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J. Indian Assoc. Child Adolesc. Ment. Health 2014; 10(1)47-68
Review Article
Determinants of psychological stress and suicidal behavior in Indian adolescents:
a literature review
Dr. Varun Kumar, Dr. Richa Talwar
Address for Correspondence: Varun Kumar, Post Graduate student, Department of
Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital,
New Delhi, India. Email: [email protected]
Abstract
Adolescence can be a stressful time for children, parents and also all others who work
with them. School students in India have a high stress level and higher rate of deliberate
self-harm. Many recent studies have found relation between stress and suicidal ideas in
school children. Stress also results in increased likelihood of substance abuse among
adolescents. A social and public health response in addition to mental health response is
crucial to prevent suicidal behavior and creating awareness about substance abuse among
adolescents. Stress also positively correlates with maladaptive strategies adopted towards
schools, teachers, and parents, peers, opposite sex and also at a broader societal level.
Policy planning and implementation of preventive measures for adolescent suicide is
therefore, need of the hour. This review article focuses on determinants of psychological
stress and suicidal behavior in Indian adolescents and various psychosocial adjustments
adopted by them.
Key words: Indian adolescents, stress, suicidal behavior, psychosocial adjustments
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Introduction
The world is home to 1.2 billion individuals aged 10–19 years. Adolescents aged between
10 to 19 years account for more than one-fifth of the world’s population [1]. India has the
largest national population of adolescents (243 million), followed by China (207 million),
United States (44 million), Indonesia and Pakistan (both 41 million) [2]. In India, this age
group forms 21.4% of the total population. Adolescents are also entitled to enjoy basic
human rights- economic, political, social and cultural- but their inability to exercise these
rights places the onus on the policy makers and adults to implement separate measures to
ensure their rights. Moreover it is necessary to invest in adolescents as the future leaders
and guardians of nation’s development [3].
Adolescents face health challenges that pediatric and adult physicians alike are often ill-
equipped to handle. Rapid physical and emotional growth, as well as the frequently
conflicting and influential cultural messages they receive from the outside world, account
for the unique nature of their health concerns. Without proper education and support,
adolescents lack the knowledge and confidence to make decisions [4].
Adolescents are generally perceived as a healthy age group, and yet 20% of them, in any
given period, experience a mental health problem, most commonly depression or anxiety.
In many settings, suicide is among the leading cause of death in young people [5]. Mental
well-being is fundamental to good quality of life. Happy and confident adolescents are
most likely to grow into happy and confident adults, who in turn contribute to the health
and well-being of nations [3]. Mental health problems among
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adolescents carry high social and economic costs, as they often develop into more
disabling conditions later in life.
In this context, in India particularly, adolescents are put under pressure to perform well in
school examinations. For some students, the experience of academic stress leads to a
sense of distress, which is generally manifested in a variety of psychological and
behavioral problems. The experience of academic stress and adolescent distress has been
identified and explored by researchers in Korea and Japan [6]. It is relevant to mention
here that in India, in the year 2011 alone, 2381 children, or more than six children per
day, committed suicide because of failure in examinations [7].
Youth suicide, however, is only the tip of iceberg, which masks the generalized anxiety
and depression experienced by many students. If denied their rights to quality education,
health care, protection and participation, adolescents are very likely to remain or become
impoverished, excluded and disempowered – increasing, in turn, the risk that their
children will also be denied their rights. For these reasons, UNICEF (United Nations
International Children's Emergency Fund) has dedicated the 2011 edition of its flagship
report The State of the World’s Children to adolescents and adolescence [8].
At the international level, a number of instruments and agreements are in place to
promote the health and development of adolescents, most notably the Convention on the
Rights of the Child and the Convention on the Rights of Persons with Disabilities. The
integration of mental health into primary health-care systems is a major endeavor to
reduce the treatment gap for mental health problems. To that end, the WHO (World
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Health Organization) and its partners have developed the 4S Framework, which provides
a structure for national initiatives to gather and use strategic information; develop
supportive, evidence-informed policies; scale up the provision and utilization of health
services and commodities; and strengthen links with other government sectors. Such
integration will increase the accessibility of services and reduce the stigma attached to
mental disorders [9]. However in India, there are no such dedicated policies or programs
catering to this specific need of adolescents.
Magnitude of Problem
Today stress is a commonly used term. Stress is understood in relation to the stressors or
with the feelings associated with it. Stress is both a physical as well as a mental condition
that pushes a person to change, grow, fight or adapt. Palsane et al. (1986) also notes that
in contrast to the western psychology where stress is believed to be produced by
environmental events, in Indian psychology goals and expectations of the individuals
bring to the potentially stressful situation. Where stress enhances function (physical or
mental, such as through strength training or challenging work), it is considered as
eustress. Persistent stress that is not resolved through coping or adaptation leading to
anxiety, withdrawal behavior and depression is considered as distress [10].
The prevalence of stress among Indian adolescents varies from 13% to 45% among
different studies done after the year 2000 [11 – 17]. Despite little research,
epidemiological studies of the prevalence of adolescent stress show that such problems
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are not uncommon. The studies reporting prevalence of stress among adolescents are
given in table 1. The results are similar to studies conducted in Saudi Arabia [18], Iran
[19], and Malaysia [20].
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Types of Stressors
Gender: Many studies [18, 19] done outside India highlighted the fact that girls are
under more stress than boys. But an Indian study by Dhuria M et al. [13] among students
in classes XI and XII in Delhi during 2009, found that psychological problems were
present more among boys than girls. Another study conducted by Sibnath Deb et al. [21]
also found boys to be more anxious than girls.
Age: Chabbra GS and Sodhi MK [16] in their study among 500 male adolescents aged 12
to 18 years in Amritsar during 2011 found that psychological problems were significantly
higher in middle adolescence (14-16 years). These adolescents with psychological
problems were having significantly more academic problems, family disputes, domestic
violence and lesser number of close friends.
Socio-economic status: A cross sectional study conducted by Sibnath Deb et al. [21] on
anxiety among high school students in Kolkata during 2010 found that adolescents
belonging to the middle socio-economic group were more anxious than those from both
high and low socio-economic groups and also adolescents with working mothers were
found to be more anxious.
Family structure: Singh H et al. [22] found that stress was more among adolescents
belonging to nuclear families. Chabbra GS and Sodhi MK [16] in their study reported
stress was more in large extended families (> 8 members). Krishnakumar P et al. [23]
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found sources of stress in the family can be death of a parent, conflicts with parents or
siblings, mental illness in the family, parental alcoholism and parental disharmony.
Academic achievement: In a study by Bhasin SK et al. [24] done in students belonging
to classes from ninth to twelfth in Delhi during 2010 it was found that stress levels were
significantly higher among the 'board classes' i.e., 10th and 12th as compared to the
classes 9th and 11th. Rajni Kumari et al. [25] found a positive correlation between stress
and academic achievement. Students with high and moderate stress performed better than
the students having less stress. Latha KS et al. [26] in their study have found that the
main sources of academic stress were getting up early in the morning, pressure to study,
having to concentrate for too long and long working hours. Verma S et al. [27] in their
study found that those who spent more time doing homework experienced lower average
emotional states and more internalizing problems, while those who spent more time in
leisure experienced more favorable states but also reported higher academic anxiety and
lower scholastic achievement.
Psychosocial stressors: A cross sectional study by Arun P and Chavan BS [13] in
Chandigarh during 2009 found a significant correlation between student’s perception of
life as a burden and the class they were studying and problems students experienced in
relation to study, their peers, future planning and with parents. Munni and Malhi [28]
reported that the adolescents exposed to violence had poorer school performance and
adjustment scores.
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Apart from the above mentioned risk factors identified as stressors, few other variables
like religion, ethnicity and number of siblings in the family are also mentioned in some
international studies. [29]
Factors Associated with Stress
Substance Use:
In DSM-IV (Diagnostic and Statistical manual of Mental disorders-IV), psychoactive
substance abuse is defined as a “maladaptive pattern of use indicated by continued use
despite knowledge of having a persistent or recurrent social, occupational, psychological
or physical problem that is caused or exacerbated by the use (or by) recurrent use in
situations in which it is physically hazardous”. [30] Suchday S et al. [31] in their study
found that stress had an association with chewing tobacco and alcohol use, and
psychosocial characteristics, such as hostility. Chabbra GS and Sodhi MK [16] also
reported a positive correlation between psychological problems and greater substance
abuse among 500 male adolescents aged between 12 to 18 years. Kaur S and Verma S
[32] in their study have found a high degree of negative correlation between abuse and
academic achievement of adolescents. Sharma A and Sharma J [33] came up with a
finding that adolescent smokers irrespective of gender and type of school were
significantly higher on anxiety, stress and family conflict. Mohan et al. [34] found that
low educational performance predict tobacco use among adolescent boys. A study
conducted in Australia also came up with similar findings [35].
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Suicidal behavior:
The average global suicide rate is 14.5 deaths per 100,000 people. But the suicide rate in
the 15-19 group adolescents reported in South India was 148 per 100,000 for girls and 58
per 100,000 for boys. [36]
In a study on the psychosocial and clinical factors associated with adolescent suicidal
attempts Kumar et al. [37] compared potential risk factors between adolescent and adult
suicide attempters and found that the adolescents had significantly higher levels of
depression, hopelessness, lethality of event, and stressful life events. Sharma et al. [38] in
their study on adolescent students found the prevalence of suicide risk behavior quite
high with almost 16% having suicide ideation and 5% having attempted suicide. Females
were seen as being more vulnerable.
Arun P and Chavan BS [13] in their school based study found that 6% of students had
suicidal ideas and 0.39% of students reported suicidal attempt. Daniel et al. [39] found
that suicidal tendency and school dropouts were strongly associated with each other.
Jena and Siddharta [40] reviewed articles on non fatal suicidal attempts of adolescents in
both Indian and international literature. They stated that non fatal suicidal behavior
among adolescents needs to be evaluated and managed effectively in order to reduce the
rates. They concluded that Indian studies in this area are very few and there is a great
need to conduct research in this area. The article also stresses upon the importance for
professionals like general practitioners, teachers, pediatricians and school counselors to
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be trained to identify non fatal suicide behaviors in adolescents so as to facilitate referral
and effective management.
In a study conducted by Wilburn VR and Smith DE [41] in United States, results indicate
that both stressful life events and low self-esteem were significantly related to suicidal
ideation in adolescents and they insisted that social and public health response in addition
to mental health response is crucial to prevent suicidal behavior among adolescents.
Psychosocial adjustments:
The term, ‘psychosocial’ refers to the interconnection between psychological and social
processes and the fact that each continually interacts with and influences each other.
‘Psychological adjustment’ refers to the adaptive psychosocial response of an individual
to a significant life change. [42]
Takahiro Hasumi et al. [43] examined the association between parental involvement and
mental well-being among the 6721 school-going adolescents aged 13 to 15 years who
participated in India’s nationally-representative Global School-based Student Health
Survey (GSHS) in 2007. Parental involvement (homework checking, parental
understanding of their children’s problems, and parental knowledge of their children’s
free-time activities) was reported by students to decrease with age, while poor mental
health (loneliness, insomnia due to anxiety, and sadness and hopelessness) increased with
age. This study shows that mental health concerns, especially symptoms of
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depression, are common among Indian adolescents and increase with age. The study also
adds that adolescents who report high levels of parental involvement in their lives tend to
report lower levels of depression, loneliness, and anxiety.
Akbar Hussain et al. [44] found that the magnitude of academic stress was significantly
higher among the public schools students where as Government School students were
significantly better in terms of their levels of adjustment. A study done by Firdous D Var
et al. [45] indicates a negative correlation between self esteem and problem areas.
Warbha L et al. [46] in their study among 145 nursing students found that psychological
distress was significantly associated with psychosocial adjustment difficulties.
A study conducted by Adhikari SR et al. [47] in Nepal revealed that adolescents undergo
various stresses and adjustment and it depends upon their ability to cope with stress in
various places like home, school, peers and teachers. In another study by Flannery DJ et
al. [48] it was found that violent adolescents as compared to their less violent and non
violent peers employed more maladaptive coping strategies.
Social support:
Social support is considered as one of the most important way of coping with academic
stress. Social support may play an important role at two different points in the causal
chain linking stress to illness [49]. First of all support may intervene between the stressful
event (and expectation of that event) and stress reaction by attenuating or preventing a
stress appraisal response. Second, adequate support may intervene between the
experience of stress and the onset of the pathological outcome by reducing or
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eliminating the stress reaction or by directly influencing physiological processes. There is
some evidence, however, that explained the main effect of support on major health
outcomes for the contrast between persons who are essentially social isolates (those with
very few or no social contacts) and persons with moderate or high level of support. [50]
The results of the study by Shadiya Baqutayan [51] indicate that there are significant
differences between the experimental group (provided classes on social support) and the
control group in relation to stress and social support. Eventually, the experimental group
proved to cope with academic stress better than the control group, and they were satisfied
with their academic performance during the experimentation.
Conclusion
After careful review of literature, it is observed that the risk factors for mental disorders
in adolescents include, but not limited to poverty, social exclusion, violence, peer
rejection, isolation and lack of family support. Protective factors for mental well-being
are linked to cohesion at the community level, family well-being, individual behavior and
skills, adolescent friendly social services including health services. Accumulated
evidences show that strengthening the protective factors in schools, homes and local
communities as well as improving quality of mental health care for adolescents, can make
important contributions to improving developmental outcomes of vulnerable young
people [52].
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Taking this into consideration Delhi government has launched a toll free YUVA help
line, 1800-11-6888 with the objective of providing support to adolescents, teachers
and parents. The YUVA Help line runs from 7.30 am to 7.00 pm on all working days
[53]. Besides these a Delhi based NGO called Viswa Yuvak Kendra provides vocational
and life skills training to orient youth towards the developmental process [54]. CBSE
(Central Board for Secondary Education) has also started a helpline number, 1800-11-
8004 for stress management and relieving tension among school students. While the
general queries are answered by the operators, students are connected to the principals or
counselors in case of exam related anxiety or stress. [55] ARSH (Adolescent
Reproductive and Sexual Health) program was implemented by the Government of India
under NRHM/RCH-II program which focuses on reorganizing the existing public health
system in order to meet the service demands of adolescents [56]. Apart from these, NASP
(National Association of School Psychologists) has a number of resources available to
assist families and educators in preventing youth suicide [57].
But the findings from the Atlas of Child and Adolescent Mental Health Resources [58]
suggest that governmental child and adolescent mental health policies are scarce
worldwide. Developing countries like India lack the policies to guide system
implementation, thus hampering service development, and undermining efforts to ensure
accountability for the manner in which resources for program development are allocated.
The UN (United Nations) resolution [59] on a World Fit for Children endorses
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the commitment that “every child has the right to develop his or her potential to the
maximum extent possible to become physically healthy, mentally alert, socially
competent, emotionally sound and ready to learn. However, evidences suggest that
endorsement of the Convention is not correlated with the development of specific policies
or programs to support child and adolescent mental health services.
Recommendations
The promotion of child and adolescent mental health is a worldwide challenge, but a
potentially rewarding one [60]. It is important that Adolescent Friendly Health Services
be made an integral part of the health system. A comparative study on utilization of
adolescent health services found that school based services were better utilized than
health facility based services [61] and parental involvement contributed to help seeking
behavior [62]. A holistic approach should be adopted which should focus on a broader
range of health issues and not just sexual and reproductive health. This would entail
convergence of all the appropriate medical specialties. Utilization of such services could
be improved by intensive information, education and communication (IEC) and involving
the parents or guardians.
Early interventions can provide long-term health and socioeconomic benefits by
prevention of the onset of mental health problems and their development into chronic
disorders. These issues are even more relevant in India, where the proportion of children
and adolescents in the population is high and the resources are scarce. India is currently
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going through a demographic transition, and intervention today is likely to result in a
decreased burden in future.
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