Evaluation of suicide rates in rural India using verbal autopsies, 1994-9

Suicide in young men

Suicide is second to only accidental death as the leading cause of mortality in young men across the world. Although suicide rates for young men have fallen in some high-income and middle-income countries since the 1990s, wider mortality measures indicate that rates remain high in specific regions, ethnic groups, and socioeconomic groups within those nations where rates have fallen, and that young men account for a substantial proportion of the economic cost of suicide. High-lethality methods of suicide are preferred by young men: hanging and firearms in high-income countries, pesticide poisoning in the Indian subcontinent, and charcoal-burning in east Asia. Risk factors for young men include psychiatric illness, substance misuse, lower socioeconomic status, rural residence, and single marital status. Population-level factors include unemployment, social deprivation, and media reporting of suicide. Few interventions to reduce suicides in young men have been assessed. Efforts to change help-seeking behaviour and to restrict access to frequently used methods hold the most promise.

Suicide mortality in India: a nationally representative survey

BACKGROUND

WHO estimates that about 170,000 deaths by suicide occur in India every year, but few epidemiological studies of suicide have been done in the country. We aimed to quantify suicide mortality in India in 2010.

METHODS

The Registrar General of India implemented a nationally representative mortality survey to determine the cause of deaths occurring between 2001 and 2003 in 1·1 million homes in 6671 small areas chosen randomly from all parts of India. As part of this survey, fieldworkers obtained information about cause of death and risk factors for suicide from close associates or relatives of the deceased individual. Two of 140 trained physicians were randomly allocated (stratified only by their ability to read the local language in which each survey was done) to independently and anonymously assign a cause to each death on the basis of electronic field reports. We then applied the age-specific and sex-specific proportion of suicide deaths in this survey to the 2010 UN estimates of absolute numbers of deaths in India to estimate the number of suicide deaths in India in 2010.

FINDINGS

About 3% of the surveyed deaths (2684 of 95,335) in individuals aged 15 years or older were due to suicide, corresponding to about 187,000 suicide deaths in India in 2010 at these ages (115,000 men and 72,000 women; age-standardised rates per 100,000 people aged 15 years or older of 26·3 for men and 17·5 for women). For suicide deaths at ages 15 years or older, 40% of suicide deaths in men (45,100 of 114,800) and 56% of suicide deaths in women (40,500 of 72,100) occurred at ages 15-29 years. A 15-year-old individual in India had a cumulative risk of about 1·3% of dying before the age of 80 years by suicide; men had a higher risk (1·7%) than did women (1·0%), with especially high risks in south India (3·5% in men and 1·8% in women). About half of suicide deaths were due to poisoning (mainly ingestions of pesticides).

INTERPRETATION

Suicide death rates in India are among the highest in the world. A large proportion of adult suicide deaths occur between the ages of 15 years and 29 years, especially in women. Public health interventions such as restrictions in access to pesticides might prevent many suicide deaths in India.

FUNDING

US National Institutes of Health.

Suicide methods in Asia: implications in suicide prevention

As the largest continent in the World, Asia accounts for about 60% of World suicides. Preventing suicide by restricting access to suicide methods is one of the few evidence-based suicide prevention strategies. However, there has been a lack of systematic exploration of suicide methods in Asian countries. To amend this shortage, the current review examines the leading suicide methods in different Asian countries, their trend, their age- and sex- specific characteristics, and their implications for suicide prevention. In total, 42 articles with leading suicide methods data in 17 Asian countries/regions were retrieved. The epidemiologic characteristics and recent trends of common suicide methods reflect specific socio-cultural, economic, and religious situations in the region. Common suicide methods shift with the introduction of technologies and constructions, and have specific age- or sex-characteristics that may render the restriction of suicide methods not equally effective for all sex and age sub-groups. Charcoal burning, pesticide poisoning, native plant poisoning, self-immolation, and jumping are all prominent examples. In the information society, suicide prevention that focuses on suicide methods must monitor and control the innovation and spread of knowledge and practices of suicide "technologies". It may be more cost-effective to design safety into technologies as a way of suicide prevention while there is no rash of suicides yet by the new technologies. Further research on suicide methods is important for public health approaches to suicide prevention with sensitivity to socio-cultural, economic, and religious factors in different countries.

Suicide prevention is possible: A perception after suicide attempt

BACKGROUND

Suicide is a preventable cause of death, inspite of which its incidence is increasing worldwide. Very few studies are done to know the perception of suicide attempters regarding prevention of their suicide attempt. Such information may be helpful in implementing preventive strategies. This study was done to find out whether those who attempted suicide and recovered perceived that their suicide attempt could have been prevented or not.

MATERIALS AND METHODS

Fifty consecutive subjects were recruited by purposive sampling method. These subjects were admitted for suicide attempt and were stable after medical management. Subjects were assessed using socio-demographic and clinical proforma, Pierce suicide intent scale and structured questionnaire to assess their perception regarding suicide. Group differences for categorical variables were examined with the chi-square test, whereas an independent 't' test was used for continuous variables.

RESULTS

Analysis revealed that 80% of suicide attempters felt that their suicide attempt could have been prevented. 64% of the study subjects perceived that family members and near and dear ones could have helped in preventing their attempt while 16% of the study subjects perceived that society could have helped.

CONCLUSIONS

Majority of subjects on recovery from the suicide attempt perceived that their suicide attempt could have been prevented by family members, near and dear ones and society.

The reliability of suicide statistics: a systematic review

BACKGROUND

Reliable suicide statistics are a prerequisite for suicide monitoring and prevention. The aim of this study was to assess the reliability of suicide statistics through a systematic review of the international literature.

METHODS

We searched for relevant publications in EMBASE, Ovid Medline, PubMed, PsycINFO and the Cochrane Library up to October 2010. In addition, we screened related studies and reference lists of identified studies. We included studies published in English, German, French, Spanish, Norwegian, Swedish and Danish that assessed the reliability of suicide statistics. We excluded case reports, editorials, letters, comments, abstracts and statistical analyses. All three authors independently screened the abstracts, and then the relevant full-text articles. Disagreements were resolved through consensus.

RESULTS

The primary search yielded 127 potential studies, of which 31 studies met the inclusion criteria and were included in the final review. The included studies were published between 1963 and 2009. Twenty were from Europe, seven from North America, two from Asia and two from Oceania. The manner of death had been re-evaluated in 23 studies (40-3,993 cases), and there were six registry studies (195-17,412 cases) and two combined registry and re-evaluation studies. The study conclusions varied, from findings of fairly reliable to poor suicide statistics. Thirteen studies reported fairly reliable suicide statistics or under-reporting of 0-10%. Of the 31 studies during the 46-year period, 52% found more than 10% under-reporting, and 39% found more than 30% under-reporting or poor suicide statistics. Eleven studies reassessed a nationwide representative sample, although these samples were limited to suicide within subgroups. Only two studies compared data from two countries.

CONCLUSIONS

The main finding was that there is a lack of systematic assessment of the reliability of suicide statistics. Few studies have been done, and few countries have been covered. The findings support the general under-reporting of suicide. In particular, nationwide studies and comparisons between countries are lacking.

Worldwide impact of economic cycles on suicide trends over 3 decades: differences according to level of development. A mixed effect model study

OBJECTIVES

To investigate the trends and correlations of gross domestic product (GDP) adjusted for purchasing power parity (PPP) per capita on suicide rates in 10 WHO regions during the past 30 years.

DESIGN

Analyses of databases of PPP-adjusted GDP per capita and suicide rates. Countries were grouped according to the Global Burden of Disease regional classification system.

DATA SOURCES

World Bank's official website and WHO's mortality database.

STATISTICAL ANALYSES

After graphically displaying PPP-adjusted GDP per capita and suicide rates, mixed effect models were used for representing and analysing clustered data.

RESULTS

Three different groups of countries, based on the correlation between the PPP-adjusted GDP per capita and suicide rates, are reported: (1) positive correlation: developing (lower middle and upper middle income) Latin-American and Caribbean countries, developing countries in the South East Asian Region including India, some countries in the Western Pacific Region (such as China and South Korea) and high-income Asian countries, including Japan; (2) negative correlation: high-income and developing European countries, Canada, Australia and New Zealand and (3) no correlation was found in an African country.

CONCLUSIONS

PPP-adjusted GDP per capita may offer a simple measure for designing the type of preventive interventions aimed at lowering suicide rates that can be used across countries. Public health interventions might be more suitable for developing countries. In high-income countries, however, preventive measures based on the medical model might prove more useful.

A state of reversed hypoxic encephalopathy following attempted suicidal hanging: a boon

Normal functional condition of the brain is achieved by maintaining the normal structure and normal function of brain parenchyma. Reduced blood supply and deficiency of available oxygen alter brain perfusion which causes hypoxia or anoxia, and, depending on the severity, alters brain functions temporarily or permanently. This can occur in cases of hanging. Some degree of permanent cerebral damage is inevitable if hypoxic-ischaemia lasts beyond 3-5 minutes. Here we present a case report in which even though the patient was hanged for more than five minutes until the formation of a ligature mark and exhibited cyanosis, unconsciousness and seizures, the outcome was favourable with prompt and early intervention. Recovery was complete such that there were no residual signs and symptoms of reduced brain perfusion.

Overcoming cultural barriers to deliver comprehensive rural community mental health care in Southern India

AIM

To describe obstacles overcome in establishing and implementing a comprehensive community psychiatry program in rural India.

BACKGROUND

Studies in low income countries point to a significant association of common mental disorders with female gender, low education, poverty, lack of access to running water in the home, and experiencing hunger. Gynecological complaints are associated with an increased risk of mental disorders. Suicide is a major public health problem with women outnumbering men in completed suicides in India. Among barriers to care are low value given to mental health by individuals in society, high prevalence of mental and neurological problems, apathy toward psychosocial aspects of health and development, and chronic lack of resources.

DESIGN/METHODS

We developed and implemented a program of care delivery thus (a) targeting the indigent women in the region; (b) integrating mental health care with primary care; (c) making care affordable and accessible; and (d) sustaining the program long term. I also review pertinent articles to demonstrate our success.

RESULTS

We provided mental healthcare for the indigent using a successful and vibrant model that overcame hurdles to treat patients from 187 villages in Southern India. Of note are low resource use, and the lack of accessibility, comprehensive care, the use of indigenous case workers and primary care professionals.

CONCLUSIONS

Rural mental health care must be culturally congruent, integrate primary care and local community workers for success.

Women who jump into wells: reflections on suicidality in women from conflict regions of the Indian subcontinent

This paper examines narratives of women from the Indian subcontinent, including Canadian refugee claimants, emerging from the conflict regions of Pakistan, Punjab, Bangladesh, and Sri Lanka, who have presented suicidal ideation or attempts or died by suicide. The focus is on the relationship of suicide and suicide behavior to particular systemic stressors related to familial, social, and group agendas. The vulnerability of individual women is presented in the context of gender issues, deeply embedded group trauma, historical legacies, and intragenerational dynamics, as well as acute stressors that contribute to the underlying distress of these women.

Behavioral emergencies in India: would psychiatric emergency services help?

INTRODUCTION

Behavioral emergencies constitute an important component of emergencies worldwide. Yet, research on behavioral emergencies in India has been scarce. This article discusses the burden, types, and epidemiology of behavioral emergencies in India.

METHODS

A computerized search of Medline, Psychinfo, and Cochrane from 1975 to 2009 was performed, and all articles were evaluated and collated. The results were summarized.

RESULTS AND CONCLUSIONS

There is an acute need for psychiatric emergency services in India. Suicides, acute psychoses, and substance-related problems form the major portion of behavioral emergencies, while current trends show a rise in disaster- and terrorism-related emergencies.

Intervention for suicide attempters: A randomized controlled study

AIM

To determine whether brief intervention and contact (BIC) is effective in reducing subsequent suicidal behavior among suicide attempters.

MATERIALS AND METHODS

Suicide attempters (n=680) admitted in a general hospital in Chennai were randomly allocated to treatment as usual and BIC whose components include brief intervention at the time of discharge and contact for 18 months.

RESULTS

Completed suicide was significantly lower in the BIC group, OR 35.4 (CI 18.4 - 78.2) as also attempted suicide, OR 17.3 (CI 10.8 - 29.7).

CONCLUSIONS

This low-cost intervention which can be readily implemented may be an important suicide prevention strategy in healthcare settings in India.

Farmers' suicide in India: implications for public mental health

Farmers' suicide in India is a cause of concern and government figures, though conservative, predict an impending epidemic. Various measures to curb this calamity are being made in a piecemeal manner. Considering it as an issue of social and mental health concern, this article attempts to evaluate the situation based on the tenet that health and illness are the result of a complex interplay between biological, psychological, social, environmental, economic and political factors. Thus in India the agrarian crisis, among other causes, has been largely debated as the major reason for the current state of farmers. It is important that (psychiatric) epidemiology and public mental health try to evolve mechanisms to understand and implement measures, and take this into consideration when attempting health promotion and prevention.

Sociodemographic profile, clinical factors, and mode of attempt in suicide attempters in consultation liaison psychiatry in a tertiary care center

BACKGROUND

The objective was to study the sociodemographic data, psychiatric disorder, precipitating events, and mode of attempt in suicide attempted patients referred to consultation liaison psychiatric services.

SETTINGS AND DESIGN

A prospective study of 6-month duration was done in a tertiary care center in India.

MATERIALS AND METHODS

During the 6-month period all referrals were screened for the presence of suicide attempters in consultation liaison services. Those who fulfilled the criteria for suicide attempters were evaluated by using semistructured pro forma containing sociodemographic data, precipitating events, mode of attempt, and psychiatric diagnosis by using ICD-10.

RESULTS

The male-to-female ratio was similar. Adult age, urban background, employed, matriculation educated were more represented in this study. More than 80% of all attempters had psychiatric disorder. Majority had a precipitating event prior to suicide attempt. The most common method of attempt was by use of corrosive.

CONCLUSIONS

Majority of suicide attempter patients had mental illness. Early identification and treatment of these disorders would have prevented morbidity and mortality associated with this. There is a need of proper education of relatives about keeping corrosive and other poisonous material away from patients as it was being commonest mode of attempt.

Epidemiology of Cleistanthus collinus (oduvan) poisoning: clinical features and risk factors for mortality

Cleistanthus collinus (local name: oduvan) poisoning is a common suicidal poisoning method used in rural southern India. There are few studies on this issue and they have small sample sizes. This study examines the epidemiology of oduvan poisoning in a large sample, highlighting socio-demographic and clinical profile, complications, and risk factors for mortality. This study is a retrospective case series of 127 oduvan intentionally poisoned patients presenting at a tertiary care teaching hospital between the years 1990-1999. Descriptive statistics, cumulative case fatality rates and time to death from ingestion of poison were calculated. Cox regression adjusting for left truncation was used to investigate the effects of covariates on death. Patients' average (sd) age was 29.1 (10.9), 62% were female, 76% were married and 49% were housewives. The cumulative case fatality rate was 30%. The median time to death after oduvan ingestion was 3 days. Common signs and symptoms included hypokalaemia, vomiting, hyponatraemia, altered sensorium, bradycardia and abnormal ECG. There was a 58% risk reduction (95% CI: 29-75) in death with each 1 mmol/l increase in plasma potassium level. Patient's age was associated with an increased risk of death and the estimated hazard ratio for an increase of 10 years in age was 1.56 (95% CI: 1.18-2.07). Use of boiled oduvan extract was associated with an increased mortality (HR: 2.71, 95% CI: 1.17-6.32) compared to ingesting fresh leaves. Risk factors for oduvan poisoning mortality were hypokalaemia, older age, mode of consumption and an elevated risk for death with presence of chronic disease. When consumed as a boiled extract, oduvan is more lethal. We recommend close monitoring, correction of plasma potassium and appropriate supportive measures.

Hanging deaths in Dammam, Kingdom of Saudi Arabia

A retrospective study was carried out on 133 suicidal hanging cases autopsied at Forensic Medicine Center in Dammam, Kingdom of Saudi Arabia (from 2003 to 2007). Of these cases, 115 (86.46%) were males and 18 females (13.54%), with an average male:female ratio of 6.38. There was an increasing trend of hanging among ages between 21 and 50 years (88.7%), and the fourth decade had the highest number of victims (about 36%) between all age groups. Local Saudi nationals comprised a small proportion of cases (21 persons, 15.8%), while the others were foreigners working in the Kingdom with an Indian precedence (63 persons, 47.4%), followed by other 11 different nationalities representing 36.8% of the cases. The peak of these suicidal acts was in June and the least was in February and December. Postmortem blood alcohol was found in 6.76% of cases, amphetamine in 3% (4 cases), and cannabinoids in 2.25% (3 cases). About 75% of the deceased persons were male laborers (100 cases), 11.27% were female housemaids (15 cases), and only 13 persons were unemployed (9.77%). Previous history of psychological illnesses was documented in 19 cases (14.28%) and stressful family problems in 6% of cases. There were previous suicidal attempts in only one case. Suicidal note was found in only seven cases. In conclusion, there was a decreasing trend of suicide by hanging in Dammam from 39 cases in 2003 to 17 cases in 2007, with a rate of 0.85/100,000 population in the last year. This was inconsistent with the overall increase in suicide rate in Dammam when compared to the previous decade.

Attempted suicides in India: a comprehensive look

Suicide continues to be one of the biggest killers in the world, with suicide rates varying between 8.1 and 58.3/100,000 population for different parts of India. Andhra Pradesh, the fourth largest state in India, is responsible for more than 11% of these. Unfortunately, most suicides are under-reported and there is scant data on attempted suicides. This study aimed to comprehensively study the characteristics of attempted suicides in Andhra Pradesh and using the primary data, make secondary projections for the forthcoming years. Using Patient Care Record (PCR) forms of all emergencies serviced by 108, the first comprehensive emergency service in India, an analysis of all cases was done to detect possible suicides during the period January-December 2007. A follow up 48 hours later was then done to confirm status and diagnosis. A total of 1007 cases were recorded as confirmed suicides. Hanging and insecticide poisoning (72%) were the most common methods used. Males preferred hanging and insecticide poisoning while females preferred self-immolation and hanging as common methods. Self-immolation and insecticide poisoning had the highest mortality (41.6%). Estimates of attempted suicides for the year 2008 revealed a mean of 3.2-3.8 per 1000 population for males, 3.3-3.7 per 1000 population for females and 6.4-7.6 per 1000 population combined. A serious epidemic of suicides seems to be in store in the coming years unless preventive steps in the form of policy changes are undertaken. Restricting access to poisonous substances or prescription drugs and taking into consideration the prevailing social, economic and cultural factors could help in reducing numbers. Starting tele-help services or offering brief interventions during hospital stays are other programs which may be considered.

Risk factors for suicide in rural south India

BACKGROUND

The relative contributions of psychosocial stress and psychiatric morbidity to suicide are a subject of debate.

AIMS

To determine major risk factors for suicide in rural south India.

METHOD

We used a matched case-control design and psychological autopsy to assess 100 consecutive suicides and 100 living controls matched for age, gender and neighbourhood.

RESULTS

Thirty-seven (37%) of those who died by suicide had a DSM-III-R psychiatric diagnosis. Alcohol dependence (16%) and adjustment disorders (15%) were the most common categories. The prevalence rates for schizophrenia, major depressive episode and dysthymia were 2% each. Ongoing stress and chronic pain heightened the risk of suicide. Living alone and a break in a steady relationship within the past year were also significantly associated with suicide.

CONCLUSIONS

Psychosocial stress and social isolation, rather than psychiatric morbidity, are risk factors for suicide in rural south India.

Suicidal ideation and suicide attempt among adolescents in Western Jamaica: a preliminary study

BACKGROUND

Although extensive studies on adolescent suicidal behavior have been conducted in developed countries such as the United States, little data exist on risk factors for suicide among adolescents in culturally and socially disadvantages settings, such as Jamaica.

AIMS

To conduct a preliminary investigation of risk factors associated with suicide ideation and attempt among youths in Western Jamaica.

METHODS

We conducted a cross-sectional study of 342 adolescents aged 10-19 years from 19 schools.

RESULTS

Multivariate analysis showed that a history of self-violence, violent thoughts toward others, mental health diagnoses other than depression, and a history of sexual abuse were positively associated with suicide attempt. Sexual abuse, mental health diagnoses other than depression, self-violence, and ease of access to lethal substances/weapons were positively associated with suicide ideation.

CONCLUSIONS

We found a relatively high prevalence of suicide ideation and suicide attempts among adolescents living in Western Jamaica. An accurate understanding of the prevailing risk factors for suicide attempts will promote a more sympathetic approach to victims and facilitate prevention efforts.

"Amor não correspondido": discursos de adolescentes que tentaram suicídio

O estudo descreve as razões de tentativas suicidas em adolescentes, analisando sua repercussão no contexto familiar e social sob o prisma antropológico. Foi utilizada a abordagem qualitativa e a etnografia como método. Os participantes do estudo foram doze adolescentes, admitidos em um hospital de emergência, em Fortaleza, Ceará, Brasil, por tentativa de suicídio por qualquer mecanismo. Realizou-se no período de março a agosto de 2005. Os resultados evidenciaram como razão primaz o amor não correspondido, tendo esse amor conotação afetiva, de namoro, de caso, da primeira entrega; contudo, não foi só nesse sentido que o "amor não correspondido" foi mencionado. Este também foi aludido quanto ao relacionamento familiar, ao carinho, à valorização da pessoa do adolescente. Neste contexto, revelou-se também a inabilidade do profissional de saúde diante desses casos, sendo necessária a ressignificação da práxis. Dessa forma, o suicídio está presente na adolescência e suscita um redirecionamento das práticas de saúde na consolidação dos princípios filosóficos e operacionais do SUS, demandando que a sociedade "abrace" as políticas que valorizam a vida.

Suicide in South India: A community-based study in Kerala

BACKGROUND

Studies from Tamil Nadu, South India, have reported the world's highest suicide rates. As per official reports, Kerala, another South Indian state has the highest suicide rate among the major states in India.

OBJECTIVE

The purpose of this analysis is to estimate the rates and age-specific incidence of suicide in a rural community in Kerala, under continuous observation for the last five years.

SETTINGS AND DESIGN

The study setting comprised of seven contiguous panchayats constituting a development block in Kerala. A prospective cohort study design was used.

MATERIALS AND METHODS

Through regular home visits, every death that occurred in the community was captured by local resident health workers and the cause of death assigned.

STATISTICAL ANALYSIS

Suicide rates by age and sex and relative share of suicide deaths to all-cause deaths in men and women were calculated.

RESULTS

During the five-year period from 2002 to 2007, 284 cases of suicide were reported. The suicide rates were 44.7/100,000 for males and 26.8/100,000 for females. Male to female suicide ratio was 1.7. Among females aged between 15 and 24, suicides constituted more than 50% of all deaths. Male to female ratio of suicide varied from 0.4 in children aged 14 years or less to 4.5 in the 45-54 year age group.

CONCLUSION

Our analysis shows that the level of under-reporting of suicides in rural Kerala is much less than that reported in Tamil Nadu.

Self-harm and self-poisoning in southern India: choice of poisoning agents and treatment

OBJECTIVE

To record cases of suicide and attempted suicide among a population of 108 000 people living in a primarily rural area of southern India, with the aim of guiding policies and strategies to restrict access to poisonous compounds at community level.

METHOD

Community-based surveillance over a period of 2 years.

RESULTS AND CONCLUSION

The overall suicide rate was 71.4 per 100 000 population; the highest burden was among men. Most people died through hanging (81, 54%) and self-poisoning (46, 31%). Of the 46 who died from self-poisoning, 78.3% had taken pesticides and 19.7% had eaten poisonous plants. Eighty per cent of the self-poisoning cases obtained the poisonous substance in or in close proximity to the home, highlighting the importance of safe storage in the domestic environment. Of the 110 fatal and non-fatal self-poisoning cases, 87 (57.5%) were taken for treatment; 50 (57.4%) went to government hospitals and 37 (42.5%) to private facilities. This indicates the importance of including the private sector in the efforts to improve case management. Furthermore, the fact that 31 (67%) of the self-poisoning patients, who eventually died, were alive after 4 h provides an incentive to focus on improved case management and access to health services.

Perinatal outcomes in a South Asian setting with high rates of low birth weight

BACKGROUND

It is unclear whether the high rates of low birth weight in South Asia are due to poor fetal growth or short pregnancy duration. Also, it is not known whether the traditional focus on preventing low birth weight has been successful. We addressed these and related issues by studying births in Kaniyambadi, South India, with births from Nova Scotia, Canada serving as a reference.

METHODS

Population-based data for 1986 to 2005 were obtained from the birth database of the Community Health and Development program in Kaniyambadi and from the Nova Scotia Atlee Perinatal Database. Menstrual dates were used to obtain comparable information on gestational age. Small-for-gestational age (SGA) live births were identified using both a recent Canadian and an older Indian fetal growth standard.

RESULTS

The low birth weight and preterm birth rates were 17.0% versus 5.5% and 12.3% versus 6.9% in Kaniyambadi and Nova Scotia, respectively. SGA rates were 46.9% in Kaniyambadi and 7.5% in Nova Scotia when the Canadian fetal growth standard was used to define SGA and 6.7% in Kaniyambadi and < 1% in Nova Scotia when the Indian standard was used. In Kaniyambadi, low birth weight, preterm birth and perinatal mortality rates did not decrease between 1990 and 2005. SGA rates in Kaniyambadi declined significantly when SGA was based on the Indian standard but not when it was based on the Canadian standard. Maternal mortality rates fell by 85% (95% confidence interval 57% to 95%) in Kaniyambadi between 1986-90 and 2001-05. Perinatal mortality rates were 11.7 and 2.6 per 1,000 total births and cesarean delivery rates were 6.0% and 20.9% among live births >or= 2,500 g in Kaniyambadi and Nova Scotia, respectively.

CONCLUSION

High rates of fetal growth restriction and relatively high rates of preterm birth are responsible for the high rates of low birth weight in South Asia. Increased emphasis is required on health services that address the morbidity and mortality in all birth weight categories.

Suicidal hanging in Manipal, South India - victim profile and gender differences

Suicide is an important health hazard worldwide. Hanging is one of the preferred means of committing suicide in India. The current research is aimed to describe the victimologic profile and find the gender differences in suicidal hanging in Manipal, South India. A 10-year retrospective review of medicolegal autopsy records was conducted at the Department of Forensic Medicine and Toxicology, Kasturba Medical College, Manipal. A total of 70 cases of suicidal hanging autopsied during the study period spanning from January 1997 to December 2006 were identified. Data on suicidal hanging was obtained, analysed and compared for males and females using Microsoft Excel and Statistical Package for Social Sciences (SPSS) for Windows, version 10.0. Males were predominantly affected (male:female - 2:1). Maximum victims of suicidal hanging were Hindus in their 3rd decade of life. Mean age for males and females was 40.62 years and 29.96 years respectively. Maximum mortalities were noted during summer months. Identification of target population is the prime issue before the process of prevention and health promotion is initiated. A difference in pattern of suicidal hanging exists among males and females. Thus, psychosocial correlates should be addressed separately for males and females in epidemiological studies for identification of population at risk and strategies for prevention.

Iatrogenic injuries leading to suspicion of homicide

Injuries produced as a result of medical intervention may lead to confusion in certain cases during investigation and postmortem examination. Proper documentation of all interventions with the injuries, if produced, is of vital importance. The present case is a rare case where the iatrogenic injuries produced by a medical practitioner during the course of treatment of a case of suicidal hanging resulted in a suspicion being raised as to the nature of death. The suspicion was further strengthened by the lack of proper documentation and inappropriate/improper use of terminology of medicolegal significance.

The Prevention of Suicide in India and the Developing World

Very high rates of suicide have been reported from India and the developing world. However, much of the debate on suicide prevention focuses on individuals, methods, site-specific solutions, or particular suicide prevention strategies. This article argues for population based approaches that focus on improving the general health of populations (e.g., macroeconomic policies that aim for social justice, schemes to meet basic human needs, organizing local support groups within vulnerable sections of society, developing and implementing an essential pesticide list, addressing gender issues, and increasing public awareness through the mass media) rather than medical, psychiatric, and other strategies that target individuals (e.g., treatment of mental illness, counseling, etc.) in order to reduce high suicide rates in India and developing countries. Individual approaches will help people in distress and prevent individuals from committing suicide, but will not reduce population suicide rates.

The global distribution of fatal pesticide self-poisoning: systematic review

BACKGROUND

Evidence is accumulating that pesticide self-poisoning is one of the most commonly used methods of suicide worldwide, but the magnitude of the problem and the global distribution of these deaths is unknown.

METHODS

We have systematically reviewed the worldwide literature to estimate the number of pesticide suicides in each of the World Health Organisation's six regions and the global burden of fatal self-poisoning with pesticides. We used the following data sources: Medline, EMBASE and psycINFO (1990-2007), papers cited in publications retrieved, the worldwide web (using Google) and our personal collections of papers and books. Our aim was to identify papers enabling us to estimate the proportion of a country's suicides due to pesticide self-poisoning.

RESULTS

We conservatively estimate that there are 258,234 (plausible range 233,997 to 325,907) deaths from pesticide self-poisoning worldwide each year, accounting for 30% (range 27% to 37%) of suicides globally. Official data from India probably underestimate the incidence of suicides; applying evidence-based corrections to India's official data, our estimate for world suicides using pesticides increases to 371,594 (range 347,357 to 439,267). The proportion of all suicides using pesticides varies from 4% in the European Region to over 50% in the Western Pacific Region but this proportion is not concordant with the volume of pesticides sold in each region; it is the pattern of pesticide use and the toxicity of the products, not the quantity used, that influences the likelihood they will be used in acts of fatal self-harm.

CONCLUSION

Pesticide self-poisoning accounts for about one-third of the world's suicides. Epidemiological and toxicological data suggest that many of these deaths might be prevented if (a) the use of pesticides most toxic to humans was restricted, (b) pesticides could be safely stored in rural communities, and (c) the accessibility and quality of care for poisoning could be improved.

Suicidal hanging: Fatalities in Istanbul Retrospective analysis of 761 autopsy cases

We retrospectively analyzed the autopsy records of the Institute of Forensic Medicine during the five-year period between 1998 and 2002 to document the characteristics of fatalities resulting from hanging which is the commonest mode of suicide in Istanbul. Upon analysis of death scene investigation and autopsy reports together with the information gathered from the police, the cases of hanging fatalities of suicidal origin were selected. Seven hundred sixty one hanging cases of suicidal origin were detected and evaluated in terms of demographic features, the type of hanging material used for ligature, cause of death, internal findings in neck organs, other traumatic findings suggesting the use of another method for suicide, toxicological findings and microscopic findings in delayed death cases. In 364 of these cases suspension was complete and in 397 incomplete. Five hundred thirty seven of those (70.56%) were male and 224 (29.44%) were female. The preponderance of male cases in our autopsy population was also detected in suicidal hanging cases. There was no case aged lower 10 and the number of the cases in the age group of cases aged over 80 was the lowest (n=3, 0.4%). In 634 of cases, the place of hanging was the subject's own house, most victims selected rope (652 cases) for the ligature with the rest using sheet, belt, cable and necktie. There were traumatic findings showing attempts of suicide other than hanging in 24 cases (tentative marks in 22 cases and non-fatal burning in 2). In 23 of cases, there were bruises of different ages. In these cases females constituted the majority suggesting violence against women that is a social problem in various cultural subgroups of our country. This violence may have played a role in the decision of suicide. Superficial bruises were detected in 56 cases and were attributed to the trauma. Fractures in neck organs were detected in 446 of cases. In fracture-determined cases, fracture in hyoid bone was seen in 177, in thyroid cartilage in 163, in both hyoid and thyroid in 106. Vertebral fracture was detected in six cases and fractures both in hyoid, thyroid and vertebra was found in four cases. Hyperemic lines around the ligature were prominent in 620 of the cases and soft tissue ecchymoses in all cases. In 305 of the cases (40.07%) diagnosis was based only on the soft tissue hemorrhage.

Pesticide poisoning in non-fatal deliberate self-harm: A public health issue: Study from Sundarban delta, India

BACKGROUND

Non-fatal deliberate self-harm (DSH), particularly with pesticides, is a major public health problem in many developing countries of the world. Agriculture is the primary occupation of most people living in the Sundarban region in West Bengal, India. Pesticides are extensively used in agriculture, and these agents are most frequently used in DSH.

AIM

This study aimed to identify the nature of methods and agents used in non-fatal DSH attempts in the Sundarban area under South 24 Parganas district of West Bengal.

MATERIALS AND METHODS

Detailed demographic and clinical data on DSH cases of 13 Block Primary Health Centres' (BPHCs') admission registers were analyzed. One Focus Group Discussion (FGD) with the Panchayat Samiti of each block (totally 13 FDGs) was conducted to elicit the Samiti members' perception about the problem of pesticide-related DSH or suicide in the region.

RESULTS

A total of 5,178 (1,887 male and 3,291 female) subjects were admitted at the BPHCs during the study period from 1999 to 2001. Organophosphorous pesticide poisoning was found to be the most common method (85.1%) in DSH. This emphasizes the importance of developing an urgent poisoning-prevention program with a special focus on improving clinical services, as well as initiating farmers' education programs focusing on safe pesticide practices at the primary-care level.

Mental health systems in countries: where are we now?

More than 85% of the world's population lives in 153 low-income and middle-income countries (LAMICs). Although country-level information on mental health systems has recently become available, it still has substantial gaps and inconsistencies. Most of these countries allocate very scarce financial resources and have grossly inadequate manpower and infrastructure for mental health. Many LAMICs also lack mental health policy and legislation to direct their mental health programmes and services, which is of particular concern in Africa and South East Asia. Different components of mental health systems seem to vary greatly, even in the same-income categories, with some countries having developed their mental health system despite their low-income levels. These examples need careful scrutiny to derive useful lessons. Furthermore, mental health resources in countries seem to be related as much to measures of general health as to economic and developmental indicators, arguing for improved prioritisation for mental health even in low-resource settings. Increased emphasis on mental health, improved resources, and enhanced monitoring of the situation in countries is called for to advance global mental health.

Empowerment of women and mental health promotion: a qualitative study in rural Maharashtra, India

BACKGROUND

The global burden of mental illness is high and opportunities for promoting mental health are neglected in most parts of the world. Many people affected by mental illness live in developing countries, where treatment and care options are limited. In this context, primary health care (PHC) programs can indirectly promote mental health by addressing its determinants i.e. by enhancing social unity, minimising discrimination and generating income opportunities. The objectives of this study were to: 1. Describe concepts of mental health and beliefs about determinants of mental health and illness among women involved with a PHC project in rural Maharashtra, India; 2. Identify perceived mental health problems in this community, specifically depression, suicide and violence, their perceived causes, and existing and potential community strategies to respond to them and; 3. Investigate the impact of the PHC program on individual and community factors associated with mental health

METHOD

We undertook qualitative in-depth interviews with 32 women associated with the PHC project regarding: their concepts of mental health and its determinants; suicide, depression and violence; and the perceived impact of the PHC project on the determinants of mental health. The interviews were taped, transcribed, translated and thematically analysed.

RESULTS

Mental health and illness were understood by these women to be the product of cultural and socio-economic factors. Mental health was commonly conceptualised as an absence of stress and the commonest stressors were conflict with husbands and mother-in-laws, domestic violence and poverty. Links between empowerment of women through income generation and education, reduction of discrimination based on caste and sex, and promotion of individual and community mental health were recognised. However, mental health problems such as suicide and violence were well-described by participants.

CONCLUSION

While it is essential that affordable, accessible, appropriate treatments and systems of referral and care are available for people with mental illness in developing country settings, the promotion of mental health by addressing its determinants is another potential strategy for reducing the burden of mental illness for individuals and communities in these settings.

The importance of poisoning vs. road traffic injuries as a cause of death in rural Sri Lanka

BACKGROUND

Road traffic crashes are considered by the WHO to be the most important global cause of death from injury. However, this may not be true for large areas of rural Asia where road vehicles are uncommon. The issue is important, since emphasising the importance of road traffic crashes risks switching resources to urban areas, away from already underfunded rural regions. In this study, we compared the importance of road traffic crashes with other forms of injury in a poor rural region of South Asia.

METHODOLOGY/PRINCIPAL FINDINGS

We collected data on all deaths from injury in the North Central Province of Sri Lanka (NCP; population 1,105,198 at 2001 census) over 18 months using coronial, hospital, and police data. We calculated the incidence of death from all forms of intentional and unintentional injury in the province. The annual incidence of death from injury in the province was high: 84.2 per 100,000 population. Half of the deaths were from self-harm (41.3/100,000). Poisoning (35.7/100,000)-in particular, pesticide self-poisoning (23.7/100,000)-was the most common cause of death, being 3.9-fold more common than road traffic crashes (9.1/100,000).

CONCLUSIONS/SIGNIFICANCE

In poor rural regions of South Asia, fatal self-harm and pesticide self-poisoning in particular are significantly more important than road traffic injuries as a cause of death. It is possible that the data used by the WHO to calculate global injury estimates are biased towards urban areas with better data collection but little pesticide poisoning. More studies are required to inform a debate about the importance of different forms of injury and how avoidable deaths from any cause can be prevented. In the meantime, marked improvements in the effectiveness of therapy for pesticide poisoning, safer storage, reduced pesticide use, or reductions in pesticide toxicity are required urgently to reduce the number of deaths from self-poisoning in rural Asia.

Pesticide poisoning in nonfatal, deliberate self-harm: A public health issue

BACKGROUND

Nonfatal, deliberate self-harm (DSH), particularly with pesticides, is a major public health problem in many developing countries of the world. Agriculture is the primary occupation of most people living in the Sundarban region in West Bengal, India. Pesticides are extensively used in agriculture and these agents are most frequently used in DSH.

AIM

This study sought to identify the nature of methods and agents used in nonfatal DSH attempts in the Sundarban area under South 24 Parganas district of West Bengal.

MATERIALS AND METHODS

Detailed demographic and clinical data on DSH cases of 13 Block Primary Health Centres (BPHCs') admission registers were analysed. Focus Group Discussions (FGDs) were conducted with the Panchayat Samithy of each block to elicit their perception about the problem of pesticide-related DSH or suicide in the region.

RESULTS

Five thousand, one hundred and seventy-eight (1,887 male and 3,291 female) subjects were admitted in the BPHCs during the study period from 1999 to 2001. Organophosphorous pesticide poisoning was found to be the most common method (85.1%) in DSH. This emphasizes the importance of developing an urgent poisoning prevention program with a special focus on improving clinical services as well as initiating farmers' education programs focusing on safe pesticide practices at the primary care level.

A review of the literature on rural suicide: risk and protective factors, incidence, and prevention

BACKGROUND

Suicide is a major cause of mortality worldwide. Differences in rates of suicide exist between urban and rural areas; however, little rigorous research has examined the phenomena of rural suicide.

OBJECTIVE

This review examines the current body of literature on rural suicide and investigates differences between rural and urban suicide, including socioeconomic, psychological, and cultural variables. Prevention and intervention strategies specific to rural communities are discussed. DESCRIPTION OF STUDIES: All empirical and epidemiological studies of rural suicide were included in the review regardless of study design or methodology.

RESULTS

Although findings are mixed, research and epidemiological data indicate that suicide is a public health concern in rural areas, with suicide rates often greater than in urban areas.

DISCUSSION

Rural locale may create geographic, psychological, and sociocultural barriers to treatment of suicide. A better understanding of the role of rurality in the development and maintenance of suicidal thoughts and behaviors is needed and may inform prevention and intervention efforts.

Suicide rates in rural Tamil Nadu, South India: Verbal autopsy of 39 000 deaths in 1997–98

BACKGROUND

In India, death registration is not complete, especially in rural areas. Chiefly for other purposes special efforts were made to identify all deaths that occurred during 1997-98 in rural areas of one of the districts in Tamil Nadu, South India, and the verbal autopsy was done.

METHODS

Trained non-medical field interviewers interviewed surviving spouses, close associates or neighbours, and wrote the verbal autopsy reports in the local language (Tamil). The reports were reviewed independently by two physicians to arrive at the probable underlying cause of death. About 5% of the data were randomly selected for re-interview.

RESULTS

The verbal autopsy was done for 38 836 deaths. Injuries accounted for 18.5% of the total deaths. About half of these were suicides. The average annual suicide rate for men and women were 71 and 53/100 000, respectively. Three-fourths of all suicides were in the socially and economically productive age-group of 15-44 years. At ages 15-24 years the female suicide rate of 109/100 000 exceeded the male rate of 78/100 000; suicide was responsible for 49% of all deaths in women and 38% of all deaths in men at these ages.

CONCLUSIONS

This is the second largest study to date that has used verbal autopsy to estimate mortality rates in India. Suicides accounted for 9% of total deaths, and the ratio of male to female suicide was 1: 0.72. The overall (male + female) annual suicide rate was 62/100 000 population. The female suicide rate at ages 15-24 years was higher than the male rate in that age-group and other female age-groups. About 50% of suicides were by self-poisoning, one-third by hanging and one-eighth by self-immolation.

Mortality rate and years of life lost from unintentional injury and suicide in South India

We calculated mortality rates and years of life lost because of unintentional injuries and suicides using community based information obtained prospectively over a 7-year period, from 1998 to 2004, among a rural and peri-urban population of 108,000 in South India. Per 100,000 population the total mortality rate for unintentional injuries and suicides combined was 137.1, with 54.9 for unintentional injuries and 82.2 for suicides respectively. Hanging and self-poisoning with pesticides were the preferred means of suicide. Unintentional injuries and suicides resulted in 26.9% of total life years lost over the study period while 18.9% of all deaths in the population were attributable to unintentional injuries and suicides in the same period. The high burden is particularly notable in the 15-29 age group, where up to 70% of years of life lost are due to injury. The burden of injuries reported in this study is significantly higher than the figures reflected in available reports for India and is likely due to the under reporting in routine mortality statistics, particularly of suicides.

A Community Health Programme in Rural Tamil Nadu, India: The Need for Gender Justice for Women

This article highlights the efforts of the Community Health and Development (CHAD) Programme of Christian Medical College to address the issues of gender discrimination and improve the status of women in the Kaniyambadi Block, Vellore, Tamil Nadu, India. The many schemes that are specifically for women and general projects for the community from which women can also benefit represent a multi-pronged approach whose aim is the improvement of women's health, education and employment in the context of community development. However, despite five decades of work with a clear bias in favour of women, the improvement in health and the empowerment of women has lagged behind that achieved by men. We believe this is because the community, with its strong male bias, utilises the health facilities and education and employment programmes more for the benefit of men and boys than women and girls. The article argues for a change of approach, in which gender and women's issues are openly discussed and debated with the community. It would appear that nothing short of social change will bring about an improvement in the health of women and a semblance of gender equality in the region.

Suicide in developing countries (1): frequency, distribution, and association with socioeconomic indicators

OBJECTIVE

Suicide is a global public health problem, but relatively little epidemiological investigation of the phenomenon has occurred in developing countries. This paper aims to (1) examine the availability of rate data in developing countries, (2) provide a description of the frequency and distribution of suicide in those countries for which data are available, and (3) explore the relationship between country-level socioeconomic factors and suicide rates. It is accompanied by two companion papers that consider risk factors and preventive efforts associated with suicide in developing countries, respectively.

METHOD

Using World Health Organization data, we calculated the average annual male, female, and total suicide rates during the 1990s for individual countries and regions (classified according to the Human Development Index [HDI]), and examined the association between a range of socioeconomic indicators and suicide rates.

RESULTS

For reasons of data availability, we concentrated on medium HDI countries. Suicide rates in these countries were variable. They were generally comparable with those in high HDI countries from the same region, with some exceptions. High education levels, high telephone density, and high per capita levels of cigarette consumption were associated with high suicide rates; high levels of inequality were associated with low suicide rates.

CONCLUSION

Epidemiological investigations of this kind have the potential to inform suicide prevention efforts in developing countries, and should be encouraged.

Rates and factors associated with suicide in Kaniyambadi Block, Tamil Nadu, South India, 2000-2002

BACKGROUND

Inefficient civil registration systems, non-report of deaths, variable standards in certifying death and the legal and social consequences of suicide are major obstacles to investigating suicide in the developing world.

OBJECTIVE

The aim of this study was to prospectively determine the suicide rate in Kaniyambadi Block, Tamil Nadu, South India, for the years 2000-2002 using verbal autopsies.

METHOD

The setting for the study was a comprehensive community health programme in a development block in rural South India. The main outcome measure was death by suicide, diagnosed by a detailed verbal autopsy and census, and birth and death data to identify the population base.

RESULTS

The average suicide rate was 92.1 per 100,000. The ratio of male to female suicides was 1:0.66. The age-specific suicide rate for men increased with age while that for women showed two peaks: 15-24 years and over 65 years of age. Hanging (49%) and poisoning with organo-phosphorus compounds (40.5%) were the commonest methods of committing suicide. Acute and/or chronic stress was elicited for nearly all subjects. More men suffered from chronic stress while more women had acute precipitating events (chi2 = 4.58; p < 0.04). People less than 44 years of age had more acute precipitating events before death while older subjects reported more chronic stress (chi2 = 17.38; p < 0.001).

CONCLUSION

The study replicates findings of an earlier study from the area. The suicide rate documented in this study is very high and is a major public health concern. There is a need for sentinel centres in India and in developing countries to monitor trends and to develop innovative strategies to reduce deaths by suicide.

Epidemiology of intentional self-poisoning in rural Sri Lanka

We investigated the epidemiology of intentional self-poisoning in rural Sri Lanka by prospectively recording 2189 admissions to two secondary hospitals. Many patients were young (median age 25 years), male (57%) and used pesticides (49%). Of the 198 who died,156 were men (case fatality 12.4%) and 42 were women (4.5%). Over half of female deaths were in those under 25 years old; male deaths were spread more evenly across age groups. Oleander and paraquat caused 74% of deaths in people under 25 years old; thereafter organophosphorous pesticides caused many deaths. Although the age pattern of self-poisoning was similar to that of industrialised countries, case fatality was more than 15 times higher and the pattern of fatal self-poisoning different.

Suicide in the elderly in Kaniyambadi block, Tamil Nadu, South India

BACKGROUND

Inefficient civil registration systems, non-report of deaths, variable standards in certifying death and the legal and social consequences of suicide are major obstacles in investigating suicide in the developing world. Very high rates of suicide have been recorded in the region in the general population and among younger people.

OBJECTIVE

This paper describes the suicide rate among the elderly in Kaniyambadi block, Tamil Nadu, South India for the years 1994-2002 using verbal autopsies.

METHOD

The setting for the study was a comprehensive community health program in a development block in rural South India. The main outcome measure was death by suicide diagnosed by a detailed verbal autopsy and census, birth and death data to identify the population base.

RESULTS

The average annual suicide rate was 189 per 100,000 for people over 55 years of age. The ratio of male to female suicides was 1: 0.66. The age-specific suicide rate for men and women increased with age. Hanging (52%) and poisoning with organo-phosphorus compounds (39%) were the commonest methods employed for committing suicide. Significantly more women chose drowning or burning than men who preferred poisoning or hanging (chi2 19.75; df 1; p < 0.001).

CONCLUSIONS

The suicide rate documented in this study among the elderly is very high. The reasons for the high suicide rate observed in older people are not known. There is a need to develop innovative strategies to reduce deaths by suicide.

Socio-economic inequalities in suicide: a European comparative study

BACKGROUND

Social factors have been shown to be predictors of suicide. It is not known whether these factors vary between countries.

AIMS

To present a first European overview of socio-economic inequalities in suicide mortality among men and women.

METHOD

We used a prospective follow-up of censuses matched with vital statistics in ten European populations. Directly standardised rates of suicide were computed for each country.

RESULTS

In men, a low level of educational attainment was a risk factor for suicide in eight out of ten countries. Suicide inequalities were smaller and less consistent in women. In most countries, the greater the socio-economic disadvantage, the higher is the risk of suicide. The population of Turin evidenced no socio-economic inequalities.

CONCLUSIONS

Socio-economic inequalities in suicide are a generalised phenomenon in western Europe, but the pattern and magnitude of these inequalities vary between countries. These inequalities call for improved access to psychiatric care for lower socio-economic groups.