EDITORIAL

SUICIDE - AN OVERVIEW 

Dr. S. SHAJI
There is possibly no society where suicidal behaviour is unknown. Also no period of history has been reported when this enigmatic human behaviour had been dormant. (Ponnudurai, 1996). Clinical medicine which has been in the forefront for preservation of life and in dealing with health and disease has regrettably ignored a major challenge of dealing with death by suicide. Philosophical overtones of this topic is still keeping the physicians away from shouldering the responsibility of handling the suicide victims in a manner that is required. (Shrivastava, A.K., 1996)
Magnitude of the Problem
Suicide is widely prevalent and no nation or culture has escaped from it, though the toll varies from place. The prevalence of suicide in today's world is quite alarming. World Health Organization in 1974 found suicide one among the first ten causes of death. In 1996 it became the second common cause of death in young adults aged between 15-35 years. National death rates from suicide suggests high prevalence in countries like Hungary, Denmark, and Japan as compared to other countries.
Increasing number of deaths by suicide is one of the major public health problems of India today. As per the data available from the national Crime Records Research Bureau, as many as 1,04,713 suicides took place in India in the year 1998. The rate of suicide works out to 10.8 per 100000 populations. The corresponding figures for 1999 was, 10,587 and the rate was 11.2. The suicide rate increased from 8.5 in 1998 to 11.2 in 1999. The south Indian states have a relatively higher suicide rate than the northern states. (P.O.George, 2002). There has been an increase 9in death rate by suicide during the past two decades. The cases reported has increased from 40,245 in 1981 to 84,244 in 1993. There is 9.2 fold increase in suicide over the last decade. Comparison of death rates due to suicide from 1978 to 1988 suggests a 59.8% increase. The rate of increase of population over the same decade being 29.8% suggests that suicide rate has increased doubly in comparison to the population growth. Even within India, different states have different suicide rates.
Kerala is a state with the highest rate of suicide in the country 31.4 per 1,00,000 against 11.2 across the country.
Definitions - Various Perspectives
The word 'suicide' was first used by Sir Thomas Browne in his 'Religio Medici' in 1642 and subsequently by Walter Charleton in 1651. Prior to the introduction of the word 'suicide', self destruction, self killing and self murder were in currency carrying  the same meaning. 'Selbstmord' continue to be popular in Germany till today (Venkoba Rao, 1992). Suicide has been defined variously for psychological, legal, social and administrative purposes. Various definitions given to suicide are reviewed here.
Suicide has been defined by Beck et al as, "a willful self-in-flicted life threatening act which results in death." Schneidman (1976) defined it as : the human act of self-inflicted, self intentional cessation of life". It is an act committed out of constricted thinking, tunneled logic and acute anguish. The World Health Organization defines suicidal act "as the injury with varying degrees of lethal intent and suicidal may be defined as a suicidal act with fatal outcome." Durkheim defined suicide as "death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result."  This excludes those who survive the attempt. Meninger implied that in committing suicide, the individual kills himself, murders somebody and also fulfils his wish to die.
From the existential point of view, suicide denotes a behaviour that seeks and finds the solution to an existential problem by marking an attempt on the life of the subject. Currently in the western world suicide is a conscious act of self-inflicted annihilation, best understood as a multi-dimensional malaise in a needful individual who defines an issue for which the suicide is perceived as the best solution.
Attempted Suicide
Stengel restricted the term suicide to all fatal acts. The non fatal acts of self -injury under taken with more of loss conscious self-destructive intent were termed as attempted suicide. Later some workers included suicide and suicidal attempt as characterized by self-destructive intention.
Para Suicide
This is a kind of suicide which is undertaken with a motivation to self harm rather than to die. It is defined as " a non fatal act in which an individual deliberately causes self injury or injects a substance in excess of any prescribed therapeutic dose. Morgan et al (1975) used the term non-fatal Deliberate self harm (DSH) for this kind of suicide. The word Para suicide was coined by Kreitman to include events like self mutilation, excessive dosage of drugs and other similar events which are mostly non-suicidal attempts.
Imitative suicide
This is a kind of suicide which takes place as a result of imitating or copying somebody. Hundreds of suicide, which followed as a result of the movie, 'Ek Duje Ke Liya' and the media inspired self immolation inspired by 'Mendel' agitation are example of this kind.
Suicide Pact
Here two or more individual decide to die together. Lovers committing suicide to revolt against the society is of this form. Similarly incidents where in parents giving poison to their children and subsequently killing themselves as well are another examples of suicide pact.
Suicide Gamble or Ambivalent Suicide
Here the individuals are in a state of dual mind whether to die or not to die. The individual then remains passive by allowing destiny to make the decision, it is also called suicide gamble.
Chronic Suicide
This is seen in the form of chronic use of alcohol, drugs or other self harming substances.
Mass suicide
In this kind of suicide a number of people commit suicide at the same time. Jauhar practiced by the Rajputh females and 'Sathi' were of this kind.
The kind of suicide to a very large extent depends upon the attempter's pre morbid personality.
SUICIDE AND ATTEMPTED SUICIDE
The distinction between suicide and deliberated self harm is not absolute. Ther is an important overlap. Some people who had no intention of dying succumb to the effects of an overdose. Others who intended to die are revived. Moreover many patients were ambivalent at this time whether they wished to die or live.
Before the 1950s, little distinction was made between people who killed themselves and those who survived after an apparent suicidal act. Stengel (1952) identified epidemiological differences between the two groups, and proposed the terms ' suicide' and 'attempted suicide' to distinguish the two forms of behaviour. He supposed that a degree of suicidal intent was essential in both groups in other words, those who survived were failed suiciders (stengel and Cook, 1958).
In the 1960s it was proposed that suicidal intent should no longer be regarded as essential, because it was recognized that most attempted suicides had performed their acts in the beleif that they were comparatively safe, aware, even in the heat of the moment, that they would survive their over-dosage, and able to disclose what they had done in good time to ensure rescue (Kessel and Grossman 1965). For this reason, Kessel proposed that the term attempted suicide should replaced by deliberate self poisoning and deliberate self harm. These terms were chosen to imply that the behaviour was clearly not accidental with out any assumption whether the desire for death was present.
Among people who attempted suicide is very much increased. In the first year afterwards, the risk of suicide is about 1-2 per cent, which is 100 times that of the general population (Kreitman, 1977). An eight year followup showed that amongst patients who were previously admitted with deliberate self-harm, about 2.8 percent eventually take their own lives and about twice the expected number die from natural, causes (Hawton and Fagg, 1983). In a third to half of completed suicides, there is a history of previous deliberate self harm. Among people who deliberately harm themselves, the risk of eventual suicide i.e. greater in those with other risk factors for suicide, (Kreitman, 1977).
It said that 10 to 15 times as many as those who complete suicide, fail in their attempts. But life after a suicide attempt is often more difficult than before. It is all the more painful in cases where suicide attempt resulted in physical disability. chronic illness or mental derangement. In addition, life becomes miserable for them, it becomes inconvenient and difficult for there  family members and relatives (P.O. George, 2002).
FACTORS AFFECTING SUICIDE
Mostly derived from retrospective reviews of completed suicides through analysis of mortality data and psychological autopsies, the risk factors include both demographic and non-demographic variable includes age, gender, marital status, employment and place of residence etc. Non-demographic variables identified as risk factors include a diagnosed psychiatric disorder (Major depression, substance abuse, schizophrenia, personality disorder), previous suicide attempts and threats, family history of psychiatric disorders and chronic illness or pain. (Mohan Das, 1997).
AGE DISTRIBUTION
The worldwide age distribution suggest that young adulthood and old age are two age groups where suicide risk is maximum. Individuals under 30 are usually attempters, where as those over 50 are completers. However in India 59 percent of the completed suicide were by individuals below 30 years of age, (Shrivasthava, 1996)
The reports on the age distribution in India are inconsistent. While some have noted female preponderance (Aiyappan and Jayadev, 1956; Sahtyavati and Murthi Rao, 1961; Nandi et al, 1979; Ponnudurai and Jayakar, 1980; Shukla et al, 1990; Benerjee etal, 1990), others have observed male preponderance in suicide (Ganapathi and Vancoba Rao, 1966; Hegde, 1980; Gopal Sharma and Gautam Sawang, 1993).
In terms of Vulnerable age group uniformly all studies have pointed towards the second and third decades of life as the most vulnerable phase for Indian suicide. Difficulties in securing jobs, problems arising out of marriages which take place increasingly during this early phase of life, and financial burden, are some of the factors which enhance the suicide risk in this age group of our people (Ponnudurai, 1998).
Shukla et al 1990 indicated that the respect the aged enjoy, and the families and society, in our culture, might be protective mechanisms in for our elders against suicide.
MARITAL STATUS
It has been pointed out that married women were more predisposed to suicidal behaviour (62.5%), whereas in males marriage doesn't tilt the balance (Ponnudurai and Jayakar, 1980). Shukla et al (1990) noted that suicide occured most commonly in the marriage males and females. Similar was the observation by Sathyavathi and Murti Rao (1961). In our country's socio-cultural set up, factors such as dowry problem, adjustment problems between two previously unknown families, financial constraints and stigma attached to separation and divorce could be some of the notable contributions for this self harming behaviour in married individuals.
 Shukle et al (1990) have put forward several reasons for suicide being more common among the married in India. Here marriage is a social obligation and is performed by elders irrespective of the individual's preparedness for it. Further marriage is believed a part of the treatment for mental illness and the mentally ill are more likely to get married, that too sooner than mentally healthy. Hence there could be several adjustment problems among the married mentally ill persons in India. Divorce being socially frowned upon and suicide provide the only escape. In the West, on the other hand, marriage is believed to be a measure of emotional stability and married people have lower rate of mental illness (Slater and Roth, 1989).
MENTAL DISORDERS AND SUICIDE
The incidence of previous psychiatric contact in suicides has been estimated to be 33% to 50% (Barraclugh, Bunch Nelson and Sainsbury, 1974). Detailed retrospective  analysis has shown that 93% of suicides are mentally ill at the time they kill themselves (WHO, 1968). Psychiatric disorders most often associated with suicide are depression, alcoholism, borderline personality disorder and schizophrenia. At the time of death about 45 - 70% might have had clinical depression.
The suicide rate, reported in the literature for various psychiatric diagnoses are : 15%(Major Depression), 10-15% (Bipolar disorder) 10% (Schizophrenia), 4 to 9.5% (Border line personality disorders, 5% (antisocial personality disorder and 2% (Alcohol dependence). (Mohan Das, 1997). Isometsa et al (1994) noted that nearly 50% of the suicide completers with major depression were undergoing psychiatric care at the time of death, but only 3% of them were receiving adequate antidepressant therapy. Psychiatric illness was prominent in most attempted suicide in the elderly, but interaction with physical illness and psychosocial stress might have added to the suicidal intent.
The relationship between suicide and depression has been well documented. Suicide attempts usually occur in a background of depressive symptoms. Depression prior to   suicide is probably universal (Venkoba Rao, 1992). Around 3-30% of the patients suffering from endogenous depression ultimately die from suicide.
The attempts is usually seen either in the initial phase of after coming out of severe depression. These are periods when the patient still experiences self-destructive ideas and is physically uninhibited. In schizophrenia, suicide may be an impulsive act or a result of hallucinations.
Drug and alcohol dependence may result in death due to deliberate or accidental over dosage. (Shrivastava 1996)
SUICIDE AND PHYSICAL ILLNESS
A wide range physical disorders have an association with suicide. Association between suicidal behaviour and illness like epilepsy, cancer, duodenal ulcer and menstrual problems have been reported. The incidence of suicide amongst patients suffering from cancer is estimated to be 20 times higher than in the rest of the population. It occurs in all forms of cancer especially in the first twelve months of diagnosis. Pain, especially chronic abdominal pain from duodenal ulcer' and gynecological disorders is an important cause for suicide and suicide attempts.
Similarly, a greater risk than in general population for suicide has been identified in persons with neurological diseases. The risk is 300 times greater in individuals with chronic renal problems and renal transplantation (Shrivastava, 1996). Suicide in postpartum period was attributed to high prevalence of psychiatric morbidity during this period.
SUICIDE AND SOCIAL CONDITION
Maladjustment with significant family members and domestic strife have been cited as the most important cause by many (Nandi et al, 1979; Hegde, 1980; Shukle et al, 1990; Gauranga Banerjee et al 1990). Ponnudurai and Jayakar (1980) pointed out that 12.5% of females committed suicide due to maladjustment with alcohol and drug abusing husbands.
In a study of 100 female burns cases in Madurai, the analysis of causes of suicide behaviour revealed marital and dowry problems, besides physical and Psychiatric illness. Marital problems figured in more than half of the cohort and they included alcoholism, extramarital relationship and wife beating behaviour in the husbands and maladjustment with the in-laws. Marital stresses were most frequent in young women. (Vencoba Rao 1992)
Other factors associated with suicide are family disruptions, divorce, unemployment, childhood bereavement etc. Suicide attempters have been found to have significantly increased number of losses due to deaths of parents in the previous three years. (Bunch, 1972).
Bereavement appears to be a signal for increased suicide risk following the death of a spouse, the risk is greater is males than in females. (Mc Mohan and Pughs, 1965)
Education is another important factor related to suicide in young adult population. This could be due to parental expectations or academic pressure or both, pushing the individual into despair to take the ultimate actions. Though sociological studies have emphasised the role of poverty in suicide, poverty is the reason in only 2.6% of the cases. possible explanation could be that the poor deal with its everyday and death is never seen as an option.
Suicide rate is also said to be directly proportional to the level of social tensions and uneasiness. But the example of Sweden Proves that this may not necessarily be the case and an ideal society is not a guarantee of absence of the despire in human nature. (Shrivastava 1996).
Poisoning with organo-phosphorous compounds appear to be the more favourite method in Indian suicide. (Ponnudurai, 1966; Sureshkumar, 2000). Nandi et al (1978) reported that a century ago poisoning and hanging were the commonest mode of suicide in Calcutta (44.2 and 41.3% respectively).
However the trend shifted towards remarkable preponderance of poisoning in his later study which he attributed to the easy availability in modern times. Similar observations has been made by recent studies as well (Shukle et al, 1997; Ponnudurai et al, 1997). In the sample studied by Satyavati and Murthi Rao (1962) hanging was reported by most women when alone in their homes. Ponnudurai and Jayakar (1980) noted hanging as the predominant choice in both sexes. In both these studies consuming poisonous substances was the next choice.
Factors like feasibility, credibility, accessibility and rapidity of action could be behind the choice on method for attempting suicide. The relationship between the availability of lethal methods of injury and suicide rate is an important unresolved problem. It is reported that availability of a method is important when it is impulsive in nature (Marzuk et al, 1992). Considering the high rate of suicide attempts with organo-phosphorous compounds in India, Ganapathy and Venkoba Rao, (1996) and Nandi et al (1979) pleader for the restriction of the sale of these compounds.
Though the cause of suicide varies from one individual to another, their experience seem to be more or less similar. What an individual experiences during the crisis leading to suicide may be understood only by inferring indirectly, by interviewing those surviving from suicide and from letters. These data suggest the presence of certain features like. ambivalence towards suicide, anger or resentment demanding unreasonableness or sometimes manipulative ness. Depression is also commonly found.
 Beck (1963) noted that the suicidal preoccupation seemed related to the patient's conceptualization of his situations as untenable and hopeless. Patient believes that he cannot tolerate a continuation of his suffering and could see no solution to his tormenting problems.
Hopelessness is an important clue that should alert clinicians to the possibility of suicidal risk in these patients. According to Beck et al (1990) hopelessness, as it occurs in depressed patients may be viewed as closely associated with severity of depression.
However, some individuals seems to be chronically hopeless, regardless of their being depressed or not. These are the individuals who are more susceptible to suicidal behaviour.
Hopelessness is an important clue that should alert clinician to the possibility of suicidal risk in these patients. It should be emphasised however that a comprehensive assessment of suicide risk should include in addition to Beck Hopelessness Scale, such clinical predictors of suicide as the presence of affective disorder, a high level of suicidal ideation, a history of suicide, history of alcohol and drug abuse and relevant demographic factors such as age, sex, and race. (Jain et al 1999). the cognitive and attitudinal phenomena of hopelessness are important target symptoms in treating suicidal individuals. By focusing on reduction of patient's hopelessness the professionals may also be able to alleviate suicidal crisis more effectively
SUICIDAL PREVENTION
Management Principles
A proper medical treatment is the first essential step in the management of suicidal attempt. The next step should be a mandatory psychiatric consultation. The process of psychological intervention can start concurrently with intensive medical treatment of the victim. Psychosocial treatment and crisis intervention must begin beside treatment in medical intensive care units. By the time the patient comes out of medical care, the suicide intervention team is ready with the intake data and the family is already under treatment.
Goals of evaluation of a suicidal patient include (Hyman, 1988; Hillard, 1992; Mohandas, 1996)
a. Assessment of suicidal thinking (ideas, wishes, motives)
b. Suicidal intent (both stated intent and inferred intent)
c. Suicidal plans
d. Any deterrents to the attempt (religion, family, fear)
e. Reaction to the attempt
f. Future orientation
g. Relevant mental status
Risk-Rescue rating suggested by Weisman and Jordan (1972) may be valuable in determining the lethality of suicide, need for hospitalization and perhaps overall prognosis. The risk factors include the agent used, impairment of consciousness, toxicity and extent of lesions, reversibility and treatment required. The rescue factors include the location of attempt, the person initiating the rescue, the probability of discovery, the access ability of rescue and the delay until recovery.
Risking Rescue Rating = Risk Score
                     Risk Score + Rescue Score
The suicide behaviour is multi-casual. The preventive measures are to be chiefly directed against the major groups of antecedents to suicide.
1. Interpersonal adjustment problems and difficult life circumstances- Specific measures should be organized for effective intervention. This includes setting up of marital and family counselling centres, students' counselling centres and adolescent clinics. Similarly, alcohol de-addiction clinics may incorporate preventive measures.
2. Physically illness - In view of the physical illness as a cause for suicide, especially those affected by pain of chronic nature (Peptic ulcer, functional abdominal pain, dysmenorrhoea).
3. Helping him to see that there are other alternative ways of dealing with his problems.
4. Taking a highly directive as well as supportive role by telling him what to do and what not to do.
5. Making him realise that his act of suicide will affect the others around him. This way be done by asking questions like-what would be your parents' reaction on hearing about your death after suicide. What would your siblings or spouse undergo ?
6. Helping him see that his distress and emotional turmoil will not be endless.
7. Helping him see more reasons to live than to die. Throughout the prevention it is necessary to take certain precautions to make the victim comfortable. The therapist should impart a feeling that distressing ideas can be expressed without any one being injured or killed. The approach should enable the individual to take openly without fearing rejection or guilt about harming the therapist. With respect to children, the child's perception of his family environment is found to be the strongest predictor of suicidal behavioural. Thus family therapy and family support should be stressed.
THE POST VENTION
The term post vention introduced by schneidman (1972), comprises those action following the suicide as mollifying the after effects in a person who has attempted suicide and dealing with the adverse effect on the survivors of the suicide completers. It has been reported that for each suicide, there are around six survivors (Schneidman 1969). However, others fix a higher figure. The survivors may be spouses, parents, grand parents, children, lovers, other relations or friends. The survivor population represents the largest mental health casualty area related to suicide. (Schneidman 1972).
People whose bereavement is associated with unnatural dying should be treated as a separate population. (Zeasook, 1987). The survivor population runs the risk of morbidity and morality (Physical and Psychiatric, Heart attack, suicide and malignancy) besides emotional, social and economic consequences besides immune functioning. Arnold Toynbee (1976)drew attention to this the peril of survivorship. Post vention measures consists of contacting the survivors of suicides to prevent the repetition of the attempt such as helping to resolve conflicts and prompt treatment of physical and mental  illness. While helping the members of the family of the deceased, the social and psychological impact of suicide on them is to be assessed. Emotional reactions like shock, grief, depression, guilt and anxiety have to be dealt with (Venkoba Rao, 1997)
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