the attempter, and among the three sub scales of BIS-11, non planning seems to be more associated with impulsivity in low to medium intent groups as from our findings so far. A suicide attempt is a major risk factor for suicide completion, and impulsivity is personality trait associated with suicide attempt [20]. Few researchers, such as Wu CS et al., outside Asia have also focused on impulsivity in suicide attempters [21]. Barca-Garcia E et al., reported significantly high impulsivity in Spanish suicide attempters using the BIS [6]. Results from another study done concluded impulsivity and lethality were inversely associated during attempt [7], suggesting that impulsive attempts tend to be less lethal. Other studies, such as the one conducted by Swann AC et al also showed different psychiatric disorders and personality traits were associated with impulsivity in suicides [22]. Soloff PH et al., reported that in patients with history of suicide attempts, borderline patients had higher scores in the BIS-11 compared with depressive patients [23]. Doihara C et al., reported both total BIS-11J and non-planning impulsiveness scores were significantly higher in attempters with schizophrenia and other psychotic disorders among the diagnostic groups [24]. There is a marked lack of consensus on the relationship between impulsivity and the medical seriousness of the attempt. Although some authors believe impulsivity is a characteristic of nonlethal suicide attempts or suicide gestures [7], others report evidence of higher levels of impulsivity in those who die by suicide than in those who do not [25]. The dissimilarities may be explained by the confusion between the state and trait dimensions of the impulsivity-suicide relationship, differing definitions of impulsivity, the measures used and the population studied [26]. The relationship between impulsivity and suicide intent merits a closer evaluation for its preventive implications. Whether and to what extent targeting these personality traits in suicide prevention programs may reduce repeat attempts in follow-up is a question that needs further research [27].

This study has some limitations, the attempters were recruited from one semi-urban teaching college and the sample size was relatively small. This study did not investigate impulsivity in patients without suicidality in comparison with the attempters. Future larger-scale and detailed studies are warranted to verify the present findings. Self-Report measures, such as the Barratt Impulsiveness Scale have the drawbacks that include the need to rely on the veracity of the individual completing the questionnaire. In addition, these measures are unsuitable for repeated use, thus limiting their usefulness in treatment studies. In the present study BIS-11 was used as a single measurement of trait impulsiveness that might discriminate between subgroups of patients. Finally, the extent to which the results generalize to other Indian samples, or individuals in other countries, is unknown.

Studies like these are important in our clinical practice because there is limited research on the relationship between impulsivity and intent in the Indian population, and more research is needed to identify and intervene in those at risk for impulsive suicide attempts in developing countries. When such high levels of suicide intent co-exist with impulsivity, it may drive an individual to transition rapidly from suicidal thoughts to suicidal behaviour as a possible response to the stressful situation with precluding other adaptive responses.

To conclude, the present findings, although limited, suggest that there is a significant association between impulsivity and intent, and basically expand the scope and relevance of impulsivity as a probable predictor of suicide intent in Indian subjects with attempted suicide. Therefore, assessing and controlling impulsivity should be considered in suicide prevention and clinicians would be well advised to evaluate the presence and severity of these personality factors during a routine evaluation of suicide attempters.