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
Anomic (a social
environment lacking norms)
individual detached from society)
(suicide for greater social good)
die rather than to endure oppression)
The WHO further reports that:
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
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.
health disorders (particularly depressive disorders & substance abuse) are
associated with more than 90% of all cases of suicide.
Europe, particularly Eastern Europe, the highest suicide rates are reported for
both men and women.
Eastern Mediterranean region and central Asia republics have the lowest suicide
30% of all suicides worldwide occur in India and China.
globally by age are as follows: 55% are aged between 15 to 44 years & 45%
are aged 45 years and above.
suicide is increasing at the greatest rate.
on suicide in India
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
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
2. Studies of 5-hydroxyindoleacetic
acid (5HIAA-a major metabolite of serotonin) in the CSF have produced
convergent results, including:5
levels in suicide attempters and completers than in control
levels in high lethality compared with low lethality attempters
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
prolactin response to fenfluramine in suicide attempters
5-hydroxytryptamine (5-HT) uptake, fewer serotonin transporter (5-HTT) sites
and increased density of 5-HT2A receptors in the platelets of suicide
studies of suicide cases include:
sites for corticotrophin- releasing hormone (CRH)9
presynaptic serotonergic binding sites
expression of 5-HT2A receptors10
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
disorders, particularly mood disorders, schizophrenia, anxiety disorders and
other substance use disorders
trauma or abuse
(ii) Environmental factors
Job or financial
Easy access to
of suicide which have a contagious influence
(iii) Sociocultural factors
Lack of social
support and sense of isolation
associated with help-seeking behaviour
accessing health care, especially mental health and substance abuse treatment
and religious beliefs (for instance, the belief that suicide is a noble
resolution of a personal dilemma.
the media and influence by others who have died by suicide
Protective factors for suicide
care for mental, physical and substance use disorders
Easy access to a
variety of clinical interventions and support for help seeking.
access to highly lethal means of suicide
connections to family and community support
ongoing medical and mental health care
problem solving, conflict resolution and non violent handling of disputes
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:
self-injurious behaviour in which there is no intent to die is classified as
defines suicidal behaviour, how is it possible to quantify a person’s intent to
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
Suicide by exsanguinations
The carotid, radial, ulnar or femoral
arteries may be targeted. Death may occur directly as a result of hypovolaemia.
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
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.
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.
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,
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
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.
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.
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.
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
of suicide in India
Poisoning (36.6%), hanging
(32.1%) and self-immolation (7.9%) were the common methods used to commit
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.
General principles of Management
hospitalization is warranted for high risk patients.
2. A treatment plan
should include the following:
of psychiatric symptoms, particularly anxiety/agitation and insomnia.
of substance abuse
close observation/24 hr supervision as indicated
lethal means and document discussion with patient and significant others
treatment plan with family and/or significant others
of social support to decrease isolation and to provide for safety and empathy
visits for serial suicide risk assessments, including careful documentation
therapy may be indicated for severe and/or refractory depression, psychotic
depression and/or catatonic features.
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
A three pronged attack to
combat suicide suggested in a 2003 monograph was
social disintegration and
Additionally, a set of
state led policies are being enforced to decrease the high suicide rate among
farmers of Karnataka. 30
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
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