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%
97.8%
81.8%
95.5%
15.1%
90%
80%
83.8%
40.0%
17.0%
70%
67.9%
60%
No data
50%
Increased
Decreased
40%
42.9%
30%
20%
18.2%
13.5%
10%
0%
Region of the Americas
European Region
2.7%
2.2%
Western Pacific Region
African Region
4.5%
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
Female
50
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
Level
Asia
Transition Economics
Central Asia
Medium
Male
Europe
Europe &
North
America
Aus. & NZ
South &
Central
Americas &
the
caribbean
Total
12.5
17.5
61.2
NA
5.9
15.4
20.4
NA
36.1
19.5
8.6
19.3
13.0
3.8
11.7
NA
1.8
11.7
9.8
NA
8.7
5.8
2.5
5.9
HDI
High
HDI
Medium
Female
HDI
High
HDI
CDC Uniform Definitions for
Self-Injurious Behavior
Self-injurious behavior
Suicidal self-injurious
behavior
Suicide
(death)
Suicide
attempt
Undetermined selfinjurious behavior
Non-suicidal selfinjurious behavior
Other suicidal
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%
Adjustment disorders 3.6%
Mood disorders
35.8%
Anxiety/somatoform disorders 6.1%
Other psychotic disorders 0.3%
Organic mental disorders 1.0%
Personality disorders
11.6%
Schizophrenia
10.6%
(8205 cases, 12292 diagnoses)
Substance-related disorders
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
Disorder
Cumulative incidence (95%
confidence interval)
Women
Cumulative incidence (95%
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
Disorder
Cumulative incidence (95%
confidence interval)
Women
Cumulative incidence (95%
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
Suicide rate per 100,000
8.00
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
variables
Annual suicide rate
Male
Total
Female
Human Development
index, 1995
+ 0.21
(n = 26)
+ 0.27
(n = 24)
- 0.12
(n = 24)
Human Development
Index, 2001
+ 0.19
(n = 33)
+ 0.24
(n = 31)
- 0.01
(n = 31)
Education Index
2001
+ 0.26
(n = 33)
+ 0.31** (n = 31)
- 0.06
Urban population
as a percent of
total population 2001
+ 0.03
(n = 33)
+ 0.18
- 0.04
Telephone density
2001
+ 0.36* (n = 33)
+ 0.44* (n = 31)
+ 0.32** (n = 31)
Gender development
index 2001
+ 0.26
+ 0.26
+ 0.004 (n = 25)
(n = 27)
(n = 31)
(n = 25)
(n = 31)
SEV & Suicide Rate
Socio-economic
variables
Total
(Contd...)
Annual suicide rate
Male
Female
Gini Ratio
(inequality)
- 0.33** (n = 29)
- 0.31** (n = 27)
- 0.23
Cigarette consumption
per head
+ 0.41* (n = 27)
+ 0.46* (n = 25)
+ 0.40* (n = 25)
Alcohol (total)
consumption per head
+ 0. 13 (n = 30)
+ 0.20
(n = 29)
- 0.02 (n = 29)
Alcohol consumption
(spirits) per head
+ 0.19
(n = 30)
+ 0.23
(n = 29)
+ 0.24
(n = 29)
Unemployment rate
2001
+ 0.08
(n = 19)
+ 0.14
(n = 17)
- 0.15
(n = 17)
Crime rate
(in major cities)
- 0.03
(n = 15)
- 0.007 (n = 15)
- 0.14
(n = 15)
Pesticide consumption
(per hectare of land)
- 0.06
(n = 24)
- 0.10
- 0.25
(n = 22)
(n = 22)
(n = 27)
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
1986
Christian
1994
total
Hindu
Muslim
Atheist
1995
1985,87
1995,96
male
female
TBI and Suicide [ 1979 – 1993 ]
No
Suicide
SMR
126114
750
3.0
• Cranial fracture
7560
46
2.7
• Cerebral contusion and ICM
11766
99
4.1
• Concussion
↑ 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 ]
91
100
• First in October
2000
75
50
• Published
2003
50
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
Universal
Biopsychosocial
Environmental
Sociocultural
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.
Management
of poisoning
Safe haven
Community support
for suicidal
Alcohol consumption
↓ 1 litre of alcohol consumption
• Sweden
↓ in suicide rate
13%
Perestroika
• Hungary
5%
• USA & Canada
4%
Men ↓ 32%
• France & Protugal
3%
Women ↓ 19%
• Switzerland
0%
1984 – 84
Edge study
• Post Cards W 1, 2, 3, 4, 6, 8, 10, 12
Repetition
TAU
INT
394
378
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
attempts
Deaths
Total
attempts
Deaths
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
attempts
Deaths
Total
attempts
Deaths
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