Suicide in a northern town of Sri Lanka

Attempted suicide in South Asian women

Humans have attempted and successfully committed suicide since time immemorial. The reasons for killing or harming oneself vary with cultures and societies and in urban or rural settings.

Taking stock -- what is known about suicide in Sri Lanka: a systematic review of diverse literature

BACKGROUND

Suicide is and has been a major public health problem in Sri Lanka and has generated a wide range of literature.

AIMS

This review aimed to systematically appraise what is known about suicide in Sri Lanka. The patterns and content of articles were examined and recommendations for further research proposed.

METHOD

The paper describes the systematic search, retrieval, and quality assessment of studies. Thematic analysis techniques were applied to the full text of the articles to explore the range and extent of issues covered.

RESULTS

Local authors generated a large body of evidence of the problem in early studies. The importance of the method of suicide, suicidal intention, and the high incidence of suicide were identified as key foci for publications. Neglected areas have been policy and health service research, gender analysis, and contextual issues.

CONCLUSION

The literature reviewed has produced a broad understanding of the clinical factors, size of the problem, and social aspects. However, there remains limited evidence of prevention, risk factors, health services, and policy. A wide range of solutions have been proposed, but only regulation of pesticides and improved medical management proved to be effective to date.

Policymaking 'under the radar': a case study of pesticide regulation to prevent intentional poisoning in Sri Lanka

BACKGROUND

Suicide in Sri Lanka is a major public health problem and in 1995 the country had one of the highest rates of suicide worldwide. Since then reductions in overall suicide rates have been largely attributed to efforts to regulate a range of pesticides. The evolution, context, events and implementation of the key policy decisions around regulation are examined.

METHODS

This study was undertaken as part of a broader analysis of policy in two parts-an explanatory case study and stakeholder analysis. This article describes the explanatory case study that included an historical narrative and in-depth interviews.

RESULTS

A timeline and chronology of policy actions and influence were derived from interview and document data. Fourteen key informants were interviewed and four distinct policy phases were identified. The early stages of pesticide regulation were dominated by political and economic considerations and strongly influenced by external factors. The second phase was marked by a period of local institution building, the engagement of local stakeholders, and expanded links between health and agriculture. During the third phase the problem of self-poisoning dominated the policy agenda and closer links between stakeholders, evidence and policymaking developed. The fourth and most recent phase was characterized by strong local capacity for policymaking, informed by evidence, developed in collaboration with a powerful network of stakeholders, including international researchers.

CONCLUSIONS

The policy response to extremely high rates of suicide from intentional poisoning with pesticides shows a unique and successful example of policymaking to prevent suicide. It also highlights policy action taking place 'under the radar', thus avoiding policy inertia often associated with reforms in lower and middle income countries.

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

INTRODUCTION

Deaths from suicide reached a peak in Sri Lanka in 1995. Several interventions reduced the suicide rate of 48.7 per 100,000 in 1995 to 23 per 100,000 in 2006, though it is still a major socioeconomic problem. All suicides have to be reported to the Inquirer of Sudden Death (ISD) or 'Coroner', according to the Criminal Procedure Code.

METHOD

All deaths where a verdict of 'suicide' was given after an inquest at the Coroner's Court, Colombo, in 2006 were studied. Close relations or friends who attended the inquest were interviewed by medically qualified research assistants. Age, sex, marital and occupational status, level of education, living circumstances and method and reasons for the suicide were studied.

RESULTS

During 2006, 151 deaths from suicide were documented, of which 93 (62%) were men. The majority (47%) were aged between 20 and 29 years. One-third of the victims was unemployed. At the time of committing suicide, 75% were living with family; 89 (59%) were married and 46 (31%) were single. Poisoning was the cause of death in 66 (44%), 48 (70%) of which were due to pesticides. Burns caused 51 (34%) deaths. Other common causes of death included hanging (11%), jumping in front of a train (7%) and drowning (3%). The commonest reason for suicide was dispute with the spouse/marital disharmony (30%). Other reasons were dispute with parents (8%), financial matters (7%), organic diseases (7%), alcoholism (7%), psychiatric illnesses (6%) and disputes in love affairs (5%). In 29 cases (19%), no definite reason for the suicide was evident.

DISCUSSION

Self-poisoning and self-immolation were the commonest methods used to commit suicide. Marital disharmony was the main reason (30%). Psychiatric illnesses were responsible for only 6%. Future interventional activities should include secure access and restriction of the availability of pesticides and drugs, empowering people to manage anger and conflicts, and recognition and treatment of alcoholism and psychiatric illnesses. The success story of the reduction in the incidence of suicides in Sri Lanka should be a lesson to many developing countries where suicide is a major socioeconomic and health issue.

High incidence of suicide by burning in Masjid-i-Sulaiman (southwest of Iran), a polluted area with natural sour gas leakage

Masjid-i-Sulaiman (MIS) is located in the southwest of Iran. Unfortunately, some parts of MIS are contaminated by subsurface leakage of natural gas containing H(2)S. In order to investigate the possible effect(s) of chronic exposure to sulfur compounds on suicidal behavior, the present study was done. In the 2-year period, 561 individuals attempted suicide (260 men and 301 women). Completed suicide comprised of 19 men and 32 women. The rate per 100,000 person-years was 19.9 for men and 34.8 for women aged over 15 years. Forty-two (13 men and 29 women) of 561 patients were self-immolators by fire with a male:female ratio 0.45. This represents 22.4 burns per 100,000 person-years and is equivalent to 7.4% of all suicide attempts. Thirty-three of 42 patients died (78.6%) who were 9 men and 24 women with male:female ratio 0.37. There is statistically significant differences between sex groups (P((2)) = 0.0091). The self-inflicted burn was the most frequent method for lethal suicide. Winter was the most common season for self-burning followed by spring. Statistical analysis showed significant difference between seasons for self-inflicted burn (P((2)) = 0.00001). Analysis of correlation showed statistically positive correlation coefficient between mean values of all reactive sulfur compounds and seasonal frequency of suicide (r = 0.923, P((1)) = 0.038).

Psychological Analysis of the Sri Lankan Conflict Culture with Special Reference to the High Suicide Rate

Summary: The extremely high suicide rate in Sri Lanka is explained by a psychological analysis of the way in which Sri Lankans deal with conflicts. This “conflict culture” includes psychological factors, such as high rates in collectivism and power distance, repressive education, influence of foreign cultures, religion, and posttraumatic stress symptoms. Structural changes toward another “conflict culture,” including conflict prevention and conflict solution in families and communities, are proposed.

Suicide on the Indian Subcontinent

Summary: The Indian subcontinent comprises eight countries (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Afghanistan, Bhutan, and the Maldives) and a collective population of more than 1.3 billion people. 10% of the world's suicides (more than 100,000 people) take place in just three of these countries, viz. India, Sri Lanka, and Pakistan. There is very little information on suicides from the other four countries. Some differences from suicides in Western countries include the high use of organophosphate insecticides, larger numbers of married women, fewer elderly subjects, and interpersonal relationship problems and life events as important causative factors. There is need for more and better information regarding suicide in the countries of the Indian subcontinent. In particular, studies must address culture-specific risk factors associated with suicide in these countries. The prevention of this important public health problem in an area of the world with myriad socio-economic problems, meager resources, and stigmatization of mental illness poses a formidable challenge to mental health professionals, policy makers, and governments of these countries.

Organic insecticides

Organic insecticide poisoning continues to be a major health problem not only in the developing communities but also in the Western population. The insecticides commonly used are the organophosphates, organocarbamates, organochlorides and pyrethroids. Patients with organic insecticide poisoning present with a spectrum of manifestations ranging from gastrointestinal symptoms of nausea, vomiting and diarrhoea to severe neurological manifestations of fasciculations, seizures and neuromuscular weakness and paralysis or cardiac manifestations of arrhythmias and conduction disturbances. A strong clinical suspicion is necessary to make an early diagnosis of insecticide poisoning. Treatment is primarily supportive and includes decontamination, protection of airways and cardiac and respiratory monitoring. Specific therapy for organophosphates and organocarbamates includes the use of anticholinergics. The use of oximes, especially high dose, is controversial and may be associated with a higher mortality rate. Low-dose oximes given early in the course of the illness may be beneficial. This paper reviews the literature on organic insecticide poisoning worldwide.

Epidemic of self-poisoning with seeds of the yellow oleander tree (Thevetia peruviana) in northern Sri Lanka

Deliberate self-harm is an important problem in the developing world. Ingestion of yellow oleander seeds (Thevetia peruviana) has recently become a popular method of self-harm in northern Sri Lanka -- there are now thousands of cases each year. These seeds contain cardiac glycosides that cause vomiting, dizziness, and cardiac dysrhythmias such as conduction block affecting the sinus and AV nodes. This paper reports a study of the condition's mortality and morbidity conducted in 1995 in Anuradhapura General Hospital, a secondary referral centre serving 750 000 people in Sri Lanka's north central province. 415 cases were admitted to the hospital during 11 months; 61% were women and 46% were less than 21 years old. A prospective study of 79 patients showed that 6% died soon after admission. 43% presented with marked cardiac dysrhythmias which necessitated ther transfer to the coronary care unit in Colombo for prophylactic temporary cardiac pacing. The reasons for the acts of self-harm were often relatively trivial, particularly in children; most denied that they wished to die. Unfortunately, the case fatality rate for oleander poisoning in Sri Lanka is at least 10%. This epidemic is not only causing many unnecessary deaths, it is also putting immense stress on the already stretched Sri Lankan health services. There is an urgent need for an intervention which could be used in rural hospitals, thus preventing the hazardous and expensive emergency transfer of patients to the capital.

Patients with suicidal burns and accidental burns: a comparative study of socio-demographic profile in India

This is a prospective study of 50 consecutive admissions to the burns unit. The socio-demographic data was collected using special proforma and interviewing the patients and relatives. All patients were administered the presumptive stressful life event scale (PSLES). Depending on the presence or absence of suicidal intent, patients were divided into two groups. The two groups were then compared with regards to their socio-demographic profile using the unrelated t-test and the Fisher's exact test. The two groups did not differ significantly with regards to age, sex, education, marital status, occupation or monthly per capita income. The patients who had suicidal intent came from joint family, had more stressful life events and suffered larger burns injuries compared with those who experienced accidental burn injuries. The majority of the patients were below the age of 35, unemployed and females outnumbered males in both the groups.

Suicide and the elderly

Impending demographic changes mean that the proportion of the elderly in the population will increase. Suicide rates increase with age. The literature on elderly suicide, with emphasis on methodology, cross-national rates and trends, correlates, cultural factors, location and method, attempted suicides and prevention, is critically reviewed in this paper.

War and suicide in northern Sri Lanka

A study on the effect of war on the suicide rate in Jaffna town for the 10-year period from 1980 to 1989 is reported. There was a marked drop in the suicide rate during the war, notably among males and youth. An inverse relationship between suicide and homicide rates was shown in the overall trends, particularly in 1987. It is hypothesized that war may function as an alternate to suicide. The use of agrochemicals for suicidal purposes declined during war, while alary seeds became more popular. The method chosen may reflect availability and cultural popularity.

The impact of availability, attraction and lethality of suicide methods on suicide rates in Germany

Substantial fluctuations have prevailed in both the rate and particular methods of suicide in the Federal Republic of Germany during the past 40 years. The current study examines the extent to which the availability, attraction and lethality of particular methods of suicide affect suicide rates. A close relationship existed in the period from 1949 and 1989 between the peaks of the suicide rate and the percentage of low threshold suicide methods according to De Catanzaro, whereby suicide in this context is understood to mean suicide by shooting or intake of solid, liquid or gaseous poisons. Our hypothetically expected lesser compensation between high and low threshold methods for women was confirmed. Between 1963 and 1976 the rate of suicide committed using domestic gas receded dramatically. Within the same period, however, the rate of suicide committed using other poisons rose accordingly.

Suicide and parasuicide in a hill resort in Malaysia

Ninety-five cases of suicide and 134 cases of parasuicide that occurred between October 1973 and September 1984 in the hill resort district of Cameron Highlands in Malaysia were analysed. Eighty-one per cent of suicides and 78% of parasuicides were of Indians, although they only form 25% of the population. The average annual suicide rate for Indians (over 10 years of age) was 157 per 100,000. About 94% of suicides and 66% of parasuicides were by ingesting agricultural poisons. The age- and sex-specific suicide rates for women were highest in the 20-24-year-old age group. Some possible reasons for high suicide rates among Indians are discussed.

Fatal deliberate self-harm seen in a Sri Lankan Hospital

A total of 328 patients were admitted for deliberate self harm (DSH) to the General Hospital Jaffna, Sri Lanka, during the year 1984. Twenty-two of these patients succumbed to their injuries. Information about these patients collected before death, and their methods of suicide, are reported.