Life-and-death questions

Published : Oct 13, 2001 00:00 IST

The International Association for Suicide Prevention holds its 21st Congress in Chennai, bringing to focus the growing concerns over the causes and effects of death by suicide.

IF death is tragic, death by suicide is even more so. While the resort to suicide essentially remains an enigma, the enormous social costs associated with life cut short by self-inflicted death has assumed serious proportions globally. More than one million people around the world take their own lives every year. The evidence is that in many societies the number of suicide deaths, particularly among the young, is rising alarmingly. This is especially so in the developing countries.

The International Association for Suicide Prevention (IASP) held its 21st Congress in Chennai from September 22 to 26. It brought together more than 450 delegates representing clinicians, psychiatrists and other mental health professionals, social workers, volunteers and others representing a cross-section of society who play an active role in preventing suicides. In keeping with the complex and multi-dimensional nature of the problem, there were technical sessions for medical experts, and presentations by social scientists, social workers and representatives of the media.

Founded in 1960, the IASP provides a platform for those engaged in the field of suicide prevention and crisis intervention. It provides specialised training to personnel in the field of suicide prevention and has been in the forefront of efforts to establish national organisations to combat the growing social burden of suicides. The Congress, organised for the first time in Asia, was also the first to be hosted by a non-governmental organisation, Sneha, the Chennai-based NGO working in the field of suicide prevention (Frontline, September 28, 2001). The Congress was co-sponsored by the World Health Organisation (WHO), the Indian Psychiatry Society, the Schizophrenia Research Foundation (SCARF), the Indian Association of Suicidology and Befrienders International, an international NGO active in the field of suicide prevention.

According to the WHO, suicide is among the top 10 causes of death in most countries and one of the three leading causes of death in the 15 to 35-year age group. The psychological and social impact of a single suicide, on the family and society, is huge. To place the magnitude of the problem in a global context, the burden associated with suicides is at least equal to those caused by wars and homicide, roughly twice of those caused by diabetes, and equal to those caused by of birth asphyxia and trauma.

The WHO estimates that in 2020, 1.5 million people are likely to commit suicide. Its projection is that the rate of suicides (measured in terms of the incidence of suicides per 100,000 population) will increase to about 19 from the current level of about 16 mainly because of the rising incidence in developing countries. The rate of suicides in the West has stabilised, primarily because of the declining rates among the elderly. However, even in Western societies, although the rates for women have stabilised at lower levels in recent years, the rates for young men are high and rising. Nine of the top ten countries in terms of male suicide rates are in Eastern Europe - the tenth is Sri Lanka (Table 1). Lithuania has the highest rate, more than four times the world average.

In almost all the countries - barring mainland China - the suicide rates for women are substantially lower than that for men. For instance, in Lithuania the suicide rate for men is more than five times that for women. The generally lower rate for women is ascribed to several factors. Alcoholism is a significant contributory factor in suicidal behaviour and women are less prone to alcohol abuse. Their greater level of religiosity is also said to make women less prone to suicide. Psychiatric evidence suggests that women have more "flexible coping skills"; are more willing than men to seek professional help when they encounter suicidal tendencies; have more "extensive social support systems" when dealing with problems; and are less prone to denying warnings such as an onset of a depressive bout.

Although suicide is a deeply personal and individual act, suicidal behaviour is determined by a confluence of factors. These are basically in two domains. One is external, which is influenced by larger social processes. The internal domain relates to factors which operate at the level of the individual. The evolution of the modern understanding of suicides and suicidal behaviour has been to marry the externalised and the internalised views. Dr. Diego De Leo, psychiatrist and president of the IASP, explains that this understanding has come a long way from the early 19th century view that equated suicidal behaviour with insanity. Two concomitant revolutions in the late 19th century - one in the field of sociology, associated with Emile Durkheim, and the other, the psychoanalytical movement led by Sigmund Freud - have been synthesised in the modern view of suicide and suicidal behaviour.

In addition, De Leo referred to recent developments in biology and genetics which have contributed to a better understanding of suicidal behaviour. He said that although suicide is a universal phenomenon, the rates vary across countries. "Social and cultural variables amplify any biological and psychological predisposition a person might have," he said. The causes for suicide are "multi-factoral, interlinked and progressive over time, pushing an individual through stages of helplessness, hopelessness and worthlessness".

Studies in both developing and developed countries reveal an overall prevalence of mental disorders of 80 to 100 per cent in cases of completed suicide. It is estimated that the lifetime risk of suicide in people with mood disorders (mainly depression) is 6 to 15 per cent; with alcoholism, 7 to 15 per cent; and with schizophrenia, 4 to 10 per cent. De Leo believes that there is a need to "integrate the new knowledge from biology and other fields to other realms of knowledge in the psycho-social, the cultural, religious and other fields". He cautions against a "medicalisation" of the problem.

It is now widely accepted that suicide is a multidimensional disorder resulting from a complex array of factors - biological, genetic, psychological, sociological and environmental. The WHO says that 40 to 60 per cent of people who commit suicide had been to a physician in the month prior to suicide. Of these, many more had seen a general physician rather than a psychiatrist. This is more so in developing countries, where mental health services are almost non-existent. Hence the role of the general practitioner in suicide prevention is crucial in these countries.

In his presidential address at the Congress, De Leo stressed the "cross-cultural" dimensions of suicidal behaviour and referred to the enduring relevance of Emile Durkheim's sociological perspective on suicides in Europe, made in his study, Suicide: A Study in Sociology, published in 1897. Durkheim postulated an externalised vision of the problem, making rigorous use of empirical data. He observed that there was no correlation between rates of psychiatric disorders and suicide rates in European countries. Instead, he found that the nature of social institutions and the changes they were undergoing offered a better explanation for the phenomenon.

De Leo referred to recent studies in Russia which indicated "economic instability, the disintegration of the USSR, as well as specific historical factors" as possible contributory factors for the high suicide rate in Russia and in Eastern Europe. A study of suicides in Bosnia revealed that while the rate was lower during the war, it had increased substantially since then, particularly among children. This finding was also associated with rising alcoholism among children in Bosnia. De Leo said: "While they had survived the most immediate threat posed by war, the young had succumbed to the long-term stress."

Speaking at the plenary session, Dr. J.M. Bertolote, coordinator, Mental and Behavioural Disorders in the Department of Mental Health at the WHO, observed that suicide rates vary enormously across countries. He pointed to the "fuzzy nature of the picture that emerges while applying any one factor in one country to another". The suicide rates among Hispanic Americans is said to be lower because of the cultural emphasis on the family and especially because of their adherence in general to Roman Catholicism. However, this factor appears ineffective in Lithuania, a predominantly Catholic country.

Dr. Benedetto Saraceno, director of the Mental Health and Substance Abuse Division at the WHO, says that governments across the world have failed to react to the mounting mental health disorders which have a strong connection to suicidal behaviour. He says that money is not the problem because cost-effective treatment is available for mental conditions such as schizophrenia and depression. But there are "significant barriers" which prevent people from accessing such facilities. The social stigma associated with mental illnesses is one; the "large, ancient and inhuman" nature of the large mental health institutions is another.

The serious shortage of psychiatrists and other mental health professionals in developing countries is also a factor. Dr. Lakshmi Vijayakumar, organising secretary of the Congress and founder of Sneha, said that there were just over 3,500 psychiatrists in India although the suicide rate was climbing sharply over the last decade.

In several countries, particularly in the developing world, the state has not even recognised suicides as a social problem, let alone taking measures to stem its rising incidence. It has been left to the voluntary sector to handle this task. Lakshmi Vijayakumar says that those attempting suicide typically exhibit an ambivalent attitude to death. She says that this gives a window of opportunity to volunteers to reach out to the potential victim. "Those on the verge of attempting suicide," she says, "typically experience a see-saw battle between the wish to live and the wish to die."

Suicide is also characterised by a streak of impulsiveness because the victims are constricted in their thinking, tending to look at things in an either/or fashion. Such people, if gently exposed to alternatives to death, can be persuaded not to choose death. If an external source of support is able to reach out to the individual at the moment of impulse, suicide can be avoided.

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