Giving up on life …..Or crying for help?

Suicide rates have exploded in recent years. Statistics indicate that more people are choosing to opt out of life using various means ranging from ingestion of poison to putting a gun onto their heads, hanging themselves from rafters, jumping in front of trains and jumping off mountains for reasons that are as manifold as the means.

Suicide is a silent stalker. Silent, because those who succeed in ending their life, never or rarely confide in anyone. And tragically, those who succumb to this are mostly the young who have much to offer and are the future of a country. Also tragic is the fact that suicide, unlike any other life threatening condition is eminently preventable.

Understanding, empathy, love are the key words that can prevent this desperate act done because no one responded to a cry for help. Here, Senior Professor, Forensic Medicine & Toxicology, Faculty of Medicine, University of Colombo, Prof. Ravindra Fernando talks about suicide in Sri Lanka, prevention, and emerging problems.

A: Those who die through suicide exceeds the number of deaths due to homicide and war combined. Suicide is among the three leading causes of death among those aged 15-44 years in some countries, and the second leading cause of death in the 10-24 years age group; these figures do not include suicide attempts, which can be many times more frequent than suicide (ten, twenty, or more times according to some studies). In Sri Lanka, last year alone, 3,144 persons - 2484 males and 660 females - committed suicide.

A: Before 1960, hanging was the commonest method of suicide in Sri Lanka. In the 1960s ingestion of acetic acid became prominent. Since the 1980s the commonest mode has been pesticides. Organophosphate and carbamate insecticides were the commonest types of pesticides used in self-poisoning.

The other substances used in poisoning-related suicides include ingestion of acids (such as acetic acid), plant such as ‘oleander’ (Kaneru) and medicinal drugs such as Paracetamol. Other methods used in suicide are burns, jumping in front of a train and drowning.

A: In 2011, 47% of suicides were caused by pesticides. 1,447 males and 360 females killed themselves by drinking insecticides and weedicides. The second commonest mode was hanging where 1,122 males and 224 females lost their lives.

A: To answer this let me briefly trace the recent history of suicide in Sri Lanka. In the early 1990s Sri Lanka had one of the highest suicide rates in the world.

Responding with empathy

Lanka Sumithrayo, Sri Lanka’s foremost non-governmental organisation, has been very much in the forefront of suicide prevention, offering confidential emotional support for people experiencing feelings of despair and distress including those leading to suicidal thoughts. Here the Kandy Branch Director of Lanka Sumithrayo (who wishes to remain anonymous) talks about how responding with empathy and understanding to a cry for help from people who desperately need emotional help, can go a long way in saving their lives.

Excerpts…

Q: To which age groups do the majority of persons with suicidal feelings belong?

A: Young people between 17-45 years. Gender-wise more females than males attempt suicide in our conservative society where males lead freer lives. Tragically, many of them really don’t want to die and their deaths could have been prevented.

Q: So what drives them to this desperate act?

A: The reasons are complex . It results from a complex interaction of biological, genetic, psychological, social, cultural and environmental factors. It has no racial or class distinctions. Inability to cope with difficult situations in life is one of the leading causes of suicide where loneliness, depression, anxiety, hopelessness and a host of negative emotions could ultimately lead to ending one’s own life, when they feel they have no one, nowhere to turn to who is close enough or anyone they trust to help them through their problems . Lanka Sumithrayo tries to show them that ending their life to escape their present misery is NOT the answer, and that their problems could be solved in less drastic ways.

Q: Such as?

A: Talking to them and showing them we care for them and are willing to help them cope with their pain. Since a person who is suicidal feels isolated and alone with his or her problem, talking about their stressful situation with a non-judgemental, accepting, understanding and caring person can throw a different light on the situation and help diffuse the suicidal impulse.

Q: How do you do this? With face to face interviews? Or on the telephone?

A: All of us who counsel them are called ‘Befrienders’, because we befriend these persons who need emotional support. The best way to deal with their problems is to have a face-to-face talk with them at our respective centres. To encourage them to talk freely, our volunteers (Befrienders) don’t keep a pen, pencil or notebook on the desk to let them know that what they say is strictly confidential. But we do take their telephone numbers after telling them we love them and want their guardians to protect them from self harm. Persons who have suicidal thoughts need to be especially watched for at least 24 hours, for any mood changes, and irrational actions. If the problem is a family dispute we also advise parents to maintain a peaceful atmosphere in the home without aggravating his\her suicidal feelings.

Another advantage of face-to-face counselling is that the counsellor can see if the person he/she is talking to is a very disturbed person. Although we don’t treat them, just touching the hand of a person who is very tense sometimes helps them relax. If necessary, the counsellor may also refer that person to our own trained medical team with the caller’s permission. We also ask them to come back to us in a couple of days for another session of counselling, and after that whenever they wished.

Q: And have they?

A. Yes. The response has been most encouraging. Most of them return for more counselling. But many also drop in just to say ‘Thank you for saving our lives’. Some of them have also returned as part time and even full time counsellors themselves.

Between 1950 and 1995, the rates increased eight fold to a peak of 47 per 100,000 in 1995, the highest in the world! In the 10 years since 1995, Sri Lanka’s suicide rates declined by 50%. Understanding the reasons for this marked transformation in the pattern of suicide in Sri Lanka may have important implications for suicide prevention in other low-and-middle-income countries.

In 1988, the year I established the National Poisons Information Centre in the National Hospital, there were 32,848 hospital admissions from poisoning.

Of this, nearly 13,000 patients were admitted from pesticide poisoning and 1,524 patients died. But 24 years later, in 2012, out of 20,460 pesticide poisoning patients only 759 died.

A: From the late 1970s until the early 1990s, WHO Class I (‘extremely or highly toxic’) organophosphorus (OP) insecticides such as parathion, methyl parathion, monocrotophos, and methamidophos were the commonest poisons taken in fatal self-harm.

The Registrar of Pesticides in Sri Lanka banned methyl parathion and parathion in 1984 and then phased out all the remaining Class I OP insecticides gradually between 1991 and 1995, with a full ban on their import in July 1995.

Our studies have shown that there were dramatic changes to the age, gender and method specific pattern of suicide over the past three decades.

A: First, there have been year on year declines in all age groups since 1995; these declines began in the 17-25 year olds (in the early 1980s), followed by the 26-35 and more than 36 age groups in the late 1980s and mid 1990s Second, there have been marked changes in the age pattern of suicide in males; in the 1980s the highest rates were in 21-25 year olds and rates declined with increasing age, whereas the opposite pattern was seen in the 2000s with rates increasing with age.

Third, the reductions in rates appear to be driven by a decline in self-poisoning suicides.

There has been a rise in suicide by hanging, but this has been small in comparison with the fall in self-poisoning suicide. Fourth, there was a rise in drug related poisoning admissions, especially in women, and some evidence of reductions in case fatality associated with all poisoning.

A: Elderly suicide is an emerging serious problem world over. For example, although the elderly (age 65 and older) comprise about 13% of the US population, they account for over 18% of all suicides.

The most common cause for elderly suicide, as for all suicides, is untreated depression. Therefore, elderly depression needs to be recognized and treated.

It is believed in some countries about one third of the seniors who are 65 or older experience depression.

Elderly persons who commit suicide are less likely to have discussed their plans beforehand, and some nonviolent deaths from suicide in the elderly may be mistakenly attributed to illness.

A: Studies have shown greater burdens of mental illness, visual impairment, neurological disease, increasing burden of disability from chronic illnesses, functional limitations, stresses that accompany late life, including retirement, loss of a loved one, social isolation, and were more likely for the elderly to commit suicide.

Therefore, it is high time Sri Lanka considers elderly suicides as an emerging health problem that needs serious consideration by health authorities.

A: It brings together individuals and organizations with an interest in suicide prevention.