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Suicide and its prevention: a global perspective

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Introduction: Suicide is the tragic and untimely loss of human life all the more devastating and perplexing because it is a conscious volitional act. Suicides have occurred since the beginning of recorded history. The word " Suicidium " was first coined by Desfontaines in the 17th century. In English it was first used by Browne in Religio Medici in 1643. Legal and religious prescriptions against suicide began to decline in the later years of the 17th century. In place of "Possession by spirit" "Unreasoning Passion" began to be associated with suicide. Esquirol wrote that "All those who committed suicide are insane" Durkheim1proposed that suicide was an outcome of social / societal situation. Since then the debate, whether it is the individual psychological vulnerability or the societal environment which causes suicide, has divided and dichotomized our thoughts on suicide.

Suicide is best understood as being multi determined and the result of the interaction between the more basic causal factors that renders the individual susceptible and those that interact with this susceptibility to cause suicide.

Epidemiology: An estimated 804000 suicide deaths occurred worldwide in 2012 (WHO 2014) which means every four seconds a person dies by suicide. The global annual suicide rate was estimated to be 11.4 / 100,000 population (Males - 15, Females - 8)

Suicide is grossly under reported due to stigma, inefficient registration system in many Low and Middle Income Countries (LAMIC), misclassification as accidents in High income countries (HIC) and criminalization of suicide attempt in many countries. The rates, characteristics and methods of suicide varies greatly between continents, countries and even within a country. The majority of global suicides (75.5%) occur in LAMIC. Globally, the elderly (over 70 years) have the highest suicide rate and those below 15 years of age have the lowest for both men and women. The mean age of suicide in HIC is 50 years, whereas it is 42 in LAMIC. Although the suicide rate is high in the elderly, the majority of suicides (64%) occurs between 15 - 49 years. In LAMIC younger adults and older women have a higher rate than in HIC, whereas middle aged men in HIC have a higher rate than middle aged men in LAMIC.

Suicide is the second, leading cause of death for those between 15 - 29 years globally. More men die by suicide than women in all countries of the world except in China where suicides by women is more. Traditionally, it is stated that the male female ratio of suicide is 3:1. However, this is true only for HIC (MF ratio 3.5:1) whereas in LAMIC the ratio is 1.57:1 signifying that more women in LAMIC die by suicide than women in developed countries. Globally for girls between 15 - 19 years, suicide is the leading cause of mortality.

Methods of suicide: Pesticide poisoning is the most common method of suicide in the world accounting for 250,000 - 300,000 deaths mostly in LAMIC. Hanging and use of firearms are the common methods in developed countries.

Suicide by self-immolation is a very violent method of dying. It is highly lethal and most of the attempts are fatal. This is the only method of suicide where women outnumber men in all countries. Self-immolation has emerged as a major cause of death and disability in parts of the Middle East and Central Asia, especially among young married Muslim women. In Pakistan 81% of self-immolations are by women while in India it is 64%, in Sri Lanka 79% and in Iran 81%. Marital conflicts and failed love affairs were the most common reasons (Ahmadi et al 2009). Self-immolation as a form of "fiery" protest has been recorded in Eastern Literature from time immemorial. Political self-immolation is prevalent even today in India, Pakistan, Sri Lanka, China, Japan and other Asian countries. Some new methods of suicide like "'Charcoal Burning" have emerged in Hong Kong, Taiwan and Korea. It is intentionally burning charcoal in a confined space and dying by carbon monoxide poisoning.

While there is reasonable data for suicides, there is an enormous dearth of data for attempted suicide across countries. Attempted suicide cause considerable morbidity and is a huge burden on health services, but relatively little is known about its prevalence in the community. It is estimated that for every suicide there are at least 20 times more attempts, which suggests that at least 15 - 17 million people attempt suicide every year.

Risk Factors:

Suicide is a deeply personal and individual act. However, it is determined by a number of individual and social factors.

Mental disorders occupy a premier position in the matrix of causation of suicides. A majority of suicide studies find that around 90% of those who die by suicide, have a mental disorder (Bertolote JM 2003 et al). Unfortunately, 82% of these reports come from Europe and North America with a mere 1.3% from developing countries, where the majority of suicides occurs and where the association between mental disorder and suicide is less pronounced. Studies from China (40%) India (35%) and Sri Lanka (37%) reveal that a smaller proportion of suicidal persons has depressive disorders, questioning the crucial and causal role of depressive disorders in suicide. A majority of suicides occur in the very first episode of depression.

The co-occurrence of alcohol misuse and suicide is well documented around the world. A study based on Global Burden of Disease 2010 stated that the relative risk of suicide in an individual with major depressive disorder was 19.9 (OR 9.5 - 41.7) with schizophrenia 12.6 (OR 11 .0 - 14.5) and alcohol dependence 9.8 (OR 9.0 - 10.7) (Ferrari et al 2014)

Previous self-harm is a major risk factor for suicide along with physical illness, family history of suicidal behavior, genetic and biological factors and early childhood adversity

Suicide is perceived as a social problem in many developing countries and hence, apart from mental disorder, equal conceptual status is given to family conflicts, social changes, etc.

Life stressors are associated with suicide all over the world, though the type of stressors varies from country to country. In developed countries marital conflicts, loneliness and depression are commonly found while in developing countries family disputes, forced / arranged marriages, exam failure, love failure are the usual reasons.

Poverty, low education, social exclusion, gender disadvantage, conflict and disaster are the major social determinants of mental health in LAMIC (Patel 2007); a recent study from Brazil found that income inequality represents a community level risk factor for suicide (Machado et al 2015)

Domestic violence is fairly common and its practice, to a large extent, socially and culturally condoned in many LAMIC. A highly significant relationship between domestic violence and suicidal ideation has been found in many LAMIC with 48% of women in Brazil, 61% in Egypt, 64% in India, 11% in Indonesia and 28% in Philippines (WHO 2001)

Availability of Methods and Means:

When a person is contemplating suicide, access to specific methods might be the factor that leads the manifestation of suicidal thoughts to action. In general men tend to choose more violent means (hanging, shooting) and women less violent methods (self poisoning). In the rural areas of many developing countries, ingestion of pesticides is a common method of suicide, reflecting easy availability, toxicity and poor storage. The situation is compounded by the limited availability of appropriate health care services and professionals.

Certain types of media reporting and portrayal of suicidal behavior can influence suicide and self-harm in the general population(Pirkis and Machlin 2013). Newspaper reporting of suicides can be particularly influential, if it is sensational, includes dramatic headlines and pictures, reports methods of suicide in detail and the subject is a celebrity (Stack 2003)

The sensational reporting of suicide by charcoal burning in Hong Kong and Taiwan had resulted in an epidemic level of the method within few years of the first report in 1995. In 1995 it accounted for <1 % of all suicides. However, in 2011 it accounted for 13% of all suicides in Hong Kong and 24% in Taiwan (SS Chang et al 2014)

Social Change:
The effect of globalization has led to sweeping changes in socio economic and socio philosophical and cultural arenas of peoples' lives which have greatly added to the stress in life, leading to higher suicide rates. Loss of job security, huge disparities in income and the inability to meet the role obligations in a new socially changed environment in the context of declining social and family networks, have resulted in increased loneliness, isolation and stress.
Risk factors are variable over time - they are dynamic, not static and may be influenced by the rapidity of change occurring within a country or region, such as, by the increasing global influence of the internet, the migration from rural to urban areas and the movement of ethnic population from one country to another and human and natural disasters.
Protective Factors
Protective factors such as resilience, social support, self-esteem, problem-solving skills and religious affiliation have not been as well studied as risk factors.

Partners, family members, peers, friends and significant others can be sources of social, emotional and financial support in times of crises. In particular, resilience gained from this support, reduces the suicide risk associated with childhood trauma ( Sarchiapone et al 2011 ) Relationships are especially protective for adolescents and elderly persons, who have a higher level of dependence. Strong connections with family and school, provides the best protective factors for adolescents.

Good self esteem, self efficacy and effective problem solving skills which include ability to seek help when required, can reduce the impact of stressors.

Religious and strong cultural beliefs that discourage suicide are seen as major protective factors. The protective value of religion and spirituality probably arises from providing access to a socially cohesive and supportive community with a shared set of values.

Ecological studies have observed suicide rates to be high in countries where religious beliefs are not actively Promoted by the State and low in countries where they are (Neeleman & Lewis 1999). High suicide rates are found in China, Russia and countries which were formerly part of the Soviet Republic which are considered atheist countries.

Suicide rates are low in Muslim countries (Syria and Saudi Arabia 0.4/100,000) The Quran strictly prohibits suicide maintaining that it is an unforgiveable sin. Islam also prohibits the use of alcohol which is a known risk factor for suicide. The low reported rates may be an artefact of under reporting due to the strong stigma associated with suicide in Muslim culture. However even in multicultural countries like Malaysia and Singapore also the suicide rate is the lowest among the Muslim population. Catholic countries have a lower suicide rate than Protestant countries. The Catholic religion also considers suicide a sin. The code of Jewish law absolutely forbids suicide, but the story of the mass suicide as in Masada I s often given as an example of Jewish thought. Jews around the world have a lower suicide rate and the suicide rate in Israel is 6.5 (WHO 2014).

Buddhism does not consider suicide as a sin or taboo. Sometimes, it can be considered as proof of honor. However suicide is censored in the Canon. Buddhist countries like Japan (23.1) and Sri Lanka (29.2) have high suicide rates whereas Thailand has a lower suicide rate (13.1) but still higher than the global rate of 11.4

Hinduism condemned individual suicide, but condoned religious suicides. In Hinduism, it is the individual faith that is important and not so much the social network. The suicide rate in India is high (20.9) and Indians, who form a sizeable minority in countries like Malaysia, Fiji, Suriname and Trinidad also have high suicide rates.

Some religious and cultural benefits also contribute to the stigma related to suicide, in part, due to their moral stance on suicide, which can discourage help-seeking behaviors. The debate continues as to whether it is the religion per se or the social connectedness that occurs in the context of religious involvement, that is protective.

Suicide prevention: The view that suicide cannot be prevented is commonly held even amongst health professionals. Chief among this negative attitude is the belief that suicide is a personal and private matter which is difficult to change, or that suicide is due to social and economic factors like unemployment over which an individual has relatively little control. However, for the overwhelming majority who engage in suicidal behavior there is probably an appropriate alternate resolution of the precipitating problems, and therefore suicide is preventable.

Suicide has been traditionally viewed as a mental health issue that is primarily addressed through clinical intervention. There is now a strong view that suicide is a public health issue and as such should be addressed by social and public health programs rather than as a part of mental health programs.

Preventive efforts can be classified in to three categories. Universal interventions target whole populations with the aim of shifting risk factors across the entire population. Selective interventions target subgroups whose members are not yet manifesting suicidal behaviors, but exhibit risk factors that predispose them to do so in the future. Indicated interactions are designed for people already beginning to exhibit suicidal thoughts or behaviors.

Universal Interventions

Restricting access to lethal means of suicide

Reducing access to means of suicide, has been recognized by WHO as one of the primary suicide prevention strategies. When someone is experiencing suicidal crisis, having access to the means of suicide is more likely to result in suicide.

Suicidal impulses are often short lived and if access to highly lethal methods is restricted, the impulse may pass or a less lethal method may be chosen. Most people who survive a suicide attempt do not go on to kill themselves.

There is strong evidence from around the world that limiting the access to the common method of suicide reduces that specific method of suicide as well as all cause suicides.
Examples of reducing access are restricting access to tall buildings, barricades over bridges, stricter gun control laws, legislation to restrict the sale of paracetamol in pharmacies and restricting access to pesticides.

In Sri Lanka where pesticide poisoning accounted for two thirds of all suicides in the 1980's, a series of bans on import of the toxic pesticides were followed by a halving in suicide rates (Gunnell et al 2007)

A preventive effort in Sri Lanka (Hawton et al 2009) provided locked boxes to households for storage of pesticides which proved the feasibility and acceptability of the intervention. A large RCT is currently underway to determine its efficacy.

SNEHA (NGO in Chennai) supported by WHO examined the usefulness of a centralized pesticide storage facility in reducing pesticide suicides. The study included constructing a locker like facility similar to a bank locker in the village. These wooden boxes were fixed to the wall and each farmer had their own locker where they could store their pesticides and access them when required. There was a marked reduction in pesticides suicides in the intervention villages when compared to control villages (Vijayakumar et al, 2013)

In a large RCT study in Europe the Saving and empowering young lives in Europe (SEYLE ), mental health awareness and skills training reduced the incidence of suicidal thoughts and attempts among secondary school children ( Wassermann et al 2015)

In many LAMIC countries where competition for places in higher education is fierce, exam failure is a recognized cause of suicide. Sneha an NGO in Chennai, India worked with media to raise awareness of the issue and worked with multiple stake holders which resulted in the State government introducing new legislation. The legislation allowed the students who had failed to rewrite their examination within one month and pursue higher studies without losing an academic year (Vijayakumar & Armson 2005). The success of this legislation has made more states in India formulating a similar legislation.

Unfortunately a recent study (Mishara & Weisstub 2014) has shown that 25 countries had specific laws and punishments for attempted suicide. Such laws increases stigma, reduces help seeking behavior, prevents immediate and appropriate medical intervention and leads to under reporting. Changing such laws can actually save lives.

Restricting the availability of alcohol to reduce the harmful use of alcohol is particularly critical within populations with a high prevalence of alcohol use. The WHO Global strategy to reduce the harmful use of alcohol (World Health Organization, 2010) outlines ten areas of policy options and interventions, including leadership, awareness and interventions; health services response; community action; drink-driving policies and countermeasures; availability of alcohol; marketing of alcoholic beverages; pricing policies; reducing the negative consequences of drinking and alcohol intoxication; reducing the public health impact of illicit alcohol and informally produced alcohol; and monitoring and surveillance.

The role of the media in suicide prevention is often underestimated. The media have a distinct responsibility in how they report instances of suicide. The fact is, responsible reporting can - and does - save lives. WHO (2012) recommends the media to avoid language which sensationalizes or normalizes suicide or presents it as a solution to a problem, avoid pictures and explicit description of the method used and provide information about where to seek help

Poverty, debt, chronic ill health and low socio economic position are associated with suicide. Adequate welfare provisions for these vulnerable members of the population is important to reduce suicides.

Selective Interventions
Gatekeeper Training : Key community members such as teachers, social workers, volunteers, youth leaders, nurses, police and prison staff and religious leaders who regularly come in to contact with individual or families in distress need to be equipped with the skills to identify, provide immediate support and refer suicidal persons.

Survivors: Survivors are those who have lost someone to suicide. It is estimated that one suicide affects at least six others significantly. Depression and suicidal behavior are higher among survivors. Post-vention (either individually or in groups) not only offers family support, but also becomes a method of suicide prevention itself.

Crisis centers: Majority of the crisis centers or hotlines are run by Non- Governmental Organizations (NGO's). International agencies like Lifeline, IFOTES and Befriending Worldwide have centers in many countries apart from national centers. The primary goal of these centers is to provide emotional support to the suicidal persons in the population through befriending and counseling in person or by telephone.

Though many innovative outreach and awareness programs have been initiated by the NGO's, majority of them have not been evaluated. September 10th has been designated as World Suicide Prevention Day and NGO's around the world have initiated a variety of innovative activities on that day. Since the first WSPD in 2003 it has now snowballed into a global movement for health professionals, volunteers and survivors to raise awareness about suicide and its prevention.

OSPI (Optimizing suicide prevention programs and their implementation in Europe) is a multilevel community program which has been initiated in ten European countries. The intervention consists of training general practitioners, public awareness campaigns, training and awareness among gatekeepers, identifying high risk groups and reducing access to the means of suicide, Szekely et al (2013) reported from Hungary a significant reduction in suicide in the intervention region compared to control areas.

In Islamic republic of Iran, young women from socio economically deprived groups who were at high risk of suicide were identified and videos documenting the stories of self immolation victims were screened to them in addition to lectures. Compared to base line self immolations, attempts decreased by 57% (Ahmadi 2007)

Indicated Interventions Previous suicide attempt is a strong risk factor for suicide. Studies from around the world reveal that 30% - 40% of persons who die by suicide, have made a previous attempt. It has also been shown that a majority of subsequent suicide or suicide attempt occurs within 18 months after the index episode. During this high risk period, if support and interventions are available, suicide and suicide attempts can be reduced. Regular follow up and contact have a significant effect on subsequent suicidal behavior.

WHO's multisite Randomized Control Trial (RCT) of the provision of brief intervention and contact has shown that suicides are significantly less in the intervention groups after 18 months follow up. Suicide attempters (n=1867) identified in the emergency department of collaborating hospitals in India, China, Sri Lanka, Brazil and Iran were randomly allocated. The intervention consisted of an hour long patient education before discharge and nine follow up visits and calls over a span of 18 months (Fleischmann et al 2008). At the end of the study there were only two suicides in the intervention group compared to 18 in the control group. A RCT was conducted in Iran, where 2300 persons who had attempted suicide by poisoning, were sent 9 post cards over a 12-month period and reassessed one year later There was a significant reduction in suicidal ideation, suicide attempts and number of attempts in those who received the post cards. (Hassanian-Moghaddam et al 2011) .These low cost and effective interventions are feasible even in resource scarce settings

. A study from UK has shown that 39% of people who died by suicide, had attended an accident and emergency department in the year before death and many of them were not in contact with mental health services (Gairin et al, 2003). It becomes important to train the health professionals working in the emergency departments of hospitals not only to recognize and refer suicidal patients appropriately but also to change their attitude to those patients. Instead of neglecting them directly or indirectly, they should be trained to be empathetic and supportive. A sizable majority of patients with mental disorders, who have been admitted in hospitals, die by suicide soon after discharge. Hence it is important that the patient and the social circumstances to which he/she goes back, are evaluated before discharge.

Safety planning is a brief clinical intervention, which was developed for use with veterans, who made a suicidal attempt, have suicide ideation or persons who were found to be at high risk of suicide (Stanly & Brown 2008)

A safety plan is a prioritized written list of coping strategies and sources of support that patients can use during or preceding suicidal crisis. The aim of the safety plan is to provide a predetermined list of potential coping strategies as well as a list of individuals or agencies that the person can contact in order to help them lower their immediate risk of suicidal behavior. By following a set of coping strategies, social support activities and help seeking behavior, the suicidal person can employ those strategies that are effective.

The basic components of the safety plan include recognizing warning signs, identifying and employing internal coping strategies without to contact another person, contacting other people as a means of distraction from suicidal thoughts or urges, contacting family or friends to resolve a crisis or discuss suicidal feelings, contacting mental health professionals and reducing the potential for use of lethal means. This intervention has been followed by many crisis and suicide prevention centres around the world now. It fosters a sense of collaboration, empowerment, hope and individual potential

Conclusion: A veil of silence shrouds suicides. Unless the stigma associated with suicide is reduced, suicide will be spoken in whispers. A very original effort has been initiated by the Canadian Mental Health Commission to increase awareness about suicide and dispel the myths. There are 308 members of parliament in Canada, the project titled "308 conversations" is to encourage all the 308 MP's, to talk about suicide in their constituency. The commission provided information and support to the MP's. This unique effort has generated a groundswell of support for suicide prevention not only in the community but also among the policy makers.

Loneliness, bereavement, failure in career or education, financial loss, debts, loss in status interpersonal problems, mental and physical illness, substance abuse, etc. have been associated with suicide. Whatever be the type of stress a suicidal persons faces, the common emotions are a sense of loneliness, helpessness and hoplessness. Suicide is an impulsive act and like any impulse it is transient. In a majority of suicidal individuals "The wish to live" and "The wish to Die" wages a see saw battle. It is not that they are definite about dying but that they are unable to cope with living in that circumstance. It is these very factors - the ambivalence and impulsiveness of the act that makes prevention of suicide possible through timely intervention.

It is very difficult to admit to the kinds of feelings that may give rise to suicidal thoughts and emotions. It is even harder to express these feelings to another person. The more openly a person talks about loss, isolation, worthlessness and suicide, the more likely the emotional turmoil is reduced.

During a suicidal crisis the comforting presence of someone who can listen and empathise reduces suicidal thoughts. Unfortunately, the emotional support systems are dwindling in many countries and cultures. Majority of communications, particularly in young adults is through social networking sites. It has many advantages, but the disadvantage is that even though one has thousands of "Virtual friends", during a crisis, a real empathetic friend is often needed. This is also the era of instant gratification starting from instant coffee to instant messaging and hence the ability to tolerate frustrations has diminished, leading to reduced self esteem and suicide.

It is important for individuals, families, communities and countries to invest resources to build supportive networks during times of rapid change. Reaching out to human being in distress, is the responsibility of every individual.

"If everyone has a right to be independent, it is equally his / her responsibility to be inter dependent" - M.K.Gandhi

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The study centre wishes to study the phenomenon of urban suffering, in other words the suffering that is specific to the great metropolises. Urban Suffering is a category that describes the meeting of individual suffering with the social fabric that they inhabit. The description, the understanding and the transformation of the psychological and social dynamics that develop from the meeting of ...

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