Suicide - Current Maze & Future Movement by Dr. Lakshmi Vijayakumar M.B.B.S., D.P.M., Ph.D.,...

Suicide - Current Maze & Future Movement

by Dr. Lakshmi Vijayakumar

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 MelbourneMember, International Academy of suicide research

M.B.B.S., D.P.M., Ph.D., FRCPsych. (Hon.)Founder, SNEHA

Member, W.H.O. International Network for Suicide ResearchHon . Associate Professor, University of MelbourneMember, International Academy of suicide research

Global Suicide rates, 2008 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)

Distribution of WHO regions by change in total suicide rate since 2000 (Mishara, 2010, based upon WHO 2009 latest year available)

MagnitudeMagnitude

• Suicide 1 million

• Suicidal Attempts 10 – 20 million

• Affected by Suicide 50 – 120 million

• Suicide 1 million

• Suicidal Attempts 10 – 20 million

• Affected by Suicide 50 – 120 million

• 1998 1.8% Global burden

• 2010 2.4%

• 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 A global perspective on the magnitude of suicide mortality

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

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

0

10

20

30

40

50

60

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

MaleFemale

MaleMale

Gender Specific RatesGender Specific Rates

Medium 12.5 17.5 61.2 NA 5.9 15.4

HDI

High 20.4 NA 36.1 19.5 8.6 19.3

HDI

Medium 12.5 17.5 61.2 NA 5.9 15.4

HDI

High 20.4 NA 36.1 19.5 8.6 19.3

HDI

GenderGender HDI

Level

HDI

LevelAsia Transition Economics Europe & South & Total

North Central

Central Asia Europe America Americas &

Aus. & NZ the

caribbean

Asia Transition Economics Europe & South & Total

North Central

Central Asia Europe America Americas &

Aus. & NZ the

caribbean

Suicide rateSuicide rate

FemaleFemale

Medium 13.0 3.8 11.7 NA 1.8 11.7

HDI

High 9.8 NA 8.7 5.8 2.5 5.9

HDI

Medium 13.0 3.8 11.7 NA 1.8 11.7

HDI

High 9.8 NA 8.7 5.8 2.5 5.9

HDI

Self-injurious behavior

Suicidal self-injurious behavior

Non-suicidal self-injurious behavior

Suicide attempt

Other suicidal behaviors*

Suicide (death)

Undetermined self-injurious behavior

CDC Uniform Definitions for Self-Injurious Behavior

* 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 ModelEcological Model

IndividualIndividualPeer/FamilyPeer/Family

SocietySociety CommunityCommunity

Mood disorders 35.8%

Schizophrenia10.6%

Substance-related disorders22.4%

No diagnosis 3.2%

Adjustment disorders 3.6%

Anxiety/somatoform disorders 6.1%

Other psychotic disorders 0.3%Organic mental disorders 1.0%

Personality disorders11.6%

Other DSM axis I diagnosis 5.1%

(8205 cases, 12292 diagnoses)

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

Life time risk of suicideLife 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.

•

• 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)

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

• 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 suicideCumulative absolute risk of suicideMen Women

Disorder Cumulative incidence (95% confidence interval)

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

Co-morbid substance abuse – Cumulative absolute risk of suicide

Men Women

Disorder Cumulative incidence (95% confidence interval)

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 & suicideMental 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%

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%)

• Previous Suicide Attempt (26 – 42%)

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

Personality CharacteristicsPersonality Characteristics

1. Impulsivity / Aggressive

2. External Locus of Control

3. Hopelessness

4. Reduced Specific Memory

1. Impulsivity / Aggressive

2. External Locus of Control

3. Hopelessness

4. Reduced Specific Memory

Genes and SuicidalityGenes and Suicidality

• Genes 43% Environment 57%

• TPH2, 5HT2A Receptor gene

• 5HTTLPR Polymorphism SS, SL & LL

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

• 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 AsiaResults: trends in suicide rates in East Asia

Chang et al Soc Sci Med 2009

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

0.00 5.00 10.00 15.00 20.00 25.00

Proportion of working population unemployed

Su

icid

e r

ate

per

100,0

00

Gunnell et al BJPsych 1999

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

SEV & Suicide RateSEV & Suicide RateSocio-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

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...)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)

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 ideationDomestic violence & suicidal ideation

Brazil 48%

Egypt 61%

Phillippines 28%

Brazil 48%

Egypt 61%

Phillippines 28%

India 64%

Indonesia 11%

India 64%

Indonesia 11%

0

10

20

30

40

50

60

70

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Hanging Jumping Poisioning Charcoal burning Others

Proportion of suicides (%) in Hong KongProportion of suicides (%) in Hong Kong

Religion & CountriesReligion & Countries

00

55

1010

1515

2020

2525

3030

3535

4040

4545

Hindu1995

Hindu1995

Buddhist1986

Buddhist1986

Muslim1985,87

Muslim1985,87

Atheist1995,96

Atheist1995,96

Christian1994

Christian1994

totaltotal malemale femalefemale

Suicide rates according to religion (per 100,000) Suicide rates according to religion (per 100,000)

TBI and Suicide [ 1979 – 1993 ]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

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)

↑ 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

• Refugees 15.2 million

• Asylum seekers 827,000 (0.83 m)

• IDP 26 million

• Repatriated 604,000

LocationLocation

• 80% in developing countries

• 50% in urban areas

• 33% in refugee camps

• 80% in developing countries

• 50% in urban areas

• 33% in refugee camps

Socio demographic factorsSocio demographic factors• Age 25 – 40

• Gender Females

• Marital status Single

• SES Higher, Educated

• Countries Far and S.E. Asia

Eastern Europe

Latin America

• Age 25 – 40

• Gender Females

• Marital status Single

• SES Higher, Educated

• Countries Far and S.E. Asia

Eastern Europe

Latin America

MethodMethod

• Blunt force Jumping

• Water torture Drowning

• Sharp force Stabbing / cutting

• Blunt force Jumping

• Water torture Drowning

• Sharp force Stabbing / cutting

One million refugees and A.S.

at risk of suicide

One million refugees and A.S.

at risk of suicide

Cyber suicides [ Japan ]Cyber suicides [ Japan ]

• First in October 2000

• Published 2003

• First in October 2000

• Published 200334

50

91

0

25

50

75

100

2003 2004 2005

Cyber bullyingCyber bullying

• Online bullying - 1/3 of children

• Every 30 mts a child attempts suicide due to bullying

• Online bullying - 1/3 of children

• Every 30 mts a child attempts suicide due to bullying

Suicide Prevention StrategiesSuicide Prevention StrategiesEnvironmental

• Reduced access to Methods

• Enlightened Media Reporting

• Cluster Prevention

Individuals at Risk

• Identifying and Easy access

• Education of GPs

• Crisis Line

Environmental

• Reduced access to Methods

• Enlightened Media Reporting

• Cluster Prevention

Individuals at Risk

• Identifying and Easy access

• Education of GPs

• Crisis Line

Psychopharmacology

• Lithium

• Clozapin

Psychotherapy

• D.B.T.

Psychopharmacology

• Lithium

• Clozapin

Psychotherapy

• D.B.T.

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

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 consumptionAlcohol consumption

↓ 1 litre of alcohol consumption ↓ in suicide rate

• Sweden 13%

• Hungary 5%

• USA & Canada 4%

• France & Protugal 3%

• Switzerland 0%

↓ 1 litre of alcohol consumption ↓ in suicide rate

• Sweden 13%

• Hungary 5%

• USA & Canada 4%

• France & Protugal 3%

• Switzerland 0%

Perestroika

1984 – 84

Men ↓ 32%

Women ↓ 19%

Edge studyEdge study

• Post Cards W 1, 2, 3, 4, 6, 8, 10, 12• Post Cards W 1, 2, 3, 4, 6, 8, 10, 12

TAU INT

394 378

Repetition 21.2% 22.8%

TAU INT

394 378

Repetition 21.2% 22.8%

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

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

PesticidesPesticides300,000 deaths in South Asia & Asia Pacific300,000 deaths in South Asia & Asia Pacific

toxicity medical management

access bio pesticides

toxicity medical management

access bio pesticides

Suicide & Attempted suicide Study villages A & B in North Western Province

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

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 & Attempted suicide Control villages A1 & B1 in North Western Province

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

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

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

Suicides in CP Villages

1998 - 2003 2003 - 2006

Keshavapuram 4 2

Pandurangapuram 5 3

Rangapuram 3 2

Bikkuthanda 3 1

• 15% ↓ in pesticide suicide 45,000

• 1 litre ↓ in alcohol 30,000

• 15% ↓ in pesticide suicide 45,000

• 1 litre ↓ in alcohol 30,000

75,000 lives

can be saved

every year

Lives savedLives saved

Thank YouThank You