INDIAN PSYCHOSOCIAL FOUNDATION
 
   INDIAN PSYCHOSOCIAL FOUNDATION
         
IJPS >
IJPS April 2011
IJPS October 2011
IJPS April 2012
IJPS October 2012
IJPS April 2013
IJPS October 2013
IJPS Apirl 2014
IJPS October 2014
IJPS Apirl 2015
IJPS Apirl 2016
IJPS October 2016
IJPS Apirl 2017
 
 
 
SUICIDE

SUICIDE: AN URGENT APPRAISAL

Netranee Anju Ramdinny-Purryag

Consultant Psychiatrist St. Jeen Pharmacy, Mauritius

 

 

Abstract

WHO estimates that each year, approximately one million people die from suicide, which represents a global mortality rate of 16 people per 100,000 or one death every 40 seconds? It is predicted that by 2020, the rate of death will increase to one every 20 seconds. In the last 45 years, suicide rates have increased by 60% worldwide Suicide is now among the 3 leading causes of death among those aged 15-44 (male & female). Suicide attempts are up to 20 times more frequent than completed suicides. Nearly 30% of all suicides worldwide occur in India and China

Introduction


Suicide has been common throughout history. While Romans considered suicide as permissible, provided one was not a soldier or a slave (that is of economic value to the state), Socrates regarded suicide as against God’s will but permissible if God sent ‘necessity’ on man.  Christian clerics condemned suicide in AD 452, and Islamic texts proscribe suicide. Emile Durham viewed suicide as a social phenomenon occurring under 4 conditions:

·         Anomic (a social environment lacking norms)

·         Egoistic (an individual detached from society)

·         Altruistic (suicide for greater social good)

·         Fatalistic (to die rather than to endure oppression)

Global Statistics

The WHO further reports that:

·         In the last 45 years, suicide rates have increased by 60% worldwide. Suicide is now among the 3 leading causes of death among those aged 15-44 (male & female). Suicide attempts are up to 20 times more frequent than completed suicides.

·         Although suicide rates have traditionally been highest among elderly males, rates among young people have been increasing to such an extent that they are now the group at highest risk in a third of all countries.

·         Mental health disorders (particularly depressive disorders & substance abuse) are associated with more than 90% of all cases of suicide.

·         In Europe, particularly Eastern Europe, the highest suicide rates are reported for both men and women.

·         The Eastern Mediterranean region and central Asia republics have the lowest suicide rates.

·         Nearly 30% of all suicides worldwide occur in India and China.

·         Suicides globally by age are as follows: 55% are aged between 15 to 44 years & 45% are aged 45 years and above.

·         Youth suicide is increasing at the greatest rate.

Statistics on suicide in India

In India half million people reported to die of suicide worldwide every year, it was 20% and slightly above the world wide is reported in India. In the last two decades, the suicide rate has increased in southern regions from 7.9 to 10.3 per 100,000..1 In a study June 2012, the estimated number of suicides in India in 2010 was about 187,000.2 A large proportion of adult suicide deaths were found to occur between the ages of 15 years and 29 years, especially in women. Suicide attempters are ten times the suicide completers.

Neurobiology of suicide

1.       Elevated plasma and urinary levels of cortisol and decreased output of urinary homovanillic acid (HVA) have been found in patients who attempt suicide in comparison with non-suicidal patient controls.3-4

2.       Studies of 5-hydroxyindoleacetic acid (5HIAA-a major metabolite of serotonin) in the CSF have produced convergent results, including:5

·         Lower 5-HIAA levels in suicide attempters and completers than in control

·         Lower 5-HIAA levels in high lethality compared with low lethality attempters

·         Low 5-HIAA associated with greater impulsivity and likelihood of repetition

·         Studies of the association between CSF-5HIAA levels and the tryptophan hydroxylase (TPH) gene reveal that carriers of 779C allele for TPH gene are more likely to have low CSF-5HIAA concentrations 6

·         Blunted prolactin response to fenfluramine in suicide attempters

·         Decreased 5-hydroxytryptamine (5-HT) uptake, fewer serotonin transporter (5-HTT) sites and increased density of 5-HT2A receptors in the platelets of suicide attempters7-8

3-Postmortem brain studies of suicide cases include:

·         Decreased binding sites for corticotrophin- releasing hormone (CRH)9

·         Decreased presynaptic serotonergic binding sites

·         Increased gene expression of 5-HT2A receptors10

4-Abnormalities have also been described in noradrenalin function, for example fewer noradrenergic neurones in the locus coeruleus of suicide cases and lower levels of postsynaptic adrenergic receptors in the cortex.11

Risk factors for suicide

(i)     Biopsychosocial factors

·         Mental disorders, particularly mood disorders, schizophrenia, anxiety disorders and personality disorders

·         Alcohol and other substance use disorders

·         History of trauma or abuse

·         Major physical illnesses

·         Previous suicide attempt

·         Family history of suicide

(ii)   Environmental factors

·         Job or financial loss

·         Relational or social loss

·         Easy access to lethal means

·         Local clusters of suicide which have a contagious influence

(iii) Sociocultural factors

·         Lack of social support and sense of isolation

·         Stigma associated with help-seeking behaviour

·         Barriers to accessing health care, especially mental health and substance abuse treatment

·         Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma.

·         Exposure through the media and influence by others who have died by suicide

Protective factors for suicide

·         Effective clinical care for mental, physical and substance use disorders

·         Easy access to a variety of clinical interventions and support for help seeking.

·         Restricted access to highly lethal means of suicide

·         Strong connections to family and community support

·         Support through ongoing medical and mental health care

·         Skills in problem solving, conflict resolution and non violent handling of disputes

·         Cultural and religious beliefs that discourage suicide and support self-preservation

However, positive resistance to suicide is not permanent. So, programs that support and maintain protection against suicide should be ongoing.

Controversies on risk and protective factors for suicide/ attempted suicide

Information about risk and protective factors for attempted suicide is more limited than on suicide. One problem in studying non lethal suicidal behaviours is a lack of consensus about what actually constitutes suicidal behaviour.12

The following questions arise:

·         Should self-injurious behaviour in which there is no intent to die is classified as suicidal behaviour?

·         If intent defines suicidal behaviour, how is it possible to quantify a person’s intent to die?

The lack of agreement on such issues makes valid research difficult to conduct. As a result, it is not yet possible to say with certainty that risk and protective factors for suicide and non-lethal forms of self-injury are the same. Some authors argue that they are, whereas others accentuate differences.13

 

Suicide Methods worldwide

 

1.      Suicide by exsanguinations

The carotid, radial, ulnar or femoral arteries may be targeted. Death may occur directly as a result of hypovolaemia.

2.      Wrist cutting 

Wrist cutting is sometimes practised with the goal of self-mutilation and not suicide. In the case of a failed suicide attempt, the person may experience injury of the tendons of the extrinsic flexor muscles, or the ulnar and median nerves which control the muscles of the hand, both of which can result in temporary or permanent reduction in the victim’s sensory and/or motor ability and/or also cause chronic somatic or autonomic pain.14

3.      Drowning

It is among the least common methods of suicide, typically accounting for less than 2% of all suicides in the USA. Due to the body’s natural tendency to come up for air, drowning attempts often involve the use of a heavy object to overcome this reflex. As the level of carbon dioxide in the victim’s blood rises, the CNS sends the respiratory muscles an involuntary signal to contract and the person breathes in water.

4.      Suffocation

One is more likely to commit suicide by breathing toxic gases, instead of preventing breathing. Helium, argon, nitrogen and carbon monoxide are commonly used in suicides by suffocation. Breathing inert gas quickly and painlessly renders a person unconscious and may cause death within minutes.

5.      Jumping from height

This method, in most cases, results in severe consequences if the attempt fails, such as paralysis, organ damage and bone fractures.In Hong Kong, jumping is the most common method of committing suicide, accounting for 52.1% of all reported suicide cases in 2006 and similar rates for the years prior to that.

There have been several documented cases of suicide by studying people who deliberately failed to open their parachutes (or removed it during free fall) and were found to have left suicide notes.15, 16

6.      Firearm

A failed suicide attempt by firearm may result in severe chronic pain for the patient, as well as reduced cognitive abilities and motor function, subdural hematoma, foreign bodies in the head, pneumocephalus and CSF leaks. For temporal bone directed bullets, temporal lobe abscess, meningitis, aphasia, hemianopsia and hemiplegia are common late intracranial complications. As many as 50% of people who survive gunshot wounds directed at the temporal bone suffer facial nerve damage, usually due to a severed nerve.

7.      Hanging

Hanging is the prevalent means of suicide in pre-industrial societies, and is more common in rural areas than in urban areas. It is also a common means of suicide in situations where other materials are not readily available, such as in prisons.

8.      Vehicular Impact

Committing suicide by deliberately placing oneself in the path of a large and fast moving vehicle, results in a fatal impact. Suicide by train impact has resulted in a 90% death rate, making it one of the most fatal suicide methods. As the trains usually travel at high speeds (usually between 80 and 200 km/h), the driver is usually unable to bring the train to a halt before the collision. This type of suicide may be traumatizing to the driver of the train and may lead to post traumatic stress disorder.

9.      Poison

Worldwide, 30% of suicides are from pesticide poisonings. The use of this method, however, varies markedly in different areas of the world, from 4% in Europe to 75% in the Pacific region.17 Poisoning by farm chemicals is very common among females in the Chinese countryside, and is regarded as a major social problem in the country. Death with carbon monoxide usually occurs through hypoxia. Carbon monoxide is in most cases used because it is easily available as a product of incomplete combustion; for example, released by cars.

10.  Drug Overdose

A typical drug overdose uses random prescription and over the counter substances. In this case, death is uncertain, and an attempt may leave a person alive but with severe organ damage, although that in itself may in turn eventually prove fatal. Considering the very high doses needed, vomiting or losing consciousness before taking enough of the active agent is often a major problem for people attempting this. Analgesic overdose attempts are among the most common, due to easy availability of over-the- counter substances.18

Methods of suicide in India

Poisoning (36.6%), hanging (32.1%) and self-immolation (7.9%) were the common methods used to commit suicide.1

Suicide and Mental Disorders

In Barrowclough and colleagues’ historic study of 100 cases of suicide, the ante mortem psychiatric state was considered to be depression in 70%, alcoholism in 15% of cases, schizophrenia in 3% and other diagnoses in 2% and not mentally ill in 7% of cases.19 This study was pivotal in portraying suicide as consequent on mental illness, and subsequent studies have produced convergent findings.20-23

Cases of suicide with any axis 1 diagnosis constituted 80-90% of the total suicides in most studies.


Diagnoses in completed suicide (DSM, Diagnostic and Statistical Manual of Mental Disorders):

Principal diagnosis

%

1.       Depressive Disorder

32

2.       Substance-related Disorder

20

3.       Personality disorder

10

4.       Anxiety Disorder

10

5.       Schizophrenia

9

6.       Other DSM-1V diagnoses

5

7.       No mental disorder

5

8.       Insufficient Information

5

9.       Bipolar Mood Disorder

3

10.   Organic disorder

1

11.   Schizoaffective & other psychoses

< 1

 

Clinical signs of suicide

1.

Talking about suicide

Any talk about suicide, dying or self-harm, such as

‘I wish I hadn’t been born’. ‘If I see you again....’ and ‘I’d be better off dead.’

2.

Seeking out lethal means

Seeking access to guns, pills, knives or other objects that could be used in a suicide attempt.

3.

Preoccupation with death

Unusual focus on death, dying or violence. Writing poems or stories about death.

4.

No hope for the future

Feelings of helplessness, hopelessness and being trapped. Belief that things will never get better or change.

5.

Self-loathing, self-hatred

Feelings of worthlessness, guilt, shame and self-hatred. Feeling like a burden.

6.

Getting affairs in order

Making out a will. Giving away prized possessions. Making arrangements for family members.

7.

Saying goodbye

Unusual or unexpected visits or calls to family and friends. Saying goodbye to people as if they won’t be seen again.

8.

Withdrawing from others

Withdrawing from friends and family. Increased social isolation. Desire to be left alone.

9.

Self-destructive behaviour

Increased alcohol or drug use, reckless driving, unsafe sex. Taking unnecessary risks as if they have a ‘death wish.’

10.

Sudden sense of calm

A sudden sense of calm and happiness after being extremely depressed can mean that the person has made a decision to commit suicide.

 


Treatment factors

Some medications may be pro-suicidal and others anti-suicidal.

SSRIs

 In adults aged 19-64 years, SSRI use is not associated with any suicide attempts or suicide deaths.24

In children and young people aged 6-18 years, SSRI use is associated with suicide attempts and suicide deaths.25

In elderly people, there is an association between violent suicide and SSRIs but not with other antidepressants.26

Lithium

Current data support the view that lithium is specifically anti-suicidal in comparison with placebo and other mood stabilisers in bipolar disorder and its use would be associated with 50% fewer suicides than might otherwise be the case.27

Suicide prevention

Approaches to suicide prevention can be grouped as follows:

·         Whole population strategies:

·         Proposed approaches include improving social welfare (eg employment, housing), school and work place mental health promotion, action on alcohol and drugs, and controlling access to means of suicide (eg plastic-bag design, firearms).

·         High risk subgroup strategies:

·         Providing counselling services for socially dislocated young males, offering assistance for children needing care, improving the assessment of parasuicide cases in accident and emergency departments and improving the recognition of depression in the general population.

 

·         The Gotland study demonstrated that educating the  general practitioners in the treatment of depression reduced that island’s suicide rate, although some authors have disputed the generalizability of the findings.28

·         Case by case intervention:

·         A conventional account is to view the relevant risk factors as (1) static (2) stable (3) dynamic and (4) future. Although the format provides no calculus for the risk of suicide (eg if a person got married but lost their job, would there be a net increase or decrease in their suicide potential?), it is nevertheless a suitable one for articulating the evaluation of a patient.


·          

 

Static factors

Stable factors

Dynamic factors

Future factors

Gender

 

Family background

 

History of overdose

 

Childhood deprivation

Age

 

Enduring mental illness

 

Personality

 

Marital/parenting status

 

Life skills

Substance Abuse

 

Anxiety symptoms

 

Relationship conflict

 

Cognitions

 

Compliance with treatment

Response to treatment

 

Bereavement

 

Onset of physical disease

 


General principles of Management

1.       Inpatient hospitalization is warranted for high risk patients.

2.       A treatment plan should include the following:

·         Management of psychiatric symptoms, particularly anxiety/agitation and insomnia.

·         Treatment of substance abuse

·         Consider close observation/24 hr supervision as indicated

·         Remove lethal means and document discussion with patient  and significant others

·         Coordinate treatment plan with family and/or significant others

·         Exploration of social support to decrease isolation and to provide for safety and empathy

·         Frequent visits for serial suicide risk assessments, including careful documentation

·         Electroconvulsive therapy may be indicated for severe and/or refractory depression, psychotic depression and/or catatonic features.

·         Actions include removal of firearms, frequent visits for serial suicide risk assessments, careful pharmacologic management with limited supply of drugs to avoid overdose and maintenance of therapeutic alliance with patient

In India

A three pronged attack to combat suicide suggested in a 2003 monograph was

·         Reducing social isolation

·         preventing social disintegration and

·         treating mental disorders.29

 Additionally, a set of state led policies are being enforced to decrease the high suicide rate among farmers of Karnataka. 30

Conclusion

The World Suicide Prevention is celebrated annually on the 10th of September. The World Health Organization has put as theme for this year: Suicide Prevention across the globe, aiming to sensitize the world population about the preventive measures which can be taken to prevent suicide. Suicide prevention requires the collaborative efforts of governments, doctors inclusive of psychiatrists, medical personnel, family members and inclusive of patients. Recognizing suicidal ideation and taking prompt action in case of suicidal ideation and attempt remains the crux to curb the dangerous toll suicide has taken globally.

References

1.       Vijaykumar L. Suicide and its prevention. The urgent need in India. Indian Journal of Psychiatry 2007; 49: 81-84.

2.       Ramasundarahettige C, Vijayakumar L, Thakur JS, Gajalakshmi V, Suraweera W. Suicide Mortality in India. A nationally representative survey. The Lancet 2012; 379:2343.

3.         Coryell W, Schlesser M. The dexamethasone suppression test and suicide prevention. American Journal of Psychiatry 2001; 158:748-53.

4.         Norman WH, Brown WA, Miller IW et al. The dexamethasone suppression test and completed suicide. Acta Psychiatrica Scandinavica 1990; 81:120-25.

5.         Roggenbach J, Muller-Oerlinghausen B, Frank L. Suicidability, impulsivity and aggression: is there a link to 5HIAA concentration in the CSF? Psychiatric Research 2002; 113:193-206.

6.         Joiner TE, Brown JS, Wingate LR. The psychology and neurobiology of suicidal behaviour. Annual Review of Psychology 2005; 56: 287-314.

7.         Pandey GN, Pandey SC, Dwivedi Y et al. Platelet serotonin-2 receptors: a potential biological marker for suicidal behaviour. American Journal of Psychiatry 1995; 152: 850-55.

8.         Pandey GN, Pandey SC, Janicak PG et al. Platelet serotonin-2 receptor binding sites in depression and suicide. Biological Psychiatry 1990; 28: 215-22.

9.         Mann JJ, Malone KM. CSF amines and higher lethality suicide attempts in depressed patients. Biological Psychiatry 1997; 41: 162-71.

10.     Numeroff CB, Owens MJ, Bissette G, et al. Reduced corticotrophin-releasing factor binding sites in the frontal cortex of suicide victims. Archives of General Psychiatry 1988; 45:577-9.

11.     Mann JJ. A current perspective of suicide and attempted suicide. Annals of Internal Medicine 2002; 136:302-11.

12.     Griffiths C, Ladva G, Brock A, Baker A. Trends in suicide by marital status in England and Wales 1982-2005. Health Statistics Quarterly 2003; 20: 25-37.

11. Carroll O, Berman AL, Maris RW et al. Beyond the tower of Babel: A nomenclature for suicidology. Suicide and life-threatening Behaviour 1996; 26: 237-252.

12. Duberstein PR, Conwell Y, Seidlitz L et al. Personality traits and suicidal behaviour and ideation in depressed inpatients 50 years of age and older. Journal of Gerontology 2000; 55B: 18-26.

13. Bukhari AJ, Saleem M, Bhutta AR et al. ‘Spaghetti wrist: management and outcome’. J Coll Physicians Surg Pak 2004; 14(10): 608-11.

14. Eckert WG, Reals WS. ‘Air disaster investigation’. Legal Medicine Annual 1978:   57-70.

15. Dolinak D, Evan W. Forensic pathology: principles and practice. Academic Press   2005: 293.

16. Gunnell D, Eddleston M, Phillips MR, Konradsen F. The global distribution of fatal pesticide self-poisoning: Systematic review. BMC Public Health 2007; 7:3 57.

17. Brock A, Sini D, Clare G. Trends in suicide by method in England and Wales. Health Statistics Quarterly 1979-2001; 20: 7-18.

18. Ameerbeg SAG. Mauritius Institute of Health. A study of risk factors associated with suicide among suicide attempters in Mauritius. Mauritius Research Grant Scheme 2001-2003.

19. Barraclough B, Bunch J, Nelson B, Sainsbury P. A hundred cases of suicide: clinical aspects. British Journal of Psychiatry 1974; 125: 355-73.

20. Rich CL, Young D, Fowler RC. San Diego Suicide Study 1: young vs. Old subjects. Archives of General Psychiatry 1986; 43: 577-82.

21. Isometsa E, Henriksson M, Marthinon M et al. Mental disorders in young and middle aged men who commit suicide. British Medical Journal 1995; 310:1366-7.

22. Cheng AT. Mental illness and suicide: a case-control study in east Taiwan. Archives of General Psychiatry 1995; 52: 594-603.

23. Conwell Y, Duberstein PR, Cox C et al. Relationships of age and Axis 1 diagnoses in victims of completed suicide: a psychological autopsy study. American Journal of Psychiatry 1996; 153:1001-8.

24. Gunnell D, Saperia J, Ashby D. Selective Serotonin Reuptake Inhibitors ( SSRIs) and suicide in adults: meta-analysis of drug company data from placebo controlled, randomised controlled trials submitted to the MHRA’s safety review. British Medical Journal 2005; 330: 385-9.

25. Olfson M, Marcus SC, Shaffer D. Antidepressant drug therapy and suicide in severely depressed children and adults: a case-control study. Archives of General Psychiatry 2006; 63: 865-72.

26. Juurlink DN, Mamdani MM, Kopp A, Redelmeier DA. The risk of suicide with selective serotonin reuptake inhibitors in the elderly. American Journal of Psychiatry 2006; 163: 813-21.

27. Cipriani A, Pretty H, Hawton K, Geddes JR. Lithium in the prevention of suicidal behaviour and all cause mortality in patients with mood disorders: a systematic review of randomized trials. American Journal of Psychiatry 2005; 162: 1805-19.

28. Rutz W, Von Knorring L, Walinder J. Frequency of suicide on Gotland after systematic postgraduate education of general practitioners. Acta Psychiatrica Scandinavica 1989;80: 151-4.

29. Deshpande RS. Suicide by farmers in Karnataka: Agrarian Distress and possible alleviatory steps. Economics and Political weekly 2002; 13(25): 206-210.

30. Singh AR, Singh SA. Towards a suicide free society. Identify suicide prevention as public health policy. Mens Sana Monographs 2003; 11(2), 3-16.