Suicide is a disastrous event and a solemn public health problem worldwide in recent era. Suicide means to exterminate oneself intentionally, certainly it is difficult to identify due to its several reasons and fatal result. In spite of all these essentials, it is still avoidable. Suicide is pervasive in both developed and under developing countries of the world particular in Pakistan. This paper aims to provide a brief overview on misconception regarding suicide, its potential causes, diverse methods and the warning signs of the suicidal person. The issue of suicide need to be addressed in all developing countries, although well known that there is lack of various resources and low priority is given to mental health in Pakistan. Proper training of the health care providers is to be strengthen, prevention programs for the youth and public awareness would be central to outfit this key concern.
Keywords: Suicide, mental health, causes and methods of suicide, Pakistan
Suicide is a catastrophic and perplexing event and a serious public health problem worldwide. Suicide means to kill oneself deliberately, indeed it is difficult to identify due to its several reasons and fatal outcome. Despite all these facts, it is still preventable. Suicide is widespread in both developed and under developing countries of the world. According to Wassan and Riaz, (2007) reported that internationally, one million people kill themselves annually due to assorted forceful reasons. It is also the third leading cause of death among 15-44 years old, and the second leading cause of death among 10-24 years old in some countries. Adding further, the statistics also disclose that on every 40 seconds, a person inflicts suicide, thus making suicide the thirteenth leading cause of death universally (WHO, 2008).
Suicide is becoming a major global health concern nowadays. According to World health organization, (2008) if we glance at developing country like Pakistan whose population is approximately 162 million people and the suicidal rate increase from few hundred to more than 3000 in 2003 (Khan, 2005). Moreover, Pakistan as an Islamic country with 97% population is being Muslims. Unfortunately, trends turn out to be increasing in Muslims as compared to other minorities. Not only in Islam, suicide is considered as a condemned act but all other religions of the world which includes Judaism, Buddhism, Hinduism, Christianity and Bahai faith consider suicide as a serious offense and they prohibit their followers to end their own lives intentionally (Wassan & Riaz, 2007).
Suicide is also considered as a major neurological problem for younger generation. Primary psychiatric consultants treat this disaster as an “emerging epidemic” (Brown, 2001). Deplorably, in Pakistan, there is lack of awareness in regard to a variety of neurological and psychiatric diseases, which are the ground root and the basic reason to cause harm to the society beyond our understanding (Wassan & Riaz, 2007). Moreover Government is giving least priority to mental health facilities as evident by the expenditure towards the mental health is only 0.4% which is insufficient to cater the needs of whole population of Pakistan (WHO, 2008).
Based on the aforementioned studies and statistics it is evident that suicide is becoming a major health concern in developed and developing countries. Despite the facts, this problem is receiving less attention globally and it’s became a serious public health issue nowadays.
Literature review regarding suicide will focus mainly on misconception regarding suicide then its causes, its method, warning signs of the suicidal person and lastly end with some practical recommendations.
Misconceptions related to Suicide
There are several misconceptions regarding suicides which are prevalent in our society. One such misunderstanding is that suicide happens without any warning signs. This is not really true as 80% of the suicidal persons provide many clues and warnings of their plan but these warnings are not being recognized (Khan, 2003). It is essential to be alert of all these behaviors exhibited by a suicidal person so that upon identification a life of a person could be preserved. Literature also reveals that the suicidal person shows warning signs that include a recent death of a close family member or a companion, depression, bipolar disorder apart from these psychological signs few behavioral signs for instance talking about hurting or killing to self such as statements like “I will not be around much longer”, a sudden appearance of being cheerful which commonly comes from the idea that the problems will end soon with their own death (Segal, 2000). These signs highly indicate that suicidal person shows some sort of verbal or non verbal clues which could be witnessed signs by their loved one, thus it is important to identify those signs and immediate action can be taken to prevent permanent injury or death.
Another familiar misconception is that suicidal person is fully intent on dying. This is entirely not accurate. Research declared that the suicide is a completely preventable incident provided that immediate action is taken. It is necessary to realize that suicidal people are ambivalent about life or death, while at that point of their crises they challenge to die but they are not fully intend to do it (Segal, 2000).
In addition, another prevalent misconception about suicide is that talking about suicide encourages suicidal person to do it. Dialogue about suicide does not encourage suicidal behavior rather it offer a way of sharing concerns and feelings. According to Segal, (2000) “discussion about suicide can be a request for help and can be a sign in the progression towards a suicide attempt. If someone talks about suicide encourage them to talk and help them to find some other appropriate solution of their problem” .Ventilating feeling about suicide is always beneficial and therapeutic for the suicidal person.
Further it is also believed that people are suicidal type. This is an irrational myth. People from all races, religions, occupations, classes, ages and sexes kill themselves and equally affected by this problem. A research on this matter shows that every individual has potential for suicide and nobody is suicidal all the time. The risk of individuals being suicidal varies across times and as circumstances change.
Causes of Suicide
Plenty of literature mentioned the diverse compelling reasons regarding committing suicide. Suicide is a complex phenomenon and it is commonly the outcome of a various feature. It consists of psychological and biological, socio-economic, demographic and environmental factors. Literature reveals that the psychological factors are the major leading cause of suicide. 90 % of the suicides are associated with mental disorders, typically with mood disorders like depression and 60 % of suicides are linked with alcohol abuse disorders. In addition, it also asserts that by 2020, depression will become the second leading cause of disability worldwide (European Communities, 2008). In case of Pakistan, literature declared that almost 34% of Pakistani population suffers from common mental disorders, and depression is alone is responsible for 90% of suicide in the country (Khan, 2007). These statistics relate the high prevalence of mental disorders worldwide and which has become an important global health burden in recent times.
An added, precipitating factors for suicide are some of the biological factors that are inherited in the families. According to Kumpula, Kolves & Leo, (2011) reveals that biological factors correlate with the suicide that include certain hormonal factors and a deficiency in the neurotransmitter serotonin in women as compared to high dopamine level in males. Other biological factors may include low cerebrospinal fluid, platelet disorders, hormonal imbalances and abnormal sleep patterns.
Poor socio-economic condition and suicide in Pakistan has been strongly associated with each other (Khan, 2007). The rates of suicide are at climax among developed countries particularly those which have developed rapidly. Inside these countries suicide rates are highest for sub-groups that have remained socio-economically disadvantage (WHO, 2008). Pakistan is the country with lowest Human Development index (HDI) and Australia remains the highest in economic prosperity (WHO, 2008). According to WHO, (2008) Pakistan is a low income group country based on World Bank 2004 criteria, moreover 50% of the population lives below poverty line (WHO,2003). The major contributing attribute relating to socio-economic includes illiteracy, unemployment, poor income, poverty and middle to low social classes. A person with low socio-economic status often lack access to the medical and community resources that promote and support human development. Thus, deprivation from these fundamental necessities made a person more prone to suicidal attempts.
It has been observed in a report of two year analysis by Khan and Hashim, (2000) in Pakistan that reported 306 suicides (aged 13–70 yrs) from 35 cities. According to the Kumpula, Kolves & Leo, (2011) reported that male suicide rates exceed those of women in many developed countries. In contrast, According to Khan, (2007) reported high ratio of female to male suicide in most of the studies in developing countries moreover, the highest age and gender-specific rates for men and women are in the age group 20-40 years. According to WHO (2008), in some countries like India, Pakistan, and Sri Lanka where arranged marriages are common as social and familial pressure on a women to continue marriage even in offensive relationship become visible factors that increases the suicide in most of the women’s. Furthermore, dowries, unhappy marriages, harassment, family issues and attitude of the society towards the women further obscure this problem.
The environment play a major role which includes environment within and outside the home and sometime becomes a place of stress for most of the people. Physical and sexual abuse in our environment become more prevalent and is increasing day by day. According to Segal, (2000) millions of people are becoming the victims of physical and sexual abuses and most of them go unreported worldwide. In addition, there are approximately 3 million reported yearly cases of abuses in those under 18 year of age in the United States; these reports are subdivided into neglect 53%, physical abuse 26%, sexual abuse 14% and emotional abuse in 5%. According to WHO (2008), committing suicide is considered as a crime and stigma is attached to the existing families and these families are reluctant to report suicide. However, in case of Pakistan the stigma is even much greater. Furthermore, families do not disclose the accurate nature of the event due to the fear of harassment by police and social stigma. Families claim it to be either an accident or in some cases, a murder (Khan & Hyder, 2006).
Suicide could not be done in a vacuum but there are various factors influence on a suicidal person which made a person prone to do this act without thinking about their own families, society and the overall nation.
Common Methods of Suicide
It has been observed that the common methods of suicide are poisoning, hanging, drowning, and firearm, jumping from height and self-shooting. According to Segal, (2000) the most common method of suicide were Suffocation (mainly hanging) 38%, Firearms 49%, poisoning 7% and miscellaneous 6% and it is estimated that for every thriving suicide there are at least 10-20 deliberate self-harms (DSH). Conversely, in Pakistan the two most common methods are hanging and poisoning. According to WHO, (2008) China, India, Pakistan and Sri Lanka are the countries where pesticide- related suicides are more prevalent than other countries. Confining the accessibility of insecticides and other poisons can potentially prevent 50% of suicides (Khan, 2007).
Suicide Warning Signs
Suicide warning signs are the initial sign that shows a person might be at a high risk of committing suicide, having serious thoughts about taking his/her life or making a plan to take the action. The most relevant warning signs stated by Segal, (2000) are previous suicide attempts, depression, threat of suicide, unusual changes in personality or behaviors, increased use of drugs and major change in life. Additionally, regularly talking about committing suicide, frequent crying, giving away their valuable things to others, saying goodbye to family and friends and often complaining about life are some of the warning signs identified by many studies. These signs are also called as alarming sign which should be identified promptly and immediate action should be taken to preserved life of a person.
Conclusion and Recommendations
Suicide become more prevalent and need to be addressed in all developing countries, although well known that there is lack of various resources and low priority is given to mental health such as in Pakistan. A review of literature reveals almost 34% of Pakistani population suffers from common mental disorders, and depression is alone is responsible for 90% of suicide in the country (Khan, 2007). To reduce the burden of this global issue to a slight extent, following recommendations are given below.
To prevent suicide firstly, as a healthcare professional it becomes our major responsibility to well equipped ourselves with proper knowledge and skills and then provide awareness to the public about the warning signs of the suicidal person moreover promote public to seek health care in case of mental health diseases like depression and other mood disorders. In addition, according to WHO (2008), increasing public awareness through the distribution of pamphlets, posters, commentaries in newspaper and on television are the approaches which also help in decreasing the suicide rates. Secondly, at hospital level, training of the emergency staff should be done regarding proper handling and referring of suicidal person to mental health facility for further management. Next, suicidal prevention program should be initiated for young generation especially focusing on young married women as they are the primary care giver for whole families and also play a major role in rearing the healthy future generation. Then, Government should play a key role to increase allocating mental health budget and proper utilizing of the budget to cater the needs of whole population in Pakistan. There is an urgent need to review the law regarding DSH and suicide in Pakistan so that people who need psychological help can do so without fear of being victimized by the police (Khan, 2007). In addition to it, implementation of mental health ordinance 2001which clearly depicts the duties of the health care professional should be strictly monitor and evaluated on yearly basis. Finally, reporting system or HIMS (Health information management system) should be improved in order to report these cases without delay. Moreover, there is a need of in-depth research to be carried out at national and international level in order to better understand the grass root of suicide both at micro and macro level and on its prevention accordingly
In conclusion, it feels distressing that despite momentous advancement in recent technology, millions of potentially avoidable deaths occurring per annum in recent time.
Suicide prevention will continue to be a big challenge for all of us as a health care professionals and there is a sincere need to realize and collaborate amongst government, NGO’s, stakeholders, religious leaders, public and mental health professionals to take this challenge and do every effort to reduce the morbidity and mortality related to suicide in our society.
Brown, P. (2001), “Choosing to die: a growing epidemic among the young”. (WHO Bulletin)-79
Khan, MM., Hashim,R.(2000). The pattern of suicide in Pakistan Crisis. The Journal of Crisis
Intervention and Suicide Prevention, 21(1): 31-38
Khan MM. (2003). Beyond rates: the tragedy of suicide in Pakistan. Trop Doct; 33: 67–9.
Khan MM (2005). Suicide prevention and developing countries. Journal of the Royal
Society of Medicine 98:459-463.
Khan MM, Hyder AA (2006). Suicides in the developing world: Case study from
Pakistan. Suicide and Life-Threatening Behavior 36:76-81.
Khan MM (2007) Suicide Prevention in Pakistan: an impossible challenge? J Pak Med
Association 57(10): 478-479
Kumpula E-K, Kolves K, De Leo D (2011). Male Suicide. What biological factors make men so
vulnerable? Chinese Mental Health Journal 25(9): 320-321
Segal, D.L (2000). Levels of knowledge about suicide facts and myths among younger and
Older adults. Clinical Gerontologist.22(2): 71-80
Wahlbeck K. & Mäkinen M. (Eds). (2008). Prevention of depression and suicide. Consensus
paper. Luxembourg: European Communities.
Wassan, A.A & Riaz, M, (2007). A Socio Religious Analysis of Suicides and its Impact on
Economic Development. Indus Journal of Management & Social Sciences.1(1) :1-13
World Health Organization, (2008). Suicide and suicide prevention in Asia / edited by Herbert
Hendin… [et al.]. Retrieved from 26th August 2012
World Health Organization. Mortality Database. WHO, 2003.