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

Report of the Indo-US health care summit 2009 - Mental health section

The 2nd Indo-US Health Care Summit held in January 2009 was a forum to discuss collaboration between physicians in the US and India on medical education, health care services and research. Six specialties were represented including Mental Health (MH). Using Depression as the paradigmatic disorder, the following objectives were developed. Objective I - Leadership and Public Education: Linkage with like-minded agencies and organizations. The core message should be simple. Major Depression is a brain disorder. Depression is treatable. Timely treatment prevents disability and suicide. Objective II - Medical Education: To improve psychiatric education, it was proposed that (1) relations between US/UK and Indian mid-level institutions be established, (2) teaching methods such as tele-psychiatry and online courses be pursued, (3) use models of teaching excellence to arouse student interest, and (4) develop core curricula for other branches of medicine, and CME. Objective III - Reduce Complications of Depression (Suicide, Alcoholism): Goals include (1) decriminalizing attempted suicide, (2) improving reporting systems, and including depression, psychosis, alcoholism, and suicide in the national registry, (3) pilot studies in vulnerable groups on risk and interventions, and (4) education of colleagues on alcoholism as a link between psychiatric and medical disorders. Objective IV - Integrating MH Treatment& Primary Health Care: The focus should be on training of general practitioners in psychiatry. Available training modules including long distance learning modules to be suitably modified for India. Collaborations and specific project designs are to be developed, implemented and monitored by each specialty group and reviewed in future summits.

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.

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.

Promoting child and adolescent mental health in low and middle income countries

Children and adolescents in low and middle income countries (LAMIC) constitute 35-50% of the population. Although the population in many such countries is predominantly rural, rapid urbanisation and social change is under way, with an increase in urban poverty and unemployment, which are risk factors for poor child and adolescent mental health (CAMH). There is a vast gap between CAMH needs (as measured through burden of disease estimates) and the availability of CAMH resources. The role of CAMH promotion and prevention can thus not be overestimated. However, the evidence base for affordable and effective interventions for promotion and prevention in LAMIC is limited. In this review, we briefly review the public health importance of CAM disorders in LAMIC and the specific issues related to risk and protective factors for these disorders. We describe a number of potential strategies for CAMH promotion which focus on building capacity in children and adolescents, in parents and families, in the school and health systems, and in the wider community, including structural interventions. Building capacity in CAMH must also focus on the detection and treatment of disorders for which the evidence base is somewhat stronger, and on wider public health strategies for prevention and promotion. In particular, capacity needs to be built across the health system, with particular foci on low-cost, universally available and accessible resources, and on empowerment of families and children. We also consider the role of formal teaching and training programmes, and the role for specialists in CAMH promotion.

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.

The impact of pesticide regulations on suicide in Sri Lanka

BACKGROUND

Between 1950 and 1995 suicide rates in Sri Lanka increased 8-fold to a peak of 47 per 100,000 in 1995. By 2005, rates had halved. We investigated whether Sri Lanka's regulatory controls on the import and sale of pesticides that are particularly toxic to humans were responsible for these changes in the incidence of suicide.

METHODS

Ecological analysis using graphical and descriptive approaches to identify time trends in suicide and risk factors for suicide in Sri Lanka, 1975-2005.

RESULTS

Restrictions on the import and sales of WHO Class I toxicity pesticides in 1995 and endosulfan in 1998, coincided with reductions in suicide in both men and women of all ages. 19,769 fewer suicides occurred in 1996-2005 as compared with 1986-95. Secular trends in unemployment, alcohol misuse, divorce, pesticide use and the years associated with Sri Lanka's Civil war did not appear to be associated with these declines.

CONCLUSION

These data indicate that in countries where pesticides are commonly used in acts of self-poisoning, import controls on the most toxic pesticides may have a favourable impact on suicide. In Asia, there are an estimated 300,000 deaths from pesticide self-poisoning annually. National and international policies restricting the sale of pesticides that are most toxic to humans may have a major impact on suicides in the region.

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.

No health without mental health

About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.

Stigma towards people with mental illness in developing countries in Asia

BACKGROUND

There is a wide range of literature on stigmatization and discrimination of people with mental illness. Most studies, however, derive from Western countries. This review aims at summarizing results from developing countries in Asia published between 1996-2006.

METHOD

Medline search focusing on English-speaking literature.

RESULTS

Comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The role of supernatural, religious and magical approaches to mental illness is prevailing. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. This holds true particularly with regards to marriage, marital separation and divorce. Psychic symptoms, unlike somatic symptoms, are construed as socially disadvantageous. Thus, somatisation of psychiatric disorders is widespread in Asia. The most urgent problem of mental health care in Asia is the lack of personal and financial resources. Thus, mental health professionals are mostly located in urban areas. This increases the barriers to seek help and contributes to the stigmatization of the mentally ill. The attitude of mental health professionals towards people with mental illness is often stigmatizing.

CONCLUSION

This review revealed that the stigmatization of people with mental illness is widespread in Asia. The features of stigmatization-beliefs about causes of and attitudes towards mental illness, consequences for help-seeking-have more commonalities than differences to Western countries.

Prevention of Deaths from Intentional Pesticide Poisoning

Abstract. Ingestion of pesticides is the most common suicide method worldwide, accounting for one third of all suicides, predominantly in Asia, Africa, Central and South America. Case fatalities are high, particularly in rural areas. This high case fatality may explain the similar numbers of male and female suicides in Asia, since more women die from their attempts. In Asia, pesticide suicides are mostly impulsive acts with little advance planning and they are less often associated with mental illness than in Western countries. Pesticides are generally chosen for their easy access. Prevention strategies include treating the problems leading to suicidal behaviors involving pesticides; changing attitudes, knowledge, and beliefs about pesticides; controlling access to dangerous pesticides, including developing secure storage practices (which are currently being evaluated); and improving the medical treatment of poisonings. More research is needed to better understand suicides involving pesticides in their cultural contexts and to evaluate the effectiveness of intervention programs, including assessment of possible substitution of methods. Also, more knowledge about protective factors may help suggest innovative prevention strategies.

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.