Suicide -

Current Maze & Future Movement

by
Dr. Lakshmi Vijayakumar
M.B.B.S., D.P.M., Ph.D., FRCPsych. (Hon.)
Founder, SNEHA
Member, W.H.O. International Network for Suicide Research
Hon . Associate Professor, University of Melbourne
Member, International Academy of suicide research
Global Suicide rates, 2008
 Distribution of WHO regions by change in total suicide rate since 2000
(Mishara, 2010, based upon WHO 2009 latest year available)

100%
17.1% 83.8% 97.8% 81.8% 95.5%

90% 15.1%

17.0%
80% 40.0%

70%

67.9%
60%

No data
50%
Increased
Decreased
40% 42.9%

30%

20%
18.2%
13.5%
10%

2.7% 2.2% 4.5%

0%
Region of the Americas European Region Western Pacific Region African Region South-East Asia Region Eastern Mediterranean Region
 Magnitude
• Suicide 1 million
• Suicidal Attempts 10 – 20 million
• Affected by Suicide 50 – 120 million

• 1998 1.8% Global burden

• 2010 2.4%
 500,000 suicides a year

61% of world suicides

 A global perspective on the magnitude of suicide mortality
60
Male
50
Female
40

30

20

10

0
5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 +

5 – 14 15 – 24 25 – 34 35 – 44 45 – 54 55 – 64 65 – 74 75 +
Male 1.4 21.1 29.3 37.0 42.5 40.9 40.7 52.1
Female 0.4 4.8 6.2 7.8 9.7 10.6 12.3 15.9
 Gender Specific Rates
Suicide rate

Gender HDI Asia Transition Economics Europe & South & Total
Level North Central
Central Asia Europe America Americas &
Aus. & NZ the
caribbean

Medium 12.5 17.5 61.2 NA 5.9 15.4

Male HDI
High 20.4 NA 36.1 19.5 8.6 19.3
HDI

Medium 13.0 3.8 11.7 NA 1.8 11.7

Female HDI
High 9.8 NA 8.7 5.8 2.5 5.9
HDI
 CDC Uniform Definitions for
Self-Injurious Behavior
Self-injurious behavior

Suicidal self-injurious Undetermined self- Non-suicidal self-

behavior injurious behavior injurious behavior

Suicide Suicide Other suicidal

(death) attempt behaviors*

* Other behaviors with some intent to die that are not suicide or suicide attempt such as
interrupted attempts or aborted attempts A. Crosby (2009)
 Ecological Model

Society Community Individual

Peer/Family
 Suicide and Mental Disorders: general population studies (N=15,629)

No diagnosis 3.2%

Other DSM axis I diagnosis 5.1%

Mood disorders
Adjustment disorders 3.6%
35.8%

Anxiety/somatoform disorders 6.1%

Other psychotic disorders 0.3%

Organic mental disorders 1.0%

Personality disorders
11.6%

Schizophrenia
10.6%

Substance-related disorders
(8205 cases, 12292 diagnoses)
22.4%
 Life time risk of suicide
• Life time risk of suicide following onset of mental disorders have been
estimated to be high.

• In an often cited review Miles (1977) estimated that 15 percent of

persons affected with depression would die from suicide, 15 per cent
with alcoholism and 10 per cent with schizophrenia.

•
A complete national sample of all persons born in Denmark between 1
January 1955 and 31 December 2006 (3.51 million people)

• Danish Psychiatric Case register (since 1969)

• Danish National Patient Register (since 1979)
• Danish Cause of Death Register (1970-2006)

• M Nordentoft in press
 Cumulative absolute risk of suicide
Men Women
Disorder Cumulative incidence (95% Cumulative incidence (95%
confidence interval) confidence interval)
Schizophrenia 6.47 (5.78-7.25) 4.87 (4.00-5.93)

Schizophrenia like disorders 5.72 (5.06-6.46) 3.97 (3.23-4.88)

Bipolar affective disorder 7.63 (5.91-9.85) 4.74 (3.46-6.50)

Other affective disorders 6.54 (5.61-7.63) 3.70 (3.00-4.56)

Substance abuse, psychiatric 4.68 (4.22-5.19) 3.42 (2.86-4.09)
Substance abuse , somatic 2.44 (2.13-2.81) 1.63 (1.33-2.00)

Anorectic disorder 6.42 (2.62-15.73) 1.97 (0.87-4.44)

Any mental illness 3.63 (3.36-3.91) 1.89 (1.68-2.12)

No mental illness 0.68 (0.60-0.78) 0.20 (0.14-0.28)
 Co-morbid substance abuse –
Cumulative absolute risk of suicide

Men Women
Disorder Cumulative incidence (95% Cumulative incidence (95%
confidence interval) confidence interval)
Schizophrenia 5.82 (4.86-6.97) 6.78 (4.78-9.61)

Schizophrenia like disorders 6.17 (5.15-7.40) 5.68 (4.36-7.40)

Bipolar affective disorder 9.89 (6.33-15.48) 5.09 (2.76-9.38)

Other affective disorders 6.71 (5.22-8.62) 6.95 (4.65-10.37)

Anorectic disorder 6.59 (1.74-24.96) 4.40 (2.28-8.46)

 Mental disorders & suicide
India China Taiwan

Depression 35% 40% 89%

Schizophrenia 8% 7% 7.9%

Comorbidity 30% 6% 55%

Prior psychiatric treatment 10% 7% 25%

Alcoholism 34% 7% 44%

• Previous Suicide Attempt (26 – 42%)

• Family history of Suicide and Mental Disorders (12 – 18%)

Personality Characteristics

1. Impulsivity / Aggressive

2. External Locus of Control

3. Hopelessness

4. Reduced Specific Memory

 Genes and Suicidality

• Genes 43% Environment 57%

• TPH2, 5HT2A Receptor gene

• 5HTTLPR Polymorphism SS, SL & LL

• SS & SL – Left frontal, prefrontal & middle temporal gyri

Source: Morrell S et al, Soc. Sci. Med. 1993; Vol 36, 6, 749-756
Results: trends in suicide rates in East Asia

Chang et al Soc Sci Med 2009

 Association between unemployment and suicide rates
(non poisons and gases) in 25-34 year old males (1921-1995)
10.00

9.00

8.00
Suicide rate per 100,000

7.00

6.00

5.00

4.00

3.00

2.00

1.00

0.00
0.00 5.00 10.00 15.00 20.00 25.00
Proportion of w orking population unem ployed
Gunnell et al BJPsych 1999
 SEV & Suicide Rate
Socio-economic Annual suicide rate
variables Total Male Female

Human Development + 0.21 (n = 26) + 0.27 (n = 24) - 0.12 (n = 24)

index, 1995

Human Development + 0.19 (n = 33) + 0.24 (n = 31) - 0.01 (n = 31)

Index, 2001

Education Index + 0.26 (n = 33) + 0.31** (n = 31) - 0.06

2001

Urban population + 0.03 (n = 33) + 0.18 (n = 31) - 0.04 (n = 31)

as a percent of
total population 2001

Telephone density + 0.36* (n = 33) + 0.44* (n = 31) + 0.32** (n = 31)

2001

Gender development + 0.26 (n = 27) + 0.26 (n = 25) + 0.004 (n = 25)

index 2001
 SEV & Suicide Rate (Contd...)
Socio-economic Annual suicide rate
variables Total Male Female
Gini Ratio - 0.33** (n = 29) - 0.31** (n = 27) - 0.23 (n = 27)
(inequality)
Cigarette consumption + 0.41* (n = 27) + 0.46* (n = 25) + 0.40* (n = 25)
per head
Alcohol (total) + 0. 13 (n = 30) + 0.20 (n = 29) - 0.02 (n = 29)
consumption per head
Alcohol consumption + 0.19 (n = 30) + 0.23 (n = 29) + 0.24 (n = 29)
(spirits) per head
Unemployment rate + 0.08 (n = 19) + 0.14 (n = 17) - 0.15 (n = 17)
2001
Crime rate - 0.03 (n = 15) - 0.007 (n = 15) - 0.14 (n = 15)
(in major cities)
Pesticide consumption - 0.06 (n = 24) - 0.10 (n = 22) - 0.25 (n = 22)
(per hectare of land)
 Domestic violence & suicidal ideation

Brazil 48% India 64%

Egypt 61% Indonesia 11%

Phillippines 28%
 Proportion of suicides (%) in Hong Kong
70
Hanging Jumping Poisioning Charcoal burning Others

60

50

40

30

20

10

0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
 Religion & Countries
Suicide rates according to religion (per 100,000)
45

40
35
30
25

20
15
10

5
0
Buddhist Christian Hindu Muslim Atheist
1986 1994 1995 1985,87 1995,96

total male female

 TBI and Suicide [ 1979 – 1993 ]
No Suicide SMR
• Concussion 126114 750 3.0
• Cranial fracture 7560 46 2.7
• Cerebral contusion and ICM 11766 99 4.1

↑ Females Age 21 – 59 years

(Teasdale & Engberg JNN S& Psy, 2001)
• Refugees 15.2 million

• Asylum seekers 827,000 (0.83 m)

• IDP 26 million

• Repatriated 604,000
 Location

• 80% in developing countries

• 50% in urban areas

• 33% in refugee camps

 Socio demographic factors
• Age 25 – 40

• Gender Females

• Marital status Single

• SES Higher, Educated

• Countries Far and S.E. Asia

Eastern Europe
Latin America
 Method

• Blunt force Jumping

• Water torture Drowning

• Sharp force Stabbing / cutting

One million refugees and A.S.

at risk of suicide
 Cyber suicides [ Japan ]

100 91

• First in October 2000 75

50
50
• Published 2003 34

25

0
2003 2004 2005
 Cyber bullying

• Online bullying - 1/3 of children

• Every 30 mts a child attempts suicide due to bullying
 Suicide Prevention Strategies
Environmental Psychopharmacology

• Reduced access to Methods • Lithium

• Enlightened Media Reporting • Clozapin

• Cluster Prevention Psychotherapy

Individuals at Risk • D.B.T.

• Identifying and Easy access

• Education of GPs

• Crisis Line
 Biopsychosocial Environmental Sociocultural

Universal Screening for  access to Positive portrayal

alcoholism Pesticide of women in media
 alcohol

Selective Improve recognition Prevent Pre / Post exam

& referral of M.D. Domestic counseling
by crisis workers Violence Assertiveness
Intergenerational
Conflict resolution

Indicated A.D. in P.H.C. Safe haven Community support

Management for suicidal
of poisoning
 Alcohol consumption
↓ 1 litre of alcohol consumption ↓ in suicide rate
• Sweden 13%
Perestroika
• Hungary 5% 1984 – 84
• USA & Canada 4% Men ↓ 32%
• France & Protugal 3% Women ↓ 19%
• Switzerland 0%
 Edge study
• Post Cards W 1, 2, 3, 4, 6, 8, 10, 12

TAU INT

394 378

Repetition 21.2% 22.8%

 Cumulative readmissions to hospital for treatment of self-poisoning
(24 months; unadjusted for multiple admissions).

Carter, G. L. et al. Br J Psychiatry 2007;191:548-553

 Pesticides
300,000 deaths in South Asia & Asia Pacific

 toxicity  medical management

 access  bio pesticides
 Suicide & Attempted suicide
Study villages A & B in North Western Province
Year Study Village A Study Village B
Total Deaths Total Deaths
attempts attempts
2000 2 0 1 0

2001 1 0 3 0

2002 3 0 1 0

2003 6 0 2 1

2004 3 1 1 0

2005 0 0 0 0
 Suicide & Attempted suicide
Control villages A1 & B1 in North Western Province

Year Control Village A1 Control Village B1

Total Deaths Total Deaths
attempts attempts
2000 0 0 1 1

2001 1 1 2 2

2002 1 0 0 0

2003 2 0 4 1

2004 4 2 1 0

2005 4 0 2 1
Suicide in NPM Villages
Village Year Before NPM After NPM
Punnukula 2001 3 -
Pullaigudem 2003 3 1
Kodipunjalavagu 2002 4 1
Devijathanda 2003 4 1

Suicides in CP Villages
1998 - 2003 2003 - 2006
Keshavapuram 4 2
Pandurangapuram 5 3
Rangapuram 3 2
Bikkuthanda 3 1
 Lives saved

• 15% ↓ in pesticide suicide 45,000

• 1 litre ↓ in alcohol 30,000

75,000 lives
can be saved
every year
Thank You