Suicide - Current Maze & Future Movement by Dr. Lakshmi Vijayakumar

1. Suicide - Current Maze & Future Movementby 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

2. Global Suicide rates, 2008

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

4. Magnitude • Suicide 1 million • Suicidal Attempts 10 – 20 million • Affected by Suicide 50 – 120 million • 1998 1.8% Global burden • 2010 2.4%

5. 500,000 suicides a year 61% of world suicides

6. 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

7. Male Gender Specific Rates Suicide rate Gender HDILevel Asia Transition Economics Europe & South & Total North Central Central Asia Europe America Americas & Aus. & NZ the caribbean 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 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 Female

8. CDC Uniform Definitions for Self-Injurious Behavior Self-injurious behavior Suicidal self-injurious behavior Undetermined self-injurious behavior Non-suicidal self-injurious behavior Suicide (death) Suicide attempt 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)

9. Ecological Model Community Society Individual Peer/Family

10. No diagnosis 3.2% Other DSM axis I diagnosis 5.1% Mood disorders 35.8% Adjustment disorders 3.6% 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% Suicide and Mental Disorders: general population studies (N=15,629)

11. 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.

12. Danish Psychiatric Case register (since 1969) • Danish National Patient Register (since 1979) • Danish Cause of Death Register (1970-2006) • M Nordentoft in press A complete national sample of all persons born in Denmark between 1 January 1955 and 31 December 2006 (3.51 million people)

13. Cumulative absolute risk of suicide

14. Co-morbid substance abuse – Cumulative absolute risk of suicide

15. 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%

16. Previous Suicide Attempt (26 – 42%) • Family history of Suicide and Mental Disorders (12 – 18%)

17. Personality Characteristics 1. Impulsivity / Aggressive 2. External Locus of Control 3. Hopelessness 4. Reduced Specific Memory

18. Genes and Suicidality Genes 43% Environment 57% TPH2, 5HT2A Receptor gene 5HTTLPR Polymorphism SS, SL & LL SS & SL – Left frontal, prefrontal & middle temporal gyri

20. Source: Morrell S et al, Soc. Sci. Med. 1993; Vol 36, 6, 749-756

21. Results: trends in suicide rates in East Asia Chang et al Soc Sci Med 2009

22. Association between unemployment and suicide rates (non poisons and gases) in 25-34 year old males (1921-1995) Gunnell et al BJPsych 1999

23. SEV & Suicide Rate Socio-economic Annual suicide ratevariables 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

24. SEV & Suicide Rate (Contd...) Socio-economic Annual suicide ratevariables 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)

25. Domestic violence & suicidal ideation Brazil 48% Egypt 61% Phillippines 28% India 64% Indonesia 11%

26. Proportion of suicides (%) in Hong Kong

27. Religion & Countries Suicide rates according to religion (per 100,000) 45 40 35 30 25 20 15 10 5 0 Muslim 1985,87 Buddhist 1986 Christian 1994 Hindu 1995 Atheist 1995,96 total male female

28. 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)

29. Refugees 15.2 million Asylum seekers 827,000 (0.83 m) IDP 26 million Repatriated 604,000

30. Location 80% in developing countries 50% in urban areas 33% in refugee camps

31. Socio demographic factors Age 25 – 40 Gender Females Marital status Single SES Higher, Educated Countries Far and S.E. Asia Eastern Europe Latin America

32. Method Blunt force Jumping Water torture Drowning Sharp force Stabbing / cutting One million refugees and A.S. at risk of suicide

33. Cyber suicides [ Japan ] • First in October 2000 • Published 2003

34. Cyber bullying • Online bullying - 1/3 of children • Every 30 mts a child attempts suicide due to bullying

35. Suicide Prevention Strategies 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.

36. 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

37. Alcohol consumption ↓ 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%

38. Edge study • Post Cards W 1, 2, 3, 4, 6, 8, 10, 12 TAU INT 394 378 Repetition 21.2% 22.8%

39. 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

42. Pesticides 300,000 deaths in South Asia & Asia Pacific  toxicity  medical management  access  bio pesticides

44. Suicide & Attempted suicideStudy villages A & B in North Western Province

45. Suicide & Attempted suicideControl villages A1 & B1 in North Western Province

46. 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

48. Lives saved • 15% ↓ in pesticide suicide 45,000 • 1 litre ↓ in alcohol 30,000 75,000 lives can be saved every year

49. Thank You