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