Study of suicides reported to the Coroner in Colombo, Sri Lanka

Marital status and suicidal behavior in South Asia: A systematic review and meta-analysis

BACKGROUND AND AIMS

The connection between marital status and suicidal behavior has been poorly assessed in South Asia. We aimed to see the proportion of marital status in individuals with suicidal behavior in South Asian countries.

METHODS

We followed PRISMA guidelines and registered the protocol in advance (PROSPERO 2023 CRD42023399906). A systematic search was conducted in Medline, Embase, and PsycINFO. Meta-analyses were performed to pool the proportion of married individuals with suicidal behavior (total [suicide + suicide attempts], suicide, and suicide attempt) in South Asian countries. We considered suicidal behavior consist of suicide and suicide attempts (nonfatal).

RESULTS

Our search identified 47 studies for this review from 6 countries published from 1999 to 2022 with a sample size ranging from 27 to 89,178. The proportion of married individuals was 55.4% (95% CI: 50.1-60.5) for suicidal behavior, 52.7% (95% CI: 44.5-60.7) for suicides, and 43.1 (95% CI: 32.9-53.9) for suicide attempts. The proportion of married persons among suicide attempts varied significantly across countries (p = 0.016) which was highest (61.8%; 95% CI: 57.2-66.2) in India, followed by Bangladesh (52.5%; 95% CI: 41.8%-62.9%) and Pakistan (45.1%; 95% CI: 30.9-59.9). The pooled proportions did not differ significantly in relation to the quality of the studies (p = 0.633).

CONCLUSION

This review identified married persons died more than others by suicide in South Asian countries while single persons attempted suicide than married. As the current study did not assess any cause-and-effect association, a cautious interpretation is warranted while considering married marital status as a risk factor.

Alcohol use, self-harm and suicide: a scoping review of its portrayal in the Sri Lankan literature

Background

Suicide is a global public health problem. Compared to other middle-income countries, much literature has been generated on the topic of self-harm and suicide in Sri Lanka. Harmful use of alcohol is a well-known risk factor to self-harm and suicide, however the connection needed further exploration.

Aim

The aim was to investigate alcohol's role in self-harm and suicide in Sri Lanka to inform policy and prevention programs and future research priorities.

Methods

We performed a scoping review exploring how the association between alcohol use, self-harm and suicide in Sri Lanka is presented in scientific literature from August 1, 2008 to December 31, 2022. Thematic analysis was used to explore emerging themes.

Results

Altogether 116 peer-reviewed articles were included. Three themes emerged: (i) gendered, inter-relational explanations of alcohol's role in self-harm, (ii) hospital management of patients who co-ingested alcohol and pesticides, and (iii) proposed research and interventions targeting alcohol, self-harm and suicide. The articles' recommendations for policy, prevention and research priorities included: Family- and community-based alcohol, self-harm and suicide reduction interventions; viewing self-harm as a window of opportunity for health personnel to intervene in families affected by harmful alcohol consumption; and introduction of and increased access to treatment of alcohol use disorder at the individual level.

Conclusion

Suggestions for alcohol, self-harm, and suicide prevention interventions were primarily targeted at the community, though this might also reflect the limited treatment, mental health, and alcohol support available in the country. Future research should explore and test context-appropriate interventions integrating alcohol and self-harm prevention and treatment.

Exploring the epidemiology of suicide attempts: Risk modeling in Kermanshah-Iran

Background

Suicide attempt is a serious global public health issue. The patterns of suicide may vary depending on the individual characteristics, methods, causes, and the geographical area-also socio-cultural context that determine it. This study identifies the spatial patterns of suicide attempts in Kermanshah province, Iran.

Method

The sample size of this cross-sectional study is 18,331 people (7234 males and 11097 females) who attempted suicide in Kermanshah province between 2006 and 2014. Data was collected from the records of patients referred to the emergency department of hospitals in Kermanshah and analyzed using tests of Mean Center, Standard Distance, and Average Nearest Neighbor.

Results

The results of the mean center and standard distance tests show that drug overdose, poisoning with toxins and pesticides, and chemicals mostly were used in the central areas of Kermanshah province. The mean center of suicide attempts by self-immolation, hanging and firearms was in the western parts of the province, while the suicide attempts with narcotic drug were concentrated in the eastern regions of the province. Out of the 18,331 cases, 74% attempted suicide with drug overdose, 13% with toxins and pesticides, 0.59% with chemicals, 4% with fire, 1% by self-immolation, 1% by hanging, 0.16% with firearms and 0.7% with cold weapons. The spatial pattern of all suicide attempts in Kermanshah was clustered (Z-score < -2.58).

Conclusion

The results of this study show that the methods of suicide attempt vary with geographical areas in the province. Therefore, it is suggested that planning tailored to the geographical location can reduce suicide attempts in Kermanshah.

Suicide methods in South Asia over two decades (2001-2020)

BACKGROUND

Suicide is a global preventable public health problem. About a quarter of all suicides in the world occur in South Asia. As means restriction is an important suicide prevention strategy, gaining knowledge of the common suicide methods and their changing trends in each country and region is crucial.

AIMS

We aimed to assess the suicide methods in South Asian countries over the last two decades.

METHODS

A search was performed in PubMed, PubMed Central, Scopus, and Google Scholar with the search terms. Original articles of quantitative studies, published in the English language, from 2001 to 2020, with full-accessible text, that rank different methods of suicide in eight South Asian countries, were included.

RESULTS

A total of 68 studies were found eligible for review. The Maximum number of studies were found from India (n = 38), followed by Bangladesh (n = 12), Pakistan (n = 9), Sri Lanka (n = 6), and Nepal (n = 3). Hanging (n = 40, 55.8%) and poisoning (n = 24, 35.3%) were the two most common suicide methods reported, in that order. Hanging followed by poisoning were the commonest suicide methods in Bangladesh, India, and Pakistan while in Sri Lanka, poisoning was the preferred method to hanging. There is a decline in suicide by poisoning and an increase in suicide by hanging in Sri Lanka, Bangladesh, and India. Although hanging is still the commonest method in Pakistan, the use of firearms is growing in recent years (2011-2020).

CONCLUSIONS

There is a steady decline in the incidence of suicides by poisoning following pesticide regulations in South Asian countries. However, there is heterogeneity of study methods, probable under-reporting of suicide, and lack of robust suicide data.

Self-immolation in Iran: Systematic Review and Meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of self-immolation epidemiology and characteristics in Iran.

METHODS

This was a systematic review and meta-analysis study. PubMed, Scopus, Web of science and Science Direct were searched for English literature and SID and Magiran for Persian in the time period of 2000 to 2016. The retrieved studies were screened and reviewed then quality assessed. Random Effect model was applied for meta-analysis. The qualitative data were analyzed by content analysis method.

RESULTS

After literature screening, 39 studies included in the analysis. Women were subject to self-immolation more than men. The rate of self-immolation estimated to be 4.5 cases in every 100,000 populations and it was the reason of 16% of hospitalized burns. The average length of hospital stay calculated to be 12.24 (95% CI: 8.85-15.59) days. The total burnt surface area was 65.3% (95% CI: 56.71-73.89). Death due to self-immolation was 62.1%. The major risk factors of self-immolation were having mental health issues, family problems and characteristics and problems in relation/communication with spouses.

CONCLUSION

Despite the low rate of self-immolation in Iran, it comprises one sixth of the hospitalized burns. The mortality rate of self-immolation also is high and this highlights the importance of providing special care. Psychological consultations and mental health screening in the primary health care would help to prevent the self-immolation.

Poverty and suicide research in low- and middle-income countries: systematic mapping of literature published in English and a proposed research agenda

Approximately 75% of suicides occur in low- and middle-income countries (LMICs) where rates of poverty are high. Evidence suggests a relationship between economic variables and suicidal behaviour. To plan effective suicide prevention interventions in LMICs we need to understand the relationship between poverty and suicidal behaviour and how contextual factors may mediate this relationship. We conducted a systematic mapping of the English literature on poverty and suicidal behaviour in LMICs, to provide an overview of what is known about this topic, highlight gaps in literature, and consider the implications of current knowledge for research and policy. Eleven databases were searched using a combination of key words for suicidal ideation and behaviours, poverty and LMICs to identify articles published in English between January 2004 and April 2014. Narrative analysis was performed for the 84 studies meeting inclusion criteria. Most English studies in this area come from South Asia and Middle, East and North Africa, with a relative dearth of studies from countries in Sub-Saharan Africa. Most of the available evidence comes from upper middle-income countries; only 6% of studies come from low-income countries. Most studies focused on poverty measures such as unemployment and economic status, while neglecting dimensions such as debt, relative and absolute poverty, and support from welfare systems. Most studies are conducted within a risk-factor paradigm and employ descriptive statistics thus providing little insight into the nature of the relationship. More robust evidence is needed in this area, with theory-driven studies focussing on a wider range of poverty dimensions, and employing more sophisticated statistical methods.

Suicide in South Asia: a scoping review

BACKGROUND

Globally, suicide is an important cause of mortality. In low- and middle income settings, it is difficult to find unequivocal data to establish suicide rates. The objective of this review is to synthesize the reporting of suicide incidence in six south Asian countries.

METHODS

We conducted a scoping review combining peer-reviewed studies (PubMed, PsycINFO, EMBASE) with in-country searches for grey literature in Afghanistan, Pakistan, Sri Lanka, India, Nepal and Bangladesh. The review included mapping reported suicide rates, quality appraisals of the studies, use of definitions of suicide and means of committing suicide.

RESULTS

In total, 114 studies and reports were included in the review, including 50 peer-reviewed publications. Reported suicide rates varied widely from 0.43/100,000 to 331.0/100,000. The average suicide rate across studies was found to be high compared to the world average, however many studies were of poor quality or not representative. The majority of studies failed to explicitly define suicide (84% of the published articles and 92% of the grey literature documents). Poisoning and hanging were consistently the most common methods of committing suicide on the sub-continent.

CONCLUSIONS

The reported suicide rates in South Asia are high compared to the global average, but there is a paucity of reliable data on suicide rates in South Asia. Reports are likely to diminish rather than exaggerate the magnitude of suicide rates. There is an urgent need to establish new, or evaluate existing, national suicide surveillance systems in the South Asian countries.

A case-control study of psychosocial risk and protective factors of self-immolation in Iran

Self-immolation is the third leading cause of years of life lost (YLL) among women in Iran. The aim of this study is to investigate self-immolation-related risk and protective factors in the western region of Iran, a province with the highest prevalent of self-immolation in the country. Using a case-control design, we compared 151 cases of self-immolation attempters who were admitted to a burn center in Kermanshah with 302-matched control group from the same community/locality between March 21st, 2009, and March 20th, 2012. We conducted descriptive, bivariate, and multivariate analysis to examine the associations of self-immolation with demographic and familial risk factors, adverse life events, mental disorders, as well as potential protective factors. According to our findings, the highest percentage of self-immolation was in the 16-25 year-old age group (60%) and in females (76%). Of the potential risk factors in the study, major depression, adjustment disorders, individual history of suicide attempts and opium dependence, were statistically significant predictors of self-immolation. Suggestions for translating the local picture of self-immolation portrayed by our findings, into meaningful prevention strategies that have a good fit with the social and interpersonal context within which self-immolation takes place are discussed.

Study on unnatural childhood deaths presented to North Colombo Teaching Hospital, Sri Lanka

INTRODUCTION

Unnatural childhood deaths are not only associated with intense trauma and separation distress, but also relate to a sense of neglect to protect children from harm. Accurate information on causes and circumstances of such deaths through a process of medico-legal investigations is essential in creating an awareness among the policy makers and educators/caregivers, to prevent these tragic deaths.

OBJECTIVE

The aim of the study was to determine the causes and the circumstances of unnatural deaths of children among the medico-legal autopsy population presented to North Colombo Teaching Hospital, Sri Lanka.

STUDY DESIGN

A retrospective descriptive study was carried out based on Reports of Postmortem Examination performed in a Tertiary Care Hospital, on children who died of unnatural causes during the period from 2009 to 2011.

RESULTS

Out of 48 unnatural childhood deaths, 24 (50%) children were older than 10 years of age. The most frequent circumstance of death was accidental 39 (81%), while the most frequent cause of death was drowning 16 (33%). Fifteen died due to accidental drowning while one was a homicidal drowning. Suicidal deaths were found only among the children older than 16 years of age. Fifty-four percent of the accidental deaths had taken place at or around the home.

CONCLUSION

Accidents accounted for the majority (or greatest number) of tragic childhood deaths. The presence of drowning as the most common cause of death indicates that an immense responsibility lies with the parents and caregivers to prevent such deaths.

Perspectives on family health, happiness and harmony (3H) among Hong Kong Chinese people: a qualitative study

Family harmony, an important Confucian ideal in Chinese society is believed to determine family happiness and therefore health, but is this accurate? This is a qualitative study of 41 Hong Kong Chinese family members. Individual recorded interviews were thematically analysed describing perceived interactions between harmony, happiness and health. Family harmony comprised four components: communication, mutual respect, lack of conflict and family time [notably 'Gou tong' (in Cantonese )-opportunity and willingness to spend time together-requiring good interpersonal communication, emphasized by female respondents]. Lack of conflict was emphasized, while diverse values, parenting styles and financial difficulties were common causes of conflict. Respect required reciprocity. Family happiness comprised four elements: family harmony, an important pre-requisite; mutual caring and supportive orientation; sense of security emphasizing financial security in middle-class versus sense of togetherness in lower social class groups and contentment. Healthy families were harmonious; 'typical' (children/two-parent/two-grandparent); happy; caring and respectful, with individual health and healthy behaviours. Family harmony, happiness and health are interrelated and built on a communicative, respectful, caring and contented set of attitudes, in particular allowing for family time. Harmony is apparently a core element of good family functioning.

Changing epidemiologic patterns of deliberate self poisoning in a rural district of Sri Lanka

Background

Acute poisoning is a major public health issue in many parts of the world. The epidemiology and the mortality rate is higher in low and middle income countries, including Sri Lanka. The aim of this study was to provide details about the epidemiology of acute poisoning in a rural Sri Lankan district and to identify the changing patterns and epidemiology of poisoning.

Methods

A prospective study was conducted from September 2008 to January 2010 in all hospitals with inpatient facilities in Anuradhapura district of North Central Province of Sri Lanka. Acute poisoning data was extracted from patient charts. Selected data were compared to the data collected from a 2005 study in 28 hospitals.

Results

There were 3813 poisoned patients admitted to the hospitals in the Anuradhapura district over 17 months. The annual population incidence was 447 poisoning cases per 100,000 population. The total number of male and female patients was approximately similar, but the age distribution differed by gender. There was a very high incidence of poisoning in females aged 15–19, with an estimated cumulative incidence of 6% over these five years. Although, pesticides are still the most common type of poison, medicinal drug poisonings are now 21% of the total and have increased 1.6 fold since 2005.

Conclusions

Acute poisoning remains a major public health problem in rural Sri Lanka and pesticide poisoning remains the most important poison. However, cases of medicinal drug poisoning have recently dramatically increased. Youth in these rural communities remain very vulnerable to acute poisoning and the problem is so common that school-based primary prevention programs may be worthwhile.

Lalith Senarathna, Shaluka F Jayamanna, Patrick J Kelly, Nick A Buckley,michael J Dibley, Andrew H Dawson. These authors contributed equally to this work.

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.