Of all the major preventable reasons for premature deaths, suicide is perhaps one of the most unnecessary, avoidable and disturbing causes. Tragically, it cuts across ages and genders. From teenagers and adolescents to the elderly a surge in suicides and attempted suicides is seen all over the world, in spite of global efforts to work together to raise more awareness on this tragic loss of life. This has prompted health officials to look at suicide in new ways in the hope of reaching out and lifting persons with suicidal thoughts out of their toxic environments and depression, giving them a more positive outlook on life.
Facing the challenges in a world where young persons are growing up in broken homes, experiencing loss of self-esteem due to failures at exams and unfortunate love affairs is not easy.
On the eve of World Suicide Prevention Day, the Sunday Observer asked Emeritus Professor of Forensic Medicine and Toxicology, University of Colombo, Senior Prof Forensic Medicine, Sir John Kotelawala Defence University, Dr Ravindra Fernando to share his views on a subject close to his heart .
Excerpts...
Q. Tomorrow is World Suicide Prevention Day. While suicide figures have dropped dramatically since their peak in 1995, Sri Lanka has been ranked as the 4th highest in suicides according to the WHO report of 2014. Are suicides and attempted suicides public health issues that need urgent attention?
A. Yes, suicide and attempted suicide are important public health issues in Sri Lanka. In the 10 years since 1995, Sri Lanka’s suicide rates declined by 50%. Still, it is too high and we have to take action to further reduce this number.
Q. What are the reasons which drive people to commit suicide?
A. In a study we published in 2010 based on suicides reported to the City Coroner in Colombo, the commonest reason for suicide, in nearly one third of cases, was disputes with the spouse or marital disharmony. Other reasons were dispute with parents (8%), financial matters (7%), diseases (7%), alcoholism (7%), psychiatric illnesses (6%) and disputes in love affairs (5%). There are other reasons such as, unemployment and drug addiction.
Q. According to WHO those most vulnerable, those with suicidal thoughts are mostly young people, globally aged 15 -24. Is it the same in Sri Lanka too?
A. Yes. In 2017, 482 young people from 17 to 25 years committed suicide. As a percentage it is 14% of all suicides.
Q. Why is this particular group so vulnerable?
A. They have to deal with academic, social, and individual pressures. Additional stress factors like poor examination performance, fear of punishment, rivalry, and violence in the family, can make them feel there is nothing to live for. They choose death because suffering becomes intolerable as per their perception. Peer pressure, social and academic pressure, turmoil in the family can lead to emotional breakdown, feeling of loneliness, rejection, failure to handle loss, and poor performance. They feel, there is little hope for change, improvement, or possibility of a better future in the life they experience
Q. What are the health impacts on those who survive suicide attempts 1) emotionally 2) physically 3) psychologically and 4) socially?
A. Suicide and self-harm can have a significant impact on family members’ emotional and social functioning. Suicide bereavement is associated with a number of adverse mental health outcomes, including depression, psychiatric admissions and suicide attempts. Physical health impact depends on the method of suicide. For example, if suicide was attempted with a pesticide, the after effects of the chemical continue to cause ill-health, at least for sometime. They are also more likely to have physical health problems. They may engage in violence such as, intimate partner abuse. Psychological reactions include loss of appetite, low energy levels and an inability to sleep in the immediate aftermath of the suicide attempt.
The young who attempt suicide are significantly more likely to have persistent mental health problems such as, depression, substance dependence and additional suicide attempts. They report being lonelier and less satisfied with their lives.
Q. Do you think counselling can help these emotionally fragile persons?
A. Counselling definitely helps. But, we do not have an adequate number of counsellers and those attempting suicides do not go for counselling or are not referred for counselling. Counsellors can help to analyse the problems faced by persons thinking of attempting suicide
Q. What are the symptoms to look for in a person intent on committing suicide?
A. Excessive sadness, moodiness, mood swings, a deep sense of hopelessness about the future, with little expectation that circumstances can improve. Sleep problems may be present. Suddenly, becoming calm after a period of depression or moodiness can be a sign that the person has made a decision to end his or her life. Choosing to be alone and avoiding friends or social activities, loss of interest or pleasure in activities the person previously enjoyed, exhibit a change in attitude or behaviour, such as speaking or moving with unusual speed or slowness, suddenly becoming less concerned about his or her personal appearance, are other features.
Q. Warning signs?
A. From 50% to 75% of those considering suicide will give someone - a friend or relative - a warning sign. However, not everyone who is considering suicide will say so, and not everyone who threatens suicide will follow through with it. However, every threat of suicide should be taken seriously.
Q. Is suicide linked to genetics?
A. A study from the Centre for Addiction and Mental Health has found evidence that a specific gene is linked to suicidal behaviour, adding to our knowledge of the many complex causes of suicide. About 90% of people who have died by suicide have at least one mental health disorder researchers noted. When assessing a person’s suicide risk, it is also important to consider environmental risk factors, such as, early childhood or recent trauma, the use of addictive drugs or medications and other factors.
Q. There is now a surge in suicide among the elderly. Why?
A. In a study of the number of suicides in elders aged 61 and over, and the reasons, for 10 years, from 2008 to 2017, I found that elderly suicides amounted to 7,156 or 20.3% or one in five. (Males 6,070 or 84.8%; females 1,086 or 15.2%). The main reasons were chronic diseases and physical disabilities (2,494), harassment by the husband and family disputes (558), economic problems, poverty and indebtedness (305), addiction to narcotic drugs (255), ill-treatment by the children (187) and grief over the death of a parent or relation (123). Counselling the elderly with such conditions is essential to reduce suicides.
Q. Most people are reluctant to talk about mental and emotional health and so don’t get help in time. Your comments?
A. This is probably why we see more suicides in males, although more attempts are made by females.
Q. Role of media in promoting/discouraging suicide?
A. Media can promote and discourage suicides. Evidence from many Western countries has proved this. There is also some convincing evidence for a direct copycat effect resulting from books offering guidelines for suicide to terminally ill persons.
TV programmes and advertisements may also promote aggressive behaviour. Once there is aggression in the family, the main sufferer is the wife or partner who will be driven to suicide.
Q. In your studies what were some common methods used by those attempting suicide in Sri Lanka.
A. In a study I performed, in 44% of cases, poisoning was the cause of death. 70% of them were due to pesticides. Burns caused 34% of deaths. Other common causes included hanging in 11%, jumping in front of a train (7%) and drowning (3%).
Restrictions on the import and sales of WHO Class I toxicity pesticides in 1995 and endosulfan in 1998, coincided with reductions in suicide in both men and women of all ages. In 2016, there were only 348 deaths from 12,621 admissions.
Q. Facilities to help suicidal persons? Gaps you like to see filled?
A. The National Institute of Mental Health (NIMH) in Sri Lanka and some volunteer organisations provide psychological support for suicidal persons. But we need more psychologists in hospitals to help suicide survivors.
Q. Your message to the public?
A. There are many DON’Ts.
With a survivor of suicide attempt, Don’t make statements like , “How could you do this to me?” or “What on earth were you thinking?” or “Whatever made you do it?
Do not blame the family member who made the attempt or blame yourself.
Do not think it will never happen again.
Do not let the person, especially adolescents, be in control of their medication upon release from hospital. Dispense the medication(s) by a responsible adult.
Do not ignore the suicidal attempt and hope things will get better.
Do not discuss and remind the person about the suicide attempt.