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Death Studies, 28: 19746, 2004

Copyright # Taylor & Francis Inc.


ISSN: 0748-1187 print / 1091-7683 online
DOI: 10.1080/07481180490249247

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COMPARATIVE STUDY OF SUICIDE POTENTIAL AMONG


PAKISTANI AND AMERICAN PSYCHIATRIC PATIENTS
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YASMIN NILOFER FAROOQI


University of California, Santa Barbara, California, USA

This study compared suicide potential and suicide attempts in 50 Pakistani and 50
American psychiatric patients all of whom reported a positive history of suicide attempts
during the past 175 years. It further explored the role of nationality, gender, diagnosis,
and marital status in respondents potential for suicide and suicide attempts. The
American sample reported a higher degree of suicide potential on the Firestone Assessment
of Self-Destructive Thoughts (FAST), more suicide attempts, and a larger number of
suicide precipitants (family conflicts, work pressure, wish for death, loneliness, financial
problems, and mental disorders/drug withdrawal) than did the Pakistani sample. For
suicide attempts, effects of 3-way interaction for gender, marital status and nationality
were found significant. However, these effects were non-significant for respondents
potentialforsuicide. In addition, the FASTwas found to have a significantly high correlation with suicide attempts.Thus, it may be inferred that the FASTcan be used as a valuable
screening instrument for the identification of patients at risk for suicide in diverse cultural
settings. However, more prospective validity studies are needed to enhance our crosscultural understanding of suicide; identification of psychiatric patients at risk for
suicide by the FAST; and for effective treatment and prevention programs for Eastern and
Western societies.

Received 24 April 2001; accepted 4 June 2003.


Yasmin Nilofer Farooqi, PhD is now Professor at the Department of Applied Psychology,
University of the Punjab, Lahore, Pakistan.
This research project was funded by the Fulbright Scholars Program, U.S. Department of
States, Bureau of Educational and Cultural Affairs and the Council for International Exchange
of Scholars,Washington, DC. Moreover, Dr. Daphne Bugental of University of California, Santa
Barbara and Drs. Lisa Firestone and Robert Firestone of the Glendon Association provided technical assistance in data collection and analysis.
Address correspondence to Yasmin Nilofer Farooqi, Department of Applied Psychology,
University of the Punjab, Lahore, Pakistan. E-mail: yasminfarooqi@hotmail.com

19

20

Y. N. Farooqi

Suicide attempts arise from a variety of social, economic, and psychological factors (Bonger, 2002; Firestone, 1987, 1988, 1994, 1997a; Firestone
& Firestone, 1996, 1998; Shneidman, 2001). Of late, there has been a
steady increase in suicide rates in Western developed countries as well
as in Eastern developing countries such as Pakistan. Attempts to understand this anti-life phenomenon are of immense concern to helping professionals around the world.
Views regarding suicide have changed through the centuries, considering the complexity of this self-destructive process. Firestone and
Firestone (in press) proposed that understanding the causes and nature
of the self-destructive thought process of the suicidal individual is fundamental to developing psychotherapeutic interventions and preventive
mental health programs for potentially suicidal patients. Beck (1976,
1991), Ellis (1973), Kaufman and Raphael (1984), and Stillion,
McDowell, Smith, and McCoy (1986) have described negative thoughts
toward self and others, which lead to depression and self-defeating behavior. Firestone & Firestone argued that the suicidal individual is divided
within himself/herself . . . one part wants to live while the other part
wants to die. Therefore, it is our responsibility to appeal to and support
the part that wants to live because their right is not to commit suicide
but to have their need for psychological assistance met so that they may
enjoy a satisfying life among us (Leonard, 1967, p. 223).
There is sufficient clinical and empirical evidence that suggests that
the individuals who had made serious suicidal attempts manifest
extremevoice attacks (self-destructive thoughts) that may set the stage
for future fatal suicide attempts (Firestone, 1987, 1988, 1994, 1997a,
1997b; Firestone & Firestone, 1996, in press). Firestone and Firestone
(1996, in press) propose that there is a relationship between destructive
thought processes and self-destructive behavior and/or suicide. According to Firestones (1997a) SeparationTheory and Voice Concept, within
each individual there are tendencies to actualize the self (self-system)
and to destroy the self (anti-self system). He further argued that the
Firestone Assessment of Self-Destructive Thoughts (FAST) provides
valuable information regarding clients functioning level along an
11-level continuum beginning with self-critical thoughts of every day life
(Level 1) and progressing to injunctions to carry out the suicide plan
(Level 11).
Research has shown that a suicide crisis is the therapists worst fear,
often paralyzing clinicians emotionally and interfering with their sound

Suicide Potential

21

clinical judgment and effective crisis-resolution. Consequently, the risk


of suicide, including suicidal attempts and completions, is disproportionately high among the mental health clients in treatment (Lindeman,
Henriksson, Isometsa, & Lonnqvist, 1999; Neimeyer & Pfeiffer, 1994;
Nekanda-Trepka, Bishop, & Blackburn, 1983). Thus, it may be argued
that no challenge can be more stressful or demanding than understanding, correctly appraising, and managing a patient who is suicidal
(Halton,Valente, & Rink, 1997; Harkavy-Friedman et al., 1999).
In an underdeveloped, economically deprived and politically
unstable country like Pakistan, research on suicide is meager. Khan
(1998) and Khan and Reza (1998a) noted that fatal and non-fatal suicide attempts are issues that are relatively ignored in Pakistan. Suicide
is considered a crime here; and there are no national statistics compiled
nor are the suicide mortality statistics reported to the World Health
Organization (WHO). Consequently, there are no current official data
or national reports that could be quoted to highlight the incidence of
fatal and non-fatal suicidal attempts by the Pakistani men and women;
especially among the psychiatric population.
Khan (1998), Khan, Islam, and Kundi (1996), and Farooqi and
Hussain (2001) traced this situation to the strong social stigma and religious sanctions against committing suicide. Unfortunately, social taboos
and religious sanctions have led to the formation of punitive laws against
any type of suicidal attempts/acts. Thus, this state of affairs has resulted
in under-diagnosis and underreporting of fatal and non-fatal suicidal
attempts in Pakistani society. Unfortunately, there has been very little
research done to assess suicide potential among the Pakistani psychiatric
population.
Khan and Reza (1998a, 1998b) and Mumford, Saeed, Ahmed, Latif,
and Mubasher (1997) argued that collecting data on suicide and
attempted suicide in Pakistan is very difficult because of a variety of
complex social, religious, psychological, and legal factors. One can well
imagine how difficult it would be when it involves data collection from
the Pakistani psychiatric population because of the added component
of shame, guilt, and embarrassment associated with the stigma of mental
illness itself.
Nevertheless, our newspapers and media are daily reporting a drastic
increase in the incidence of fatal suicide attempts since 1999. Ahmed
(1999) attributed the rapid increase in suicide rate to increase in poverty,
unemployment, and hunger as a result of frighteningly rapid price hikes

22

Y. N. Farooqi

and economic depression at a national level. Unfortunately, there has


been very little scientific or clinical research done in Pakistan to assess
suicide potential among psychiatric patients so that better interventions
and preventive measures could be introduced for those who pose a high
risk for self-destructive behavior or fatal suicide attempt. Currently,
there is no scale or measurement tool available in the Pakistani mental
health system to assess elements of suicidal ideation and intention, and
to predict/prevent suicidal behavior. However, Farooqi and Hussain
(2001) found a significant positive relationship (r .56, p < .05) between
suicide potential (measured by the UrduVersion of the FAST 1, Farooqi,
1999) and history of suicide attempts (reported/recorded) in the
Pakistani samples. Thus, the FAST may prove a valuable tool for
assessing suicide risk and be especially useful to Pakistani professionals who need a quick and simple scale to gain information about
their clients suicidality.
Much of the international research in this area has focused on suicide
and certain psychiatric diagnostic categories, such as depression and
substance abuse, probably because these groups pose a high risk for suicide (Appleby, 1992; Apter et al., 1995; Brent et al., 1993, 1994; Goldring
& Fieve, 1984; Rossow & Lauritzen, 1999; Singh, Nigman, Gahlaut, &
Sinha, 1987; Strakowski, McElroy, Keck & West, 1996; Weissman,
Klerman, Markowitz, & Ouellette, 1989). Goldenberg (1995) and
Maier and Falkai (1999) noted that depression, generalized anxiety disorder and somatoform disorder show an excess of co-morbidity both in
general population and psychiatric patients. Tsai, Lee, and Chen (1999)
and Shah and Ganesvaran (1999) stated that bipolar disorders with substance abuse and/or previous suicide attempts and schizophrenia among
psychiatric in-patients are strong predictors of suicide.
Bakish (1999) mentioned co-morbidity of anxiety with major depression, which generally occurs more often than either diagnosis separately
(Isometsa et al., 1996). This type of diagnosis is associated with more
severe symptoms, a chronic and poorer outcome, and higher incidence
of suicide.
The main purpose of the current research project is to compare
the suicide potential among Pakistani (predominantly Muslim) and
1
Firestone Assessment of Self-DestructiveThoughts. Copyright #1999 by R.W. Firestone and
L. Firestone. Translated and reproduced by Yasmin Nilofer Farooqi, PhD with permission of the
publishers,The Psychological Corporation. All rights reserved.

Suicide Potential

23

American (predominantly Christian) psychiatric patients using the


FAST. It can be inferred from previous research findings and clinical
studies that high scores on the FAST would identify those individuals
with past history of suicide attempts (Firestone & Firestone, 1996,
and Farooqi & Hussain, 2001). The study will further explore the relationship between internalized self-destructive voice attacks (measured
by the Total FAST Score) and self-destructive behavior patterns (measured by the number of past suicidal attempts) of the Pakistani and
American samples. Finally, the study investigates gender differences
in suicide potential, suicide attempts, and suicide precipitants for both
samples.
Canetto (199271993) and Langhinrichsen-Rohling et al. (1998) suggested that suicidal behavior among women is typically non-fatal with
women outnumbering men at a rate of 2:1 in all industrialized countries
except Poland and India. Canetto (1994, 1997) and Canetto and Lester
(1995, 1998) noted that socioeconomic disadvantage, unemployment,
hostile relationships, and history of suicidal behavior among family and
friends are associated with non-fatal suicidal behavior in women.
Dahlen and Canetto (2002), Canetto and Feldman (1993), and
Hirschberger, Florian, and Mikulincer (2002) argued that gender plays
a role in the risk for suicidal behavior as well as in how suicidal behavior
is evaluated in a specific cultural setting. Brent (1998) found suicide
completion rate four times higher in American men than women,
whereas the rate of suicide attempts is two to three times higher in
females than males. Moreover, the most common method for completed
suicide in American men is firearms, followed by hanging, carbon monoxide and jumping.
McIntosh (1999, 2000) reported that out of the total suicide deaths
occurring in the United States in 1996, 81% were males. It may be
argued that in the USA, non-fatal suicidal behavior is both more socially
acceptable and common in women, probably because suicidal behavior
in American females receives greater sympathy than the same behavior
in males. There is sufficient empirical data that suggest that in the
United States, women become suicidal because of relationship
problems, and men in response to social and economic crises (Crosby,
Cheltenham, & Sacks, 1999; Marks, 198871989; Stillion, White,
Edwards, & McDowell, 1989). Dahlen and Canetto (2002) argued that
suicidal decisions following a physical illness would be viewed as more
acceptable than suicidal decisions precipitated by a relationship or an

24

Y. N. Farooqi

achievement in American men. Wellman and Wellman (1986) and


Miller (1994, as cited in Stillion & Stillion, 199871999) reported that
American men are more likely to agree that people should have the right
to kill themselves and that such actions can be justified and rational.
Farooqi and Hussain (2001) found higher suicide attempts and suicide potential among Pakistani men than Pakistani women. It may be
argued that in Pakistan the legal system, social stigma, and religious
sanctions bring relatively more shame, embarrassment, and guilt for
the female suicide attempters than do the male attempters. As a result,
reported suicidal deaths are more common in Pakistani men than in
Pakistani women. Another reason may be that suicide is a socially
tabooed, legally prohibited, and religiously condemned act. Thus, it
may be that the underreporting of suicide for the Muslim Pakistani
women might contribute to the apparently higher suicide rate among
men (Khan & Reza, 1998b). Another reason may be that Pakistani
men in their roles as the bread winner of the family are hit hard by
the current economic depression faced by the entire country in the
wake of being declared a nuclear state and as a result of the influx of
refugees after the Afghan war.
It has been further noted that economic crisis, achievement loss, and
health crises are the precipitant events for suicide in Pakistani men,
whereas debilitating illness, interpersonal losses and overwhelming
family conflicts are more prevalent precipitating factors for Pakistani
women (Farooqi & Hussain, 2001). Furthermore, Pakistani women are
economically and physically dependent on their male counterparts
(fathers, brothers, sons, uncles, etc.). Consequently, they end up feeling
more helpless and hopeless if they fail to fulfill their traditional roles as
an obedient daughter, wife, sister, or mother.
Nevertheless, the reported suicidal deaths are more common in
Pakistani men than in women, perhaps because they tend to use more
lethal methods of suicide (such as shooting or running in front of a train
or jumping from a high building), whereas Pakistani women usually
access less lethal methods such as overdose on prescription drugs dispensed by a licensed doctor. The same pattern was found for the male
suicide deaths in the United States though the suicide precipitants were
different for men and women in the two countries.
Specific cultural scripts of femininity and masculinity could influence
which suicidal behavior women and men will exhibit under what kind
of circumstances and how it will be interpreted in diverse cultures

Suicide Potential

25

(Canetto, 1997).Thus, it is quite logical to expect gender and nationality


to influence self-destructive thought processes and final judgments about
suicidal behavior. Therefore, this researcher explored effects of gender
on number of suicide attempts (reported/recorded), suicide precipitants,
and degree of suicide potential (measured by the Total FAST Score)
among Pakistani and American psychiatric patients. I hope that the
findings of this study would enhance our understanding of the complex
and multifaceted phenomenon of suicide from diverse cultural perspective. In addition, it may further validate the diagnostic value of the
FAST for timely assessment/prediction of suicide risk in the psychiatric
patients from diverse cultural backgrounds. Consequently, more effective treatment and prevention strategies could be introduced for those
who pose a high risk for suicide across the globe.

Method
For the present research, a retrospective ex post facto research design
was used. The sample was composed of 100 psychiatric patients (50
Pakistanis and 50 Americans). The inclusion criteria for both samples
were that the patients should be receiving some psychopharmacological
treatment in a hospital/clinic setting for the past 275 days; they must
not have experienced active suicidal ideation, threats, and/or attempts
within the past 1 month; but have a positive history of non-fatal suicide
attempts within the past 175 years; and they must voluntarily agree to
participate in this research project.
The American sample was randomly selected from data collected by
Firestone and Firestone (1996, 1998) for their validity studies of the
FAST. All the patients were selected from various outpatient and inpatient units of different hospitals and clinics in California. In an attempt
to make the Pakistani sample representative and comparable to the
American sample, the Pakistani psychiatric patients were also selected
from various outpatient and inpatient units of different hospitals and
clinics in Lahore, Pakistan. Only those patients were selected who
agreed to participate in this research, had been diagnosed by their treating psychiatrists on Axis 1 of DSM-IV (American Psychiatric Association, 1994) for depression/depressive illness, anxiety disorders,
schizophrenia, or substance-related disorders and met the abovementioned inclusion criteria like their American counterparts.

26

Y. N. Farooqi

It is worth mentioning here that instead of interrupting the ongoing


psychopharmacological treatment of the Pakistani patients, I requested
the treating psychiatrists to conduct the mental status examination of
each of the Pakistani patients prior to the administration of the FAST
to rule out the possibility of any confounding impact of medications on
the cognitive-perceptual processes of the patients that might have interfered with their inner voiceson the FAST, which was used as a measure
of suicide potential.
Participants
The majority of the American subjects (n 50) were men ranging in age
from 18754 years with high school education and monthly income
between $5,99979,999. However, majority of the Pakistani participants
(n 50) were women in the age range of 18745 years and none were
divorced or widowed. The Pakistani participants had an average
monthly income less than $80 and their education was below high
school. These differences between Pakistani and American participants
may be attributed to low literacy rate and unstable political-economic
situation of Pakistani society. All the Pakistani patients like the
American patients had been diagnosed by their treating psychiatrist on
Axis 1 of DSM-IV (American Psychiatric Association, 1994) for
depression/depressive illness, anxiety disorders, schizophrenia, or
substance-related disorders. The percentage of each sample suffering
from various psychiatric disorders was similar. Further details about
demographic characteristics of both samples can be found inTable 1.

Instrument
Suicidal potential was measured by the FAST, a self-report questionnaire consisting of 84-items drawn from eleven levels of progressively
self-destructive thought process that may lead to actual suicide. The
respondents were asked to endorse how frequently they experienced the
negative thoughts or voices toward themselves (in the second person)
on a 5-point Likert-type scale fromnever tomost of the time.
According to Firestone and Firestone (1996, 1998), factor analysis of
the FAST provided four factor-based composites: (a) self-defeating
composite (measure of feelings of low self-esteem), (b) an addictions

27

Suicide Potential
TABLE 1 Descriptive Characteristics of the Sample (N 100)
American Patients
(n 50)
Characteristics

Freq

Percent

Pakistani Patients
(n 50)
Freq

Percent

Gender
Males
Females

26
24

52%
48%

30
20

60%
40%

Marital Status
Single
Married
Separated
Widowed
Divorced

26
6
3
1
14

52%
12%
6%
2%
28%

29
19
2
0
0

58%
38%
4%
0
0

Education
Grade School
High School
173 Years of College
Bachelors Degree
Masters Degree

8
20
15
5
2

16%
40%
30%
10%
4%

17
16
11
6
0

34%
32%
22%
12%
0

Diagnosis
Depression
Anxiety Disorder
Schizophrenia
Substance-Related Disorders

20
10
10
10

40%
20%
20%
20%

20
10
12
8

40%
20%
24%
16%

Income
US Dollars Pak Rupees
$ 079,999 Rs 075,999
$10719,999 Rs 6711,999
$20729,999 Rs 12717,999
$30749,999 Rs 18723,999
$50 > Rs 24 >

31
8
8
2
1

62%
16%
16%
4%
2%

23
22
3
1
1

46%
44%
6%
2%
2%

5
2
4
3
2
5
3

10%
4%
8%
6%
4%
10%
6%

4
1
7
7
3
6
10

8%
2%
14%
14%
6%
12%
20%

Occupation
Professional
Manager
Clerical
Labor
Skilled Labor
Student
Homemaker

(Continued)

28

Y. N. Farooqi

TABLE 1 Continued
American Patients
(n 50)
Characteristics

Freq

Percent

Pakistani Patients
(n 50)
Freq

Percent

Disabled
Other

10
16

20%
32%

8
4

16%
8%

Precipitants for Suicide


Illness
Family Conflicts
Work Pressure
Wish for Death/Loneliness
Grades/StudyAnxiety
Financial Problems
Interpersonal Conflicts/loss
Mental Disorder/Drugs
Multiple Events from above

3
4
0
1
5
1
0
3
33

6%
8%
0%
2%
10%
2%
0%
6%
66%

18
14
2
2
5
1
2
1
5

36%
28%
4%
4%
10%
2%
4%
2%
10%

Age
Suicide Attempts
Range for reported or
recorded suicide attempt

R 18754 years

R 18745 years

R 1720

R 175

Note. $ US Dollars per month; Rs Pakistani Rupees per month; n Number of patients;
Freq Frequency; R Range.

composite (measure of cycle of addictions), (c) a self-annihilating


composite (measure of loss of feeling for self and depersonalization),
and (d) a suicide intent composite (measure of active suicide ideation
and planning). Each composite consists of different items from the 11
levels of the FAST. In addition, the FAST provides an overall global
measure of suicidal potential or self-destructive behavior, called the
Total FAST Score, which represents the sum of the scores obtained on
all levels. The internal consistency and test7retest reliability estimates
for the FAST meet or exceed acceptable reliability standards. The
validity of the FAST (examined through content-related, constructrelated and criterion-related methods) was also found very high as
reported by the Firestones (1996, 1998) and Farooqi and Hussain
(2001). Thus, it may be argued that the FAST is a reliable and valid
measure of suicide potential for clients with a wide range of diagnoses
from culturally diverse populations, both Eastern and Western.

Suicide Potential

29

Procedure
The Pakistani patients were administered Urdu version of the FAST
(Farooqi, 1999) within the hospital settings by a research associate who
remained there along with this researcher to answer any questions or
communicate with those who might have become disturbed by feelings
aroused during the FAST testing. The patients responses on the FAST
were immediately scored so that their treating psychiatrists/psychologists could be informed if the scores were in the range of concern.
This was done to provide for the clients safety so that necessary interventions could be initiated. Furthermore, both therapists and patients
provided information on past suicide attempts through a structured
interview as was done in case of the American sample. In case of disparity between the patients and the therapists reported suicide attempts
the patients reported suicide attempts were considered. Moreover, a
structured interview was conducted by this researcher to obtain demographic information from the Pakistani sample on a separate sheet as
was done in case of the American sample.

Results
The data given in Tables 2 and 3 suggest that the American sample
reported more suicide attempts, a larger number of suicide precipitants,
and a higher degree of suicide potential as compared with the Pakistani
sample. In addition, the American participants in all diagnostic groups
reported more self-defeating, addictive, and self-annihilating voices
than the Pakistanis.
Figure 1 shows that within the American sample men reported more
suicide attempts, whereas in the Pakistani sample more women reported
suicide attempts.
Figures 2 and 3 suggest that the American patients suffering from
depression reported the highest rate of suicide attempts and greater
potential for suicide than all other diagnostic groups.This may be attributed to lack of socially acceptable ways to express anger and higher level
of social and economic competition and pressure for men in American
society. However, in the Pakistani sample, those suffering from substance-related disorders (mostly men) showed greater suicide potential
but reported a lower rate of actual suicide attempts than other diagnostic

30
59.65
83.10
150.85
251.45
1.80
3.40

Pakistani
American

Pakistani
American

Pakistani
American

Pakistani
American

Pakistani
American

Addictions
Composite

Self-Annihilating
Composite

Suicide Intent
Composite

Total FAST
Score

Suicide Attempts
Reported/Recorded

.79
4.31

51.35
66.31

26.01
29.11

33.06
37.57

4.93
8.95

22.07
27.74

SD

20
20

20
20

20
20

20
20

20
20

20
20

1.80
1.70

133.60
211.60

53.20
62.80

73.10
84.70

6.60
15.60

53.90
115.20

1.48
.95

53.04
78.81

28.79
31.54

40.38
40.19

4.38
7.29

20.43
31.84

SD

10
10

10
10

10
10

10
10

10
10

10
10

Anxiety-Disorders

Note. M Mean Scores; SD Standard Deviation; N Number of patients.

75.40
113.05

9.35
20.20

66.70
118.20

Pakistani
American

Self-defeating
Composite

Nationality

FAST Factor-based
Composites/Suicide
Attempts

Depression

1.17
2.40

149.08
210.50

53.83
65.20

72.17
89.90

11.75
18.40

66.00
102.20

.39
1.51

63.53
77.35

30.83
28.92

40.56
40.23

6.92
9.86

25.47
37.42

SD

Schizophrenia

12
10

12
10

12
10

12
10

12
10

12
10

1.50
1.10

193.50
218.20

73.00
67.60

94.50
91.40

18.13
23.60

80.88
103.20

.76
.32

40.82
64.56

17.97
30.33

22.15
42.69

4.09
7.17

32.16
22.79

SD

Substance Abuse
Disorders

8
10

8
10

8
10

8
10

8
10

8
10

TABLE 2 Comparison of FAST Factor-based Composite Scores (Suicidal Potential) and Suicide Attempts Reported by the Pakistani and
American Psychiatric Patients byTheir Diagnosis

31

Suicide Potential

TABLE 3 Precipitant Events for Suicide Attempts Reported By the Pakistani and
American Patients
American Patients
Type of
Precipitant Events
Illness
Family Conflicts
Work Pressure
Wish for Death
and/or Loneliness
Grades/Study
Anxiety
Financial Problems
Interpersonal
Conflicts/Loss
Drug Withdrawal/
Mental Disorder
Multiple Events

Pakistani Patients

Freq

Percent

Freq

Percent

3
4
0
1

6%
8%
0
2%

18
14
2
2

36%
28%
4%
4%

10%

10%

1
0

2%
0

1
2

2%
4%

6%

2%

33

66%

10%

(Family Conflicts,Work
Pressure,Wish for Death
Financial Problems,
Mental Disorder)

Suicide Attempts
American Sample: Mean 2.40 (SD 2.94)
(n 50)
Range 1720
Pakistani Sample: Mean 1.62 (SD .92)
(n 50)
Range 175
Note. Freq Frequency.

groups. Instead, the Pakistani patients suffering from depression and


anxiety (mostly women) reported a higher rate of suicide than schizophrenics and substance-related disorders.
Table 4 shows that a statistically significant correlation was obtained
between the Total FAST Score and suicide attempts (r .26, p < .05).
Moreover, the self-annihilating composite (a measure of loss of feelings
for self and depersonalization) and the suicide intent composite (a measure of suicide ideation and planning) were found to have higher correlations with suicide attempts (r .29, p < .05; r .28, p < .05, respectively)
and the Total FAST as the dependent variables (r .91, p < .05; and
r .88, p < .05, respectively).
Table 5 further suggests that the Total FAST was highly correlated
with all 11 levels and four composites for the two samples. Thus, it may

32

Y. N. Farooqi

FIGURE 1. Suicide attempts among Pakistani and American patients by gender.

be inferred that the Total FAST Score could be used as a global assessment of patients suicidal potential for culturally diverse populations as
was done in this study.
MANOVA for two dependent variables (suicidal potential and suicide
attempts) and four fixed factors (nationality, gender, diagnosis, and marital status) was conducted to determine the effects of interaction. Table 6
suggests a trend toward a 3-way interaction for Nationality 6 Gender
6 Marital Status on patients suicide attempts (F 4.84, df 1, p < .05,

Suicide Potential

33

FIGURE 2. Suicide attempts reported by Pakistani and American patients by


diagnosis.

Z2 :07). However, these effects were nonsignificant on patientssuicide


potential though significant for two-way interaction for Diagnosis 6
Gender (F 3.27, df 3, p < .05, Z2 :14) and Nationality 6 Marital
Status (F 7.32, df 1, p < .05, Z2 :10).
Figures 4 and 5 suggest that the married Pakistani patients reported
more suicide attempts and higher degree of suicide potential than the

34

Y. N. Farooqi

FIGURE 3. Suicidal potential among Pakistani and American patients by diagnosis.

single and the separated. None were widowed and/or divorced in the
Pakistani sample. In contrast, the American widow (n 1) reported the
highest rate of suicide attempts, whereas the separated patients (mostly
men) showed higher degree of suicide potential than the single, the married, and the divorced.

35

Suicide Potential

TA BLE 4 Relationship Between Suicide Attempts and FAST Factor-based


Composite Scores

Composite
Self-Defeating
Addicitions
Self-Annihilating
Suicide Intent
FAST Total Score

Suicide Attempts

Total Fast Score

.19
.15
.29**
.28**
.26**

.06
.15
.00**
.01**
.01**

.91**
.63**
.91*

.00**
.00**
.00**
.00**

1.00

Note. r Correlation Coefficients; *p < .05. **p < .01.

TABLE 5 Relationship Between the Total FAST Score and Level/ Factor-based
Composite Scores
Levels/Composites
Level 1: Self-DepreciatingThoughts
Level 2: Thoughts Rationalizing
Self-Denial
Level 3: Cynical Attitudes Towards
Others
Level 4: Thoughts Influencing Isolation
Level 5: Self-Contempt: Vicious
Self-AbusiveThoughts
Level 6: Thoughts Supportive of Cycle
of Addiction
Level 7: Thoughts Contributing to
Hopelessness
Level 8: Giving Up on Oneself
Level 9: Injunctions to Inflict
Self-Harm
Level 10: Thoughts Planning Details
of Suicide
Level 11: Injunctions to Carry Out
Suicide Plans
Self-Defeating Composite
Addicitions Composite
Self-Annihilating Composite
Suicide Intent Composite
Note. r Correlation Coefficients; *p < .05. **p < .01.

.85**
.74**

.00*
.00*

.70**

.00*

.83**
.87**

.00*
.00*

.63**

.00*

.86**

.00*

.85**
.75**

.00*
.00*

.81**

.00*

.82**

.00*

.91**
.63**
.91**
.88**

.00*
.00*
.00*
.00*

36
1
1
1

Suicide Attempt
Total FAST Score
Suicide Attempt

22.69

7.89
4313.02

964.62
2.99
10858.32
9.95
16544.63
1.00
5449.14
8.27
11798.95
4.78
26370.52

Mean
Square

4.84

1.69
1.20

.27
.64
3.01*
2.12
4.59
.21
1.51
1.77
3.27*
1.02
7.32**

Note. All non-significant two-way and three-way interactions were omitted. *p < .05. **p < .01. df degrees of freedom.

Nationality6Gender6
Marital status

Nationality6
Marital Status

Diagnosis6Gender

Marital Status

Gender

Diagnosis

1
1
3
3
1
1
4
4
3
3
1

Total FAST Score


Suicide Attempt
Total FAST Score
Suicide Attempt
Total FAST Score
Suicide Attempt
Total FAST Score
Suicide Attempt
Total FAST Score
Suicide Attempt
Total FAST Score

Nationality

df

Dependent Variable

Source

.03*

.20
.28

.61
.43
.04*
.11
.04*
.65
.21
.15
.03*
.39
.01**

.07

.03
.02

.00
.01
.13
.09
.07
.00
.09
.10
.14
.05
.10

Partial Eta
Squared

TABLE 6 The Role of Nationality, Diagnosis, Gender, Marital Status on Measure of Suicide Potential (FAST Total Score) and Reported
Suicide Attempts

Suicide Potential

37

FIGURE 4. Suicide attempts reported by Pakistani and American patients by


marital status.

Discussion
The main findings of this study are that the American sample reported
more suicide attempts, a series of multiple suicide precipitants and

38

Y. N. Farooqi

FIGURE 5. Suicidal potential among Pakistani and American patients by marital


status.

higher degree of suicide potential than the Pakistani sample. In addition, those suffering from depression reported more suicide attempts
and suicide potential in both samples. The Pakistani female patients
and the American men reported more suicide attempts. However, the
Pakistani men and the American women showed a higher degree of
suicide potential.

Suicide Potential

39

The high level of self-destructiveness in the American sample may be


attributed to complex psychosocial and economic pressures.There is sufficient research data to suggest that killing oneself is considered more
appropriate in the American society (especially in case of American
men) when faced with a series of multiple crises, such as illness, family
and relationship conflicts, work pressure, financial problems, wish for
death, loneliness, drug withdrawal, and mental disorders. Our findings
confirmed these trends from the past studies. In contrast, the relatively
low rate of suicide attempts in the Pakistani sample may be attributed to
the underreporting of suicide, social taboos, religious sanctions and punitive laws against fatal and non-fatal suicide attempts inthispredominantly
Muslim society.These findings are consistent withthe prior research work
of Alem, Kebede, Jacobson and Kulgren (1999).They foundthat Muslims
reported relatively fewer life-time attempts (2.9%) than Christians
(3.9%), probably to avoid social, religious, and legal repercussions.
Underreporting of suicide by the Pakistani mental health professionals, perhaps to avoid involvement with a complex legal system or as
a result of pressures and/or pleas from the relatives of the suicidal
patients, could be a confounding variable that might have contributed
to the apparently lower rate of suicide attempts and suicide potential in
the Pakistani sample. Another reason may be unavailability of sound
assessment tools and an acute shortage of trained professionals in the
Pakistani mental health system. Consequently, it is very difficult to readily assess, report, treat, and prevent suicide in Pakistan.
Some striking differences between the two samples were noted as a
result of the interaction between gender and diagnosis of the respondents. In the Pakistani sample those suffering from substance-related
disorders (mostly men) reported higher suicide potential but a lower rate
of actual suicide attempts. In contrast, the American males with substance-related disorders reported more suicide attempts and lower
degree of suicide potential. There is sufficient empirical evidence that
suggests that in industrialized countries like the United States, the problem of substance abuse in men often results in financial problems, poor
health, diminished mental status, family conflicts, interpersonal losses,
violence, and problems with law and job. Consequently, such male
patients often end up feeling so hopeless and helpless that they end up
killing themselves in a grip of despair.
Our findings further suggest that those with schizophrenia and
substance-related disorders showed the next highest degree of suicide

40

Y. N. Farooqi

potential in both samples. These results are consistent with the prior
international research data that suggest depression, schizophrenia, and
substance-related diagnostic groups pose a higher risk for suicide in the
Western and Eastern societies.
Contrary totheAmericanpatients suffering fromanxiety, the Pakistani
patients suffering from anxiety (mostly women) reported more suicide
attempts. In the Pakistani mental health system, anxiety, and depression
in women are perceived as relatively mild mental disorders, probably
because most of these women are expected to play limited roles within
the four walls of their houses. Moreover, in the male dominant Pakistani
society these disorders are perceived more feminine. In addition,
women suffering from depression and anxiety are often blamed by the
society, their family, and even professionals for not being strong and
good Muslims. Thus, under-diagnosis and under-treatment of these
disorders may further exacerbate the female patients state of emotional
distress, guilt, self-blame, shame, and self-hate. Consequently, in the
grip of this kind of crisis and lack of timely social7professional support,
the Pakistani women are quickly driven to suicide as a way out.
Depression and substance-related disorders are the most under-diagnosed and under-treated psychiatric disorders in men across the globe
especially in developed countries like the USA. Moreover, there are
other underlying factors associated with these disorders, such as family
discord, interpersonal conflicts, work-related pressures, financial problems, legal or disciplinary crisis (which often exacerbate feelings of
hopelessness), helplessness, and despair in such patients. Thus, it may be
inferred that a suicide attempt may be the patients way of communicating strong feelings of anger (voice attacks) and an overwhelming desire
to escape the psychological pain and unbearable circumstances as
reported by the American patients in this study.
In Pakistan, this situation could be further complicated because the
use of alcohol and other addictive chemical substances is considered a
sin and a crime mainly because of Islamic ideology. As a result, in the
Pakistani mental health system patients with substance-related problems do not receive the same kind of non-judgmental professional
attention as do the other diagnostic groups. Thus, when faced with
choice between two sinssuicide or drugsperhaps these patients
(mostly men) choose substance-abuse as a way of killing themselves to
escape the unbearable psychological pain of shame, guilt and embarrassment, and problems with law associated with actual suicide attempts

Suicide Potential

41

in Pakistani society. Nevertheless, our findings further suggest underlying strong feelings of despair and anger in these male patients, which
were communicated in their highTotal FAST Scores.
In the Pakistani sample, married women reported more suicide
attempts as compared with married men and single and separated
women.This finding is in contrast to the previous findings fromWestern
developed countries that suggest a lower rate of suicide attempts in the
married but higher rate among the singles, the widows, and the
divorced. It may be that in traditional and religious Pakistani society a
suicide attempt is perceived as a feminine behavior. Pakistani married
women in their passive-dependent roles receive relatively more sympathy when they attempt suicide than men despite the punitive laws and
religious sanctions against suicide in general. In contrast, any suicide
attempt by troubled Pakistani men is viewed as a violation of their traditional masculine sex-role message of strength, decisiveness, forbearance,
and inexpressiveness.This might have resulted in a higher rate of suicide
attempts in the Pakistani married women who are often overwhelmed
by feelings of helplessness and hopelessness, probably because of frequent and chronic conflicts with in-laws over dowry as compared with
the Pakistani men.
Furthermore, the patriarchal Pakistani society encourages a traditional complex joint family system, matching or mismatching of spouses
by mostly arranged marriages, an expensive dowry system, lack of equal
rights for divorce, chronic intergenerational family conflicts, passive
and chronic power struggles between spouses, severe economic hardships, unreported domestic violence/abuse, and hostile relationships
with in-laws. Moreover, Pakistani women are often economically and
physically dependent on their male counterparts. Divorce brings shame
and embarrassment and is neither an equal nor an easy choice for married Pakistani women who are rarely economically independent. Consequently, they end up feeling more helpless and hopeless if they fail to
fulfill their traditional roles as a wife and mother.
Problems in marital life multiplied with untreated psychiatric disorders may trigger more intense unresolved anger, feelings of helplessness
and hopelessness resulting in self-attacks/self-destructive behavior in
case of Pakistani married women. Perhaps the high rate of suicide
attempts among married Pakistani psychiatric female patients in this
study suggests their passive way of gaining attention or communicating
anger or love or to escape unbearable circumstances of marital life.

42

Y. N. Farooqi

Another finding of this research is that the most of the Pakistani


women reported illness, family conflicts, and interpersonal losses as suicide precipitants, whereas Pakistani men reported more of financial problems, mental disorders, work stress, and study pressure. In contrast, it
was noted that the American women reported more relationship problems whereas men reported more of the social, economic, illness, and
multiple stressors as suicide precipitants. These findings are consistent
with the prior research data.
Our findings suggest that the FASTcan be used as a valuable and reliable screening test to evaluate the imminence of risk for suicide in culturally diverse psychiatric populations. These findings were consistent
with those of Farooqi and Hussain (2001) that suggest the FASTcould
successfully discriminate between the suicidal and non-suicidal subjects
in a Pakistani Muslim sample. Nevertheless, prospective validity studies
are still needed in which an assessment is made of the relationship
between theTotal FAST Score and future suicide attempts.
These findings suggest that issues of hopelessness, helplessness, and
giving up must be readily addressed in cases of those suffering from
depression, schizophrenia, anxiety, and substance-related disorders to
prevent an outburst of self-destructive behavior and self-limiting cycle
of addiction, the extreme end of which is suicide. R. W. Firestone (1997)
proposes voice therapy as an effective treatment strategy to combat
self-destructive voice attacks and to prevent suicidal behavior in culturally diverse psychiatric patients who pose high risk for suicide but actually do not want to die.
Despite limitations of this comparative study, the implication of our
findings are significant for the cross-cultural understanding of suicide,
identification of patients at risk for suicide, and treatment and prevention programs for suicidal patients.

References
Ahmed, S. (1999, June 10716). Can suicide be prevented? The Review: Dawn, 9.
Alem, A. K., Kebede, D., Jacobson, L., & Kullgren, G. (1999). Suicide attempts
among adults in Butajira, Ethiopia. Acta Psychiatrica Scandinavica, 397, 70776.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed).Washington, DC: Author.
Appleby, L. (1992). Suicide in psychiatric patients: Risk and prevention. BritishJournal
of Psychiatry, 161, 7497758.

Suicide Potential

43

Apter, A., Gothelf, D., Orbach, I.,Weizman, R., Ratzoni, G., Har-even, D., & Tyano,
S. (1995). Correlation of suicide and violent behavior in different diagnostic categories in hospitalized adolescent patients. Journal of the American Academy of Child
and Adolescent Psychiatry, 34, 9127919.
Bakish, D. (1999). The patient with comorbid depression and anxiety: The unmet
need. Journal of Clinical Psychiatry, 60(Suppl. 6), 20724.
Beck, A. T. (1976). Cognitive therapy and emotional disorders. New York: New American
Library.
Beck, A. T. (1991). Beck Suicide Inventory. San Antonio,TX: Psychological Corporation.
Bonger, B. (2002). The suicidal patient: Clinical and legal standards of care (2nd ed).
Washington, DC: American Psychological Association.
Brent, D. A. (1998). Suicide/suicidal behavior. Gale Encyclopedia of Childhood and Adolescence. Retrieved July 20, 2002 from http://findarticles.com/cfo/g/
2602000512/p1/article. Jhtml ? Term suicide
Brent, D. A., Joshua, P. A., Moritz, G., Allman, C., Friend, A., Roth, C., Schweers, J.,
Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A
case-control study. Journal of the American Academy of Child and Adolescent Psychiatry,
32, 5217530.
Brent, D. A., Johnson, B. A., Perper, J., Connolly, J., Bridge, J., Bartle, S., & Rather, C.
(1994). Personality disorder, personality traits, impulsive violence, and completed
suicide in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry,
33, 108071087.
Canetto, S. S. (199271993). She died for love and he for glory: Gender myths of suicidal
people. Omega, 26, 1717.
Canetto, S. S. (1994). Gender issues in the treatment of suicidal individuals. Death
Studies, 18, 5137527.
Canetto, S. S. (1997). Gender and suicide behavior: Theories and evidence. In R. W.
Maris, S. S. Canetto, & M. M. Silverman (Eds.), Review of suicidology (pp.
1387167). NewYork: Guilford.
Canetto, S. S., & Feldman, L. B. (1993). Covert and overt dependence in suicidal
women and their male partners. Omega, 27, 1777194.
Canetto, S. S., & Lester, D. (1995).Women and suicidal behavior: Issues and dilemmas.
In S. S. Canetto & D. Lester (Eds.),Women and suicidal behavior (pp. 378). NewYork:
Springer.
Canetto, S. S., & Lester, D. (1998). Gender, culture and suicidal behavior.Transcultural
Psychiatry, 35, 1637191.
Crosby, A. E., Cheltenham, M. P., & Sacks, J. J. (1999). Incidence of suicidal behavior
in the United States, 1994. Suicide and Life-Threatening Behavior, 29, 1317140.
Dahlen, E. R., & Canetto, S. S. (2002). The role of gender and suicide precipitant in
attitudes toward nonfatal suicide Behavior. Death Studies, 26, 997116.
Ellis, A. (1973). Humanistic psychotherapy:The rationale-emotive approach. NewYork: Julian.
Farooqi, Y. N. (1999). Translation and Adaptation of Firestone Assessment of Self-Destructive
Thoughts FAST. San Antonio,TX: The Psychological Corporation.
Farooqi, Y. N., & Hussain, S. (2001). Suicidal potential among pakistani psychiatric
patients and non-clinical adults. Proceedings of International Symposium on Psychiatry
(pp. 31732). Lahore, Pakistan:Caxton.

44

Y. N. Farooqi

Firestone, R.W. (1987). The voice: the dual nature of guilt reactions. AmericanJournal
of Psychoanalysis, 47, 2107229.
Firestone, R.W. (1988).Voice therapy: A psychotherapeutic approach to self-destructive behavior.
NewYork: Human Sciences Press.
Firestone, R. W. (1994). Psychological defenses against death anxiety. In R. A.
Neimeyer (Ed.), Death anxiety handbook: Research, instrumentation, and application
(pp. 2177241).Washington, DC: Taylor & Francis.
Firestone, R. W. (1997a). Combating destructive thought processes:Voice therapy and separation
theory. London: Sage.
Firestone, R.W. (1997b). Suicide and the inner voice: Risk assessment, treatment, and case management. London: Sage.
Firestone, R. W., & Firestone, L. A. (1996). Firestone Assessment of Self-Destructive
Thoughts. San Antonio,TX: The Psychological Corporation.
Firestone, R. W., & Firestone, L. (1998). Voices in suicide: The relationship between
self-destructive thought processes, maladaptive behavior, and self-destructive
manifestation. Death Studies, 22, 4117443.
Firestone, R. W., & Firestone, L. (in press). Suicide reduction and prevention. In C.
Felthan (Ed.), Benefits of counseling and psychotherapy. (pp. 48780). London: Sage.
Goldenberg, D. (1995). Self-destructive cognition in severely anxious and depressed patients.
Unpublished doctoral dissertation, California Graduate Institute, Los Angeles.
Goldring, N., & Fieve, R. R. (1984). Attempted suicide in manic-depressive disorders.
AmericanJournal of Psychotherapy, 38, 3737383.
Halton, C. L.,Valente, S. M., & Rink, A. (1997). Suicide: Assessment and intervention. New
York: Appleton-Century-Crofts.
Harkavy-Friedman, J. M., Restifo, K., Malaspina, D., Kaufman, C. A., Amador, X.
F., & Yale, S. A. (1999). Suicide behavior in schizophrenia: Characteristics of individuals who had and had not attempted suicide. American Journal of Psychiatry,
156(8), 127671278.
Hirschberger, G., Florian,V., & Mikulincer, M. (2002). Gender differences in the willingness to engage in risky behavior. Death Studies, 26, 1177141.
Isometsa, E.T., Henriksson, M. M., Heikkinen, M. E., Aro, H. M., Marttunen, M. J.,
Kuoppasalmi, K. I., & Lonnqvist, K.(1996). Suicide among subjects with personality disorders. AmericanJournal of Psychiatry, 153, 6677673.
Kaufman, G., & Raphael, L. (1984). Relating to self: Changing inner dialogue. Psychological Reports, 54, 2397250.
Khan, M. M. (1998). Suicide and attempted suicide in Pakistan. Crisis, 19, 1727176.
Khan, M. M., Islam, S., & Kundi, A. K. (1996). Parasuicide in Pakistan: Experience
at the University Hospital. Acta Psychiatrica Scandinavica, 93(4), 2647267.
Khan, M., & Reza, H. (1998a). Benzodiazepine self-poisoning in Pakistan: Implications for prevention and harm reduction. Journal of Pakistan Medical Association, 48,
2937295.
Khan, M. M., & Reza, H. (1998b). Gender differences in suicide-related behavior in
Pakistan: Significance of socio-cultural factors. Suicide and Life-Threatening Behavior,
28, 62768.
Langhinrichsen-Rohling, J., Lewinsohn, P., Rohde, P., Seeley, J., Monson,
C. M., Meyer, K. A., & Langford, R. (1998). Gender differences in the

Suicide Potential

45

suicide-related behaviors of adolescents and young adults. Sex Roles: A Journal of


Research, 39, 11712.
Leonard, C. V. (1967). Understanding and preventing suicide. Springfield, IL: Charles C.
Thomas.
Lindeman, S., Henriksson, M., Isometsa, E., & Lonnqvist, J. (1999). Treatment of
menta disorders in seven physicians commiting suicide. Crisis, 20(2), 86789.
Maier,W., & Falkai, P. (1999). The epidemiology of comorbidity between depression,
anxiety disorders and somatic diseases. International Clinical Psychopharmacology,
14(Suppl. 2), S176.
Marks, A. (198871989). Structural parameters of sex, race, age, and education and
their influence on attitudes towards suicide. Omega, 19, 3277336.
McIntosh, J. L. (1999). 1996 official final statistics USA: Suicide. [on-line] Available:
www.iusb.edu/  jmcintos/SuicideStats.html.
McIntosh, J. L. (2000). International Comparisons. In American Association of Suicidology
1998 Official US Statistics Overhead Set. South Bend, IN: American Association of
Suicidology. P. 45.
Mumford, D. B., Saeed, K., Ahmad, I., Latif, S., & Mubashar, M. H. (1997). Stress
and psychiatric disorders in rural Punjab. A community survey. British Journal of
Psychiatry, 170, 4737478.
Neimeyer, R. A., & Pfeiffer, A. M. (1994).The ten most common errors of suicide interventions. In A. A. Leenaars, J. T. Maltsberger, & R. A. Neimeyer (Eds.),Treatment
of suicidal people (pp. 2077224).Washington, DC: Taylor & Francis.
Nekanda-Trepka, C. J. S., Bishop, S., & Blackburn, I. M. (1983). Helplessness and
depression. BritishJournal of Clinical Psychology, 22, 49760.
Rosenbaum, M., & Richman, J. (1970). Suicide: The role of hostility and death
wishes from the family and significant others. American Journal of Psychiatry, 126,
165271655.
Rossow, I., & Lauritzen, G. (1999). Balancing on the edge of death: Suicide attempts
and life-threatening overdoses among drug addicts. Addiction, 2, 2097219.
Shah, A., & Ganesvaran,T. (1999). Suicide among psychiatric in-patients with schizophrenia in an Australian mental hospital. Medicine Science Law, 39(3), 2517259.
Shneidman, E. S. (2001). Comprehending suicide: Landmarks in 20th century suicidology.
Washington, DC: American Psychological association.
Singh, S. B., Nigman, A., Gahlaut, D. S., & Sinha, G. C. (1987). Attempted suicide: A
personality study. Journal of Personality and Clinical Studies, 3(2), 1177121.
Stillion, J. M., & Stillion, B. D. (199871999). Attitudes toward suicide: Past, present
and future. Omega, 38, 77797.
Stillion, J. M., McDowell, E. E., Smith, R. T., & McCoy, P. A. (1986). Relationships
between suicide attitudes and indicators of mental health among adolescents. Death
Studies, 10, 2897296.
Stillion, J. M., & White, H., Edwards, P. J., McDowell, E. E. (1989). Ageism and sexism in suicide attitudes. Death Studies, 13, 2477261.
Strakowski, S. M., McElroy, S. L., Keck, P. E. & Jr, West, S. A. (1996). Suicidality
among patients with mixed and manic bipolar disorder. AmericanJournal of Psychiatry, 153, 6747676.

46

Y. N. Farooqi

Tsai, S.Y., Lee, J. C., & Chen, C. C. (1999). Characteristics and psychosocial problems
of patients with bipolar disorder at high risk for suicide attempt. Journal of Affective
Disorders, 52, 1457152.
Wellman, M. M., & Wellman, R. J. (1986). Sex differences in peer responsiveness to
suicide ideation. Suicide and Life-Threatening Behavior, 16, 3607378.
Weissman, M. M., Klerman, G. L., Markowitz, J. S., & Ouellette, R. (1989). Suicidal
ideation and suicide attempts in panic disorder and attacks. New England Journal of
Medicine, 321, 120971214.