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 Post subject: Suicide in Sri lanka - Facts and Trends
 Post Posted: Sun Mar 12, 2006 1:32 am 
Suicide in Sri lanka - Facts and Trends

Written by RH
Sources: WHO/BMJ/Internet


As late as the 1950s, Sri Lanka had a low suicide rate of 6 per 100000. This rate doubled to 12 per 100000 by 1964 and increased to 19 per 100000 by 1969. This was followed by a sharp increase. The official estimates for 1996 were 37 per 100000, making Sri Lanka one of the countries with the highest number of suicides per unit of population. The suicide rate peaked in 1995 with 8,500 deaths (23 per day!) -- then said to be the highest in the world -- but has since dropped to 4,995 deaths in 2001 following a series of government measures including restricting access to toxic pesticides mostly used by rice farmers.

A study revealed substantial underreporting and the real extent of the problem and the actual rates are estimated to be 44-50 per 100000. Significantly, the proportion of youth committing suicide increased from 33 per 100000 in 1960 to 44 per 100000 in 1980.

Suicides are the fourth most frequent cause of death in hospitals in Sri Lanka. The separatist war in Sri Lanka, which has raged since 1972, has been responsible for the deaths of at least 50,000 people in 15 years. Deaths due to suicide, in the same period, are estimated to be 106000 -- twice the number due to war.

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The rising incidence of suicide and pesticide poisoning led the Sri Lankan government to set up a special commission in 1995 to advise on ways to tackle the problems. In that year, suicides were the main cause of death among Sri Lankans aged 15-49 years, according to health ministry figures.

In the same year, pesticide poisoning ranked six among causes of hospital deaths, with 1,571 deaths and 15,730 cases. In six rural districts, however, pesticide poisoning was the main cause of hospital deaths.

According to Nalini Ellawela, director at Sri Lanka Sumithrayo, the country's premier counseling centre, most of the suicides are caused by love affairs gone wrong, poverty, parental pressures on marriage, unemployment, unwanted pregnancies, failure at examinations, fear of punishment, inability to pay loans and in recent years, women going to the Middle East to work.

However, the rate at which people continue to attempt suicide remains high, said Lakshmi Ratnayake, former chairman of Sri Lanka Sumithrayo and now head of the agency's unit that deals with rural communities.

Sri Lanka, which has a predominantly Buddhist population, reveals that a large number of suicides are among Buddhists, even though their religion does not favour suicide. The belief in rebirth and the lack of definite statements on suicide by Buddha makes suicide much less ‘sinful’ than killing another person.

Worldwide, the exact number of people ending, attempting or thinking of ending their lives is not known. Suicide is one of the leading causes of death across the world, especially in the 15-35 year age group. As per WHO estimates, nearly one million people will commit suicide during the first year of this millennium. This amounts to an average of one death every 40 seconds and an attempt every three seconds. Deaths recorded due to suicide across the world indicate only the tip of the iceberg.

In every country, suicide is reported to the police, whereas the health sector conducts forensic examination for completed suicides and provides care for the attempted ones. Deaths due to suicide are underreported to avoid sociocultural stigma, escape police enquiries and legal harassment, and benefit from the insurance sector. They are also misclassified as accidents. Hence these official numbers are gross underestimates. Further, the information related to attempted suicides is not compiled by any single agency.

The word "suicide" was first used by Sir Thomas Browne in 1642 in his Religio Medici. The word originated from SUI (of oneself) and CAEDES (murder). Since then, the word has evoked constant and continuous debate and has been defined in various ways for medical, social, psychological, administrative, legal, spiritual and religious purposes.

Suicide has been glorified or condemned through the ages and the debate continues even today. With the thinking on and understanding of suicides changing, it is now regarded more as a tragedy than a ritual.

The first scientific attempt to understand the rationale behind suicide started in 1763 with the work of Merian who emphasized that suicide was neither a sin nor a crime, but a disease. The first in-depth examination by Farlet in 1822 of suicide by Jean Jacques Rousseau concluded that the great writer had graphically and sequentially described the circumstances leading to his own death, thus enabling a broader understanding of suicide. In 1905, a famous psychiatrist, Dr R. Gaupp, indicated for the first time that there were some peculiar and unique personality traits among people committing suicide. Over the last 50 years, researchers have advanced this idea further to conclude that it is the state of mind, along with all external influences, which result in suicide.

Suicide evokes mixed reactions: varying from anger, distress, ridicule, anxiety, tension, fear and sadness. Often, one wonders: "Why did it happen?"; "Could this have been prevented?"; "Can young lives be saved?"; "Was there an alternative solution to the problem?"

Though suicides and para-suicides have been attempted since the beginning of mankind, a sea change has been observed recently in our understanding of the problem. Cumulative research, media reports and anecdotal evidence over the past three decades reveal that suicides are an emerging epidemic in the world. Research in different regions of the world has focused on understanding the problem in its various dimensions. However, this understanding has not been effectively translated into practice, thus leading to continued loss of lives.

In Sri Lanka preventing suicide has become a national public health priority. Nearly 70% of those who have committed suicide in 1999 have ended their lives by poisoning after the use of pesticides or unspecified substances. Another 14% have been subjected to strangulation or suffocation due to hanging themselves. Other methods of committing suicide include burning themselves, jumping in front of a moving train and getting drowned.

Self-poisoning is a common method of committing or attempting suicide in rural Sri Lanka. The poisons used are pesticides, yellow oleander (Thevetia peruviana) seeds, and medicinal or domestic agents. In Sri Lanka, the sparseness of medical facilities, access to highly toxic poisons –particularly the pesticides widely used in rural areas – and the lack of cheap antidotes means that self-poisoning is frequently fatal.

As part of a collaboration between the universities of Colombo and Oxford, a research team has collected data on self poisoning in Anuradhapura General Hospital, a secondary referral centre for 900 000 people living in the North Central Province of Sri Lanka (Ref. 1).

According to the study report, during 1995 and 1996, 2559 (1443 men and 1116 women) were admitted to Anuradhapura hospital with acute poisoning, almost all as a result of deliberate self harm. Of them, 325 (12.7%) have died in the hospital. Organophosphate and carbamate pesticides caused 914 admissions to hospital and 199 (21.8%) deaths, and oleander poisoning accounted for 798 admissions to hospital and 33 (4.1%) deaths over a 21 month period. The number of patients admitted to hospital with acute poisoning in this region of Sri Lanka has increased enormously over the past five years, causing great stress to the already overstretched medical services. The study found that Sri Lankans who deliberately tried to poison themselves took up 41% of intensive care beds in Anuradhapura General Hospital in 1995 and 1996, compared with 9% for heart complaints.

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Many people admitted for deliberate self poisoning were young. Two-thirds of those who poisoned themselves were under 30 and 60% of women who died were under 25. Few expressed a desire to die but, unfortunately, deaths are relatively common among the young. For most of the youngsters, self poisoning seems to be the preferred method of dealing with difficult situations. Examples include a 16 year old girl who died after eating oleander seeds because her mother said she could not watch television; a 13 year old boy who drank organophosphates after his mother scolded him, and who spent three weeks in intensive care being ventilated; and a 14 year old boy who presented in complete heart block after eating oleander seeds because his pet mynah bird had died. The researchers said the young people were learning from those around them. A shocking 90% knew someone who had committed suicide. They also put the high numbers down to a lack of support for the young and the effects of war, poverty and lack of opportunities.

Oleander seeds contain poisonous cardiac glycosides similar to the drug digoxin which in excess amount cause serious heart problems. Organophosphate pesticides, the commonest type of pesticide used in self-poisoning, are more toxic than oleander seeds and absorbed faster. A much larger proportion of patients die with organophosphate pesticides which cause respiratory paralysis.

A recently published medical article reported differences in pesticide related suicides by gender and age. Among Sri Lankan males the rates peaked between 60–64 years and males demonstrated higher pesticide related suicide mortality risk than females (Ref 2).

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Gender differentials are discernible as suicide is seen as an easy way out of a problem by more men than women, at any particular time interval of the lifespan. The gender gap appears to be widening over the years, as reflected by the relative frequency of suicides. The probability of a man committing suicide was double that of a woman in 1950, whereas it is found to be more than three times higher in 1999.


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Ref 1: Deliberate self harm in Sri Lanka: an overlooked tragedy in the developing world, Michael Eddleston, M H Rezvi Sheriff, Keith Hawton. BMJ 1998;317:133-135

Ref 2: Demographic risk factors in pesticide related suicides in Sri Lanka. E B R Desapriya, P Joshi, G Han and F Rajabali. Inj Prev 2004;10:125



Quote:
Sri Lanka unlocks brains of the dead to crack the secret code of suicide

Staff Reporter
February 01, 2005


It may sound morbid, even bizarre, but Sri Lankan scientists are going ahead anyway. In a bid to unravel the mystery behind Lanka's soaring suicide rate highest in South East Asia anatomists will soon start picking the brains of the dead.

They will begin by extracting cells from adult cadaver brains and then get down to identifying "susceptible genes" that are pushing Lankans to the brink.

The answer to the 10-fold rise in suicide rates from the 1950s to 1990s will emerge after "microarray studies" are done on these cells, says Dr Ranil De Silva, Senior Lecturer of Anatomy at the University of Sri Jayewardenepura in Nugedoga.

The first-of-its kind project will be undertaken by the university in collaboration with scientists from the National University of Singapore, says Dr De Silva. "An alarming 70,000 people have committed suicide from 1990 to 2000 in Sri Lanka, with an estimated 14 million suicide bids. The rate has increased by 10 times between 1950s to 1990s. To get to the root of the problem, we have decided to adopt a two-pronged approach. While the first would be an epidemiological study, the second one would involve taking brain cells of cadavers to zero in susceptible genes," he says.

"The initial leads would be available in about six months," adds Dr Silva, who heads the Neuroscience Society of Sri Lanka and is here for the national conference of the Indian Psychiatric Society.

Also here for the annual conference is the National University of Singapore's Dr Zhu Yi Zhun, who says, "by studying the new genes we would try to find out whether fear, anxiety, depression affects them which could trigger suicidal tendencies."

"There are a lot of neuro factors... We have carried out a study of cadaver brains in Singapore where we have analyzed 20 brains. The initial groundwork is done and the project would be started in the next few months," says Dr Zhun, who has already made two trips to the island.

"We have been granted one million Singapore dollars by the Ministry of Health, a large share of which would be utilized for the study," he adds.

The study, Dr De Silva says, is fuelled by the knowledge that altered RNA expression levels can have profound influences on brain function. "Therefore, a systematical search for genes of variable expression will provide candidate susceptibility genes that might influence many diseases of the human brain... Knowledge about variability in the expression of genes that are targets for drug action will help to develop drugs that can ve prescribed selectively to patients for whom they will be effective and safe," he says. The epidemiological studies, Dr De Silva says, have already got off the ground with Sri Lankan experts preparing questionnaires for every hospital patient who has attempted suicide.

In the case of those who have died, the questionnaire would be passed on to the next of kin to assess trigger factors. The other problem scientists will focus on is the rising alcoholism level in Lanka and its possible connection to suicides, besides environment and genetic variants.

"Sri Lanka has one of the highest alcohol consumption in the world. A strong association between alcoholism and suicide has been noted and there has been a serious rise in the suicide rates in the 1990s along with the increase in the production and consumption of both licit and illicit alcohol. We hypothesize that environment and genetic variants may contribute significantly to increasing suicide and alcoholism in Sri Lanka," says Dr De Silva.


@ LankaLibrary.com


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 Post subject: Poison Plant Oleander Fuels Suicides in Sri Lanka
 Post Posted: Wed Apr 12, 2006 4:43 pm 
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Poison Plant Oleander (Kaha Kaneru) Fuels Suicides in Sri Lanka

@ BBC / Apr 12, 2006
Poison plant fuels suicide bids
By Jolyon Jenkins /Producer, Me and My Poison


A common roadside plant, Kaha Kaneru, fuels a suicide epidemic in Sri Lanka. "Most of the time people get oleander with very small, minor reasons. I think we have to do something to reduce the rate of admission to the hospital."

Sri Lanka has been suffering from a growing epidemic of suicide attempts. It is fuelled by the ready availability of poison from the fruit of a common roadside plant.

Michael Eddleston is a British doctor who has spent much of the past ten years in Sri Lanka.

It is becoming the suicide capital of the world. The poison of choice is the seed of the Yellow Oleander tree.

The Yellow Oleander is an ornamental plant often used for hedging that grows all over the island.

"Often young people use it as a way of getting back at people" - Michael Eddleston

It has yellow trumpet-like flowers and a fruit the size of a conker. Inside is a single large seed. One is enough to kill you.

Although the plant grows in large parts of the tropics, it's only in Sri Lanka that it has become associated with suicide - and only fairly recently, with an incident 25 years ago.

Two girls in the northern part of the island took the seed and died.

Publicity

As a result of the newspaper publicity it entered the public consciousness.

"The next year," says Michael Eddleston, "there were 23 cases; the year after that 46, then 126, and ever since then it has continued to rise year on year as it spreads across the island.

"It completely overwhelms the health service. Often young people use it as a way of getting back at people. They get scolded and they take a yellow oleander seed.

"I remember one girl said her mother wanted her to get up and do the shopping. She said no, her mother scolded her and she took a Yellow Oleander seed.

"I remember a Muslim girl - her mother said she couldn't watch TV during Ramadan, so she took a seed in front of her mother.

"We had no ambulance to get her in time and we had no good treatments. She died."

Family strife

It's not just young people. In a remote hospital in Pollonaruwa, where Michael Eddleston has done much of his research, I met an old man, a strict Buddhist, recovering from a suicide attempt.

He had fallen out with his wife, over his habit of feeding the neighbourhood dogs. You care more about those dogs than me, said the wife.

The man, feeling that his Buddhist principles were under attack, walked out and swallowed a seed from a tree in his garden.

Luckily, relatives discovered him and got him to Pollonaruwa in time.

Many of these protest suicide attempts are only semi-serious but up to 10% of them are fatal anyway - a much higher percentage than in the west, where we have good anti-poisoning drugs and facilities.

Michael Eddleston wanted to do something about that.

The poison from Yellow Oleander is similar to a drug used in the West to treat heart beat irregularities, digoxin. Digoxin slows down the heart beat.

Dramatic effect

An oleander seed is like 100 digoxin tablets in one container, and the effect on the heart is dramatic: it gets slower and slower, and then stops.

Western doctors have at their disposal an anti-body against digoxin.

""I feel very sorry about these innocent people" - Dr Kachana

Michael Eddleston thought it might also work against Yellow Oleander, and ran a trial in Sri Lanka to test the theory.

The drug did indeed work, but no anti-digoxin is currently used in Sri Lanka. Why? Because it's too expensive. To treat one patient could cost in the region of $3000.

Mr Eddleston said the price was held high because of the American market: most clients are American doctors who have accidentally given their patients too much digoxin and need to get the heart going again.

For them, he said, it's worth paying almost anything to avoid a law suit.

So the price of the drug remains high, geared to a market which demands the highest quality, purest drug - a purity that is an unaffordable luxury in Sri Lanka.

Money pressures

For much of the last decade, Michael Eddleston has tried to find a local manufacturer in the Indian subcontinent that can make anti-digoxin at a price the Sri Lankan market can afford.

But, I wondered, will this ever be seen as a priority in a country that has so many calls on its health care budget?

Isn't there bound to be a lack of willingness to spend money on people who have brought their problems on themselves?

If so, it's not an attitude I found at Pollonaruwa hospital. Dr Kachana, one of the doctors on the poison ward told me: "I feel very sorry about these innocent people.

"Most of the time they get oleander with very small, minor reasons. I think we have to do something to reduce the rate of admission to the hospital."

And she recommends a government campaign to get people to cut down their Yellow Oleander trees.

It won't be easy. In a village I spoke to a poisoning victim who still had the plant that nearly killed him in his garden.

Had he thought of cutting it down, I asked. Yes he had, he said. But the plant was still there.


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