World Suicide Prevention Day 10/09/2012
SUICIDE – YOUNG AT RISK IN INDIA
Dr.M. A.ALEEM.M.D.D.M.,(Neuro)
Consultant Neurologist and Epileptologist.
Trained at Institution of neurology Queen’s Square London.
Professor of Neurology KAPV Government Medical college.
MGM Government Hospital Trichy -620017. Tamilnad,India.
Introduction:
On average, almost 3000 people commit suicide daily. For every person who completes a suicide, 20 or more may attempt to end their lives. At the global level, awarness needs to be raised that suicide is a major preventable cause of premature death.Every year World Suicide Prevention Day on 10 September is adopted to promotes worldwide commitment and action to prevent Suicides September 10th, 2012 marks the 10th anniversary of the world Suicide Prevention Day: ten years of research, ten yars of prevention, ten years of education and dissemination of information.The theme of world Suicide Prevention Day this year 2012 is “Suicide Prevention across the Globe: Strengthening Protective Factors and Instilling Hope”
The Magnitude of the problem:
Suicidal behaviour has become a major public health problem across the world. It is a complex phenomenon that usually occurs along a continuum, progressing from suicidal thoughts, to planning, to attempting suicide, and finally dying by suicide, which represents the final tragic outcome of a morbid process. Approximately one million people worldwide die by suicide each year. This corresponds to one death by suicide every 40 seconds. Suicide attempts and suicidal ideation are far more common; for example, the number of suicide attempts may be up to 20 times the number of deaths by suicide. It is estimated that about 5% of persons attempt suicide at least once in their life and that the lifetime prevalence of suicidal ideation in the general population is between 10 and 14%. Suicide is one of the leading causes of death in the world and over the last years rates have increased by 60% in some countries. In addition, suicide statistics may not always be accurate. Many suicides are hidden among other causes of death, such as single car, single driver road traffic accidents, unwitnessed drownings and other undetermined deaths. In addition, suicide is estimated to be under-reported for multiple reasons including stigma, religious concerns and social attitudes. The psychological and social impact of suicide of the family and community is enormous. Statistics:
<!--[if !supportLists]-->§ <!--[endif]-->Every year, almost one million people die from suicida;a ”global” mortality rate of 16 per 100,000, or one death every 40 seconds.
<!--[if !supportLists]-->§ <!--[endif]-->In the last 45 years suicide rates have increased by 60% worldwide. . Suicide is among the three leading causes of death among those aged 15-44 years in some countries, and the second leading cause of death in the 10-24 years age group;these figures do not include . suicide attempts which are up to 20 times more frequent than completed suicide.
<!--[if !supportLists]-->§ <!--[endif]-->Suicide worldwide is estimated to represent 1.8% of the total global burden of disease in 1998 and 2.4% in countries with market and former socialist economies in 2020.
<!--[if !supportLists]-->§ <!--[endif]--> Although traditionally suicide rates have been highest among the male elderly, rates among young people have been increasing to such an extent that they are now the group at highest risk in a third of countries, in both developed and developing countries.
<!--[if !supportLists]-->§ <!--[endif]-->Mental disorders (particularly depression and alcohol use disorders) are a major risk factor for suicide in Europe and North America; however, in Asian countries impulsiveness plays an important role. Suicide is complex with psychological, social, biological, cultural and environment factors involved.
Problems in India:
Suicide in India is slightly above world rate. Of the half million people reported to die of suicide worldwide every year, 20% are Indians, for 17% of world population. In the last two decades, the suicide rate has increased from 7.9 to 10.3 per 100,000 with very high rates in some southern regions. In a study published in The Lancet in June 2012, the estimated number of suicides in India in 2010 was about 187,000, making the cause of 3 percent of death that year. 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. In India age standardized are suicide death rate per 100,000 people at all age 18.6for boys and 12.7 for girls and women. Suicide become the second leading cause of death among the young in India.
The WHO reports about 1 million suicides a year, which would be a rate of about 14 per 100,000 in a global population of 7 billion. Suicide may soon be leading cause of death in india. In our country among men, 40 per cent of suicides were among people age 15-29. For women, it was nearly 60 per cent.
The rapid changes on society that have come with globlalization, the breakdown of the families. Suicide become the second-leading cause of death among the young in India. “The young face very high competition and pressure from families to succeed. Many parents think their child should come first in the class. Of course, that can’t happen,” may also lead to suicide . When youths start to despair, they often don’t think to seek help, or shun the idea because “they think psychiatry is only for crazy people,” So most of them landed in suicide. The risk of completing a suicide was 43% higher in men, who finished secondary or higher education, in comparison to those who had not completed primary education. Among women, the risk increased to 90%.
Four o f India’s southern states Tamil nadu, Andhra Pradesh, Karnataka and kerala that together constitute 22% of the country’s population recorded 42% of suicide deaths in men and 40% of self-inflicted fatalities in women in 2010.Maharashtra and West Bengal together accounted for an additional 15% of suicide deaths. Delhi recorded the lowest suicide rate in the country. In absolute numbers, the most suicide deaths in individuals, aged 15 years or older, were in AP (28,000), Tamil Nadu (24,000) and Maharashtra (19,000). Of the total deaths by suicide in individuals aged 15 years or older, about 40% suicide deaths in men and about 56% in women occurred in individuals aged 15-29 years. Suicides deaths occurred at younger ages in women (average age 25 years) than in men (average age 34 years). Educated persons were at greater risk of completing a suicide.
About half of suicide deaths (49% among men, and 44% among women) were due to poisoning(36.6%), mainly ingesting of pesticides. Hanging was the second(32.1%) most common cause for men and women, while burns(7.9%) accounted for about one-sixth of suicides by women.
Age differences:
Suicidal behaviour can occur at any age. The frequency of suicidal behaviour escalates steeply from childhood through middle to late adolescence and into adulthood. Suicide ranks as the second cause of death worldwide among 15-19 year olds, with at least 100,000 adolescents dying by suicide every year. Suicide rates are high among middle-aged and older adults and highest among those aged 75 and older. Elderly people are likely to have higher suicidal intent and use more lethal methods than younger people, and they are less likely to survive the physical consequences of an attempt.
Gender Differences:
On average, there are about three male suicides for every female suicide. This is more or less consistent across different age groups and in almost every country in the world. Conversely, rates of suicide attempts tend to be 2-3 time higher in women than in men, although the gender gap has narrowed in recent years. The disparity in suicide rates has been partly explained by the use of more lethal means and the experience of more aggression and higher intent to die, when suicidal, in men than women.There was a 64% correlation between domestic violence of women and suicidal ideation.
Who is at risk of Suicide?
(i) People with a history of suicide attempts of self harm:
A history of previous suicide attempt(s) of self harm is the strongest predictor of future death by suicide, corresponding to a 30-40 times higher suicide rate than the general population. The first days and weeks following psychiatric hospitalization represent the most critical period of suicide risk for patients. This finding highlights the need to attend carefully to continuity of care for psychiatric patients.
(ii) People with a psychiatric disorder and/or substance-related disorder:
It has beendocumented that approximately half of the people who seriously consider taking their lives have been diagnosed with a mental disorder during their life, and that up to 90% of people who die by suicide have dt least one psychiatric diagnosis. Among all dianoses, depressive disorders are most commonly associated with suicidal behaviour, followed by substance-related disorders, schizophrenia and personality disorders. Alcohol and drug abuse and dependence have been identified as important risk factors for suicidal thoughts and behaviours. Current substance use, even in the absence of abuse or debendence, is a significant rick factor for unplanned suicide attempts among those with suicidal thoughts. Comorbidity,namely the presence of two or more psychiatric disorders or a psychiatric disorder and a substance use disorder, significantly increases the risk of suicide.
(iii)Those who experience stressful life events:
Stressful life events often act as precipitants of suicide attempts or suicide by those with a diminished capacity to cope with them. Impulsive attempts may follow stressful life events, including family and interpersonal conflicts, relationship breakdowns, other interpersonal difficulties, the presence of legal/disciplinary problems, and financial and job difficulties. Periods of economic crisis and unemployment are associated with greater social vulnerability and often an increase in deaths by suicide.Bereavement, consistently described as one of life’s most stressful events, has been shown to elevate the risk of suicide and suicidal behaviour in vulnerable people, particularly if the death is by suicide. The rick of suicide is aiso greater among patients with severe physical illnesses, such as cancer or HIV infection – in face, increased suicide rick has been found to be associated with a large number of medical conditions, ranging from asthma to traumatic brain injury. The experience of persistent stress also may explain the elevated risk of suicide in some occupations, such as physicians, military personnel and police officers, as well among people in prison. Moreover distal stressors, e.g. childhood trauma, have consistently been linked to an increased risk of suicidal behaviour in adult life.
(iv) Young at risk in India
Young Indians are more likely to commit suicide than previously thought, especially those living in weathier and more educated regions, according to recent India’s rapid development is driving many youths to despair. Opportunities that have come with two decades of economic boom and open markets have also brought more job anxiety, higher expectations and more pressure to achieve, mental health.
Suicide rates are highest in the 15-29 age group, peaking in southern regions that are considered richer and more developed with better education, social welfare and health care. That puts the young at high risk-a new phenomenon experts said has happened recently as more middle-class youths strive to meet achievement expectations, and new technologies like cell phones and social networking sites help break down traditional family units once relied on for support. Few likely reasons for the rise in suicide among young people beyond the increased pressure that has come with new economic opportunity and social fragmentation. The higher rates may come from “the greater likelihood of disaponintments when aspirations that define success and happiness are distorted or unmet by the reality faced by young people in a rapidly changing society are also a few likely factors to commit suicide by young in India.
Strengthening Protective Factors and Instilling Hope
(i) Protective factors:
Despite the wide experience of the above-cited rick factors in populations, the fact that completed suicide is a relatively rare event indicates that there are a range of protective factors that act to mitigate the effects of exposure to risk factors. Among psychological factors, resilience (the ability to cope with adverse life events and adjust to them), a sense of personal self-worth and self-confidence, effective coping and problem-solving skills, and adaptive help-seeking behaviour are ofter considered to be protective against the development of suicidal behaviours. Social and cultural factors such as religious and social integration, social connectedness and maintenance of good relationships with friends, colleagues and neighbours, access to support from relevant others and ready access to health care are associated with a reduced risk of suicide and reduced repetition of attempted suicide. In addition, a healthy lifestyle, with maintenance of good diet and sleep habits, regular physical activity, abstinence from smoking and illicit drug use, is also associated with a reduced risk of suicidal behaviour.
In Tamilnadu adolencent health programme and Chief Minister.Jayalalitha’s computer schme to school students are very much helpful to prevent suicide among students. Along with the easy school education, better exam results in tamilnadu are also helpful to prevent suicide in students.
(ii)Respect of Self Esteem:
World Health Organization states that “Worldwide, suicide is among the top five causes of mortality in the 15-to 19-years age group and in many countries it makes first or second as a cause of death among both boys and girls in this age group”. And recommends “strengthening student’s self-esteem” to protect children and adolescents against mental distress and dependency, and enables them to cope adequately with difficult and stressful life situations. And “prevention bullying and violence at school” that specific skills should be available in the education system to prevent bullying and violence in and around the school promises in order create a safe environment free of intolerance. And as well “to de-stigmatize mental illness”.
Treatment:
There are various treatment modalities to reduce the risk of suicide by addressing the underlying conditions causing suicidal ideation, including, depending on case history, medical pharmacological and psychotherapeutic talk therapies.
The conservative estimate is that 10% of individuals with psychiatric disorders may have an undiagnosed medical condition causing their symptoms, upwards of 50% may have an undiagnosed medical condition which if not causing is exacerbating their psychiatric symptoms. Illegal drugs and prescribed medications may also produce psychiatric symptoms. Effective diagnosis and if necessary medical testing which mau include neuroimaging to diagnose and treat result of psychiatric symptoms, most often including depression, which are present in up to 90-95% of cases.
Recent research has shown that Lithium has been effective with lowering the risk of suicide in those with bipolar disorder to the same levels as the general population. Lithium has also proven effective in lowering the suicide risk in those with unipolar depression as well.
There are multiple evidence-based psychotherapeutic talk therapies available to reduce suicidal ideation suth as dialectical behaviour therapy (DBT) for which multiple studies have reported varying degrees of clinical effectiveness in reducing suicidality. Benefits include a reduction in self-harm behaviours and suicidal ideations. Cognitive Behavior Therapy for suicide prevention (CBT-SP) is a form of DBT adapted for adolescents at high risk for repeated suicide attempts
Suicide prevention is possible:
Suicide is a multi-determined phenomenon that occurs against a background of complex interacting biological, social, psychological and environmental rick and protective factors. Despite the complexity of this phenomenon, suicide can be prevented.
(i)Primary prevention:
Primary prevention of suicide requires broad modifications of social, economic and biological conditions to prevent members of a population from becoming suicidal. Primary prevention involves population-based interventions, rather than focusing on the individual at risk. Primary preventive interventions include restricting access to lethal methods, promoting physical health and positive mental health, promoting a responsible representation of suicide in social and other media, seeking to reduce stigmatization of mental illness and suicide and encouraging help-seeking behaviour through public awarness and education campaigns.
(ii)Secondary prevention:
Secondary prevention is aimed at minimising suicide risk in high-risk populations. In this sense, early identification of suicidal individuals, accurate diagnosis and effective treatment of mental health problems, especially mood disorders and substance-related disorders are crucial. More than half of the patients who die by suicide have seen their primary care physician within the month before their death. Therefore, improving primary care physicians’ recognition of psychiatric symptoms and disorders, suicide risk evaluation, treatment interventions and referral skills are key components of suicide prevention. Similarly, providing educational programs for “gatekeepers” (people who regularly come into contact with individuals or families in distress, such as clergy, first responders, pharmacists, teachers and police) can improve recognition of the risk of suicide and self-harm and facilitate referral of vulnerable people to appropriate assessment and treatment facilities.
(iii)Tertiary prevention:
Finally, tertiary prevention is aimed at preventing relapses of suicidal behaviour after a suicide attempt. This also involves the critical work of postvention __ the care, support and treatment of those impacted by suicide.
Suicide prevention in India:
In our country A three pronged attack to combat suicide are (1) reducing social isolation, (2) prevent social disintegration,and (3) treating mental disorders. Additionally a set of state led policies an being enforced to decrease the high suicide rate among farmors. Counselling program for school and college students along with their parents and teachers are also helpful to prevent suicide among students. Suicides can be prevented through interventions like banning the most toxic pesticides and teaching rural communities on safe storage of pesticides. India should also start mental health promotion for toung people through schools and colleges and introduce crisis counseling services and services for treatment of depression and alcohol addiction.” In India current concern about suicides has focused on agricultural workers, over three in four suicide death in India occur in other occupational group( including those who are unemployed and homemakers). Most suicide death occurred in rural areas –the age standardized death rates were about two times higher in rural than in urban areas. A reduced risk of suicide versus other causes of death in women who were widowed, divorced or separated, compared with married women and men. So marriage at appropriate age and time can also helpful to prevent suicide in reporductive age group.
Dr.M. A.ALEEM.M.D.D.M.,(Neuro) Consultant Neurologist and Epileptologist. Trained at Institution of neurology Queen’s Square London. Professor of Neurology KAPV Government Medical college. MGM Government Hospital Trichy -620017. Tamilnad,India.
