Study of suicides reported to the Coroner in Colombo, Sri Lanka

Med Sci Law 2010;50:25-28
doi:10.1258/msl.2009.009012
© 2010 British Academy of Forensic Science

 

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Study of suicides reported to the Coroner in Colombo, Sri Lanka

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Ravindra Fernando MD FRCPath * ,
Medhani Hewagama MB BS ,
W D D Priyangika MB BS ,
Sonali Range MD  and
Shashi Karunaratne MB BS 


* Department of Forensic Medicine and Toxicology, Faculty of Medicine
South Asia Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

Correspondence: Professor Ravindra Fernando. Email: ravindrafernando{at}hotmail.co.uk




Abstract

TOP

Abstract
Introduction

Method

Results

Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

Introduction: Deaths from suicide reached a peak in Sri Lanka in 1995. Severalinterventions reduced the suicide rate of 48.7 per 100,000 in1995 to 23 per 100,000 in 2006, though it is still a major socioeconomicproblem. All suicides have to be reported to the Inquirer ofSudden Death (ISD) or ‘Coroner’, according to theCriminal Procedure Code.

Method: All deaths where a verdict of ‘suicide’ was givenafter an inquest at the Coroner’s Court, Colombo, in 2006 werestudied. Close relations or friends who attended the inquestwere interviewed by medically qualified research assistants.Age, sex, marital and occupational status, level of education,living circumstances and method and reasons for the suicidewere studied.

Results: During 2006, 151 deaths from suicide were documented, of which93 (62%) were men. The majority (47%) were aged between 20 and29 years. One-third of the victims was unemployed. At the timeof committing suicide, 75% were living with family; 89 (59%)were married and 46 (31%) were single. Poisoning was the causeof death in 66 (44%), 48 (70%) of which were due to pesticides.Burns caused 51 (34%) deaths. Other common causes of death includedhanging (11%), jumping in front of a train (7%) and drowning(3%). The commonest reason for suicide was dispute with thespouse/marital disharmony (30%). Other reasons were disputewith parents (8%), financial matters (7%), organic diseases(7%), alcoholism (7%), psychiatric illnesses (6%) and disputesin love affairs (5%). In 29 cases (19%), no definite reasonfor the suicide was evident.

Discussion: Self-poisoning and self-immolation were the commonest methodsused to commit suicide. Marital disharmony was the main reason(30%). Psychiatric illnesses were responsible for only 6%. Futureinterventional activities should include secure access and restrictionof the availability of pesticides and drugs, empowering peopleto manage anger and conflicts, and recognition and treatmentof alcoholism and psychiatric illnesses. The success story ofthe reduction in the incidence of suicides in Sri Lanka shouldbe a lesson to many developing countries where suicide is amajor socioeconomic and health issue.





Introduction

TOP

Abstract

Introduction
Method

Results

Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

Suicide is considered a complex behaviour that has biological,psychological and social implications. Deaths from suicide reacheda peak in Sri Lanka in 1995. Several interventions reduced thesuicide rate of 48.7 per 100,000 in 1995 (highest suicidal deathrate in the world) to 22.9 per 100,000 in 2006. However, itis still a major socioeconomic problem.

All suicides have to be reported to the Inquirer of Sudden Death (ISD) or ‘Coroner’, for an inquest according to the Criminal Procedure Code of Sri Lanka.1 At an inquest, thepolice present evidence relating to the death. Close familymembers, friends or eye witnesses to an incident such as consuminga poison, give evidence. The ISD obtains the cause of deathfrom doctors, and sometimes after an autopsy examination. Havingconsidered all these, the ISD pronounces the verdict of suicide.

The objective of this prospective study was to document epidemiologicaldata on suicides reported to the ISD of the city of Colombo.





Method

TOP

Abstract

Introduction

Method
Results

Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

All deaths during the one-year period from 1 January to 31 December2006 where a verdict of ‘suicide’ was given afteran inquest at the Coroner’s Court, Colombo, were studied. Closerelations or friends who attended the inquest were interviewedby pre-intern medical officers. A pre-coded data collectionform was developed, pre-tested and modified as necessary. Eachdata sheet was hand-checked for completion. Ages, sex, maritaland occupational status, level of education, living circumstances,and method and reasons for the suicide were studied.

Ethical approval for the study was obtained from the ethicalreview committee of the National Hospital of Sri Lanka.





Results

TOP

Abstract

Introduction

Method

Results
Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

During the study period, 151 deaths from suicide were documentedand analysed. The study included 93 men (62%) and 58 women (38%).

The majority (31.1%) of those who committed suicide were in the 20–29 year age group; 70% were in the 20–49 year age group, indicating that most of the deaths from suicide occurred among the young and middle-aged population (Table 1). As shown in Table 2, 89 suicide victims (59%) were married and 46 (31%) were single. Occupational status of victims showed that one-third of them were unemployed (Table 3).



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Table 1 Age group of suicide victims



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Table 2 Marital status of suicide victims



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Table 3 Occupational status of victims

 

Analysis of the level of education of victims showed that nine (6%) had no school education at all while 22 (15%) had studied up to years 6–11 (Table 4). Living circumstances showed that the majority, 114 (75%), were living with family at the time of committing suicide (Table 5).



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Table 4 Level of education of victims



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Table 5 Living circumstances of the victims

 

Analysis of the method of suicide (Table 6) showed that self-poisoning was the commonest method (n = 66; 44%). Of these,48 (70%) deaths were due to pesticides. Paraquat was the pesticideused by 31; 10 ingested organophosphorus insecticides; and inseven cases the pesticide was not known. Self-immolation caused51 (34%) deaths. Other common causes of death included hanging(11%), jumping in front of a train (7%) and drowning (3%).



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Table 6 Method of suicide

 

According to the evidence given at the inquest, the commonest reason for suicide was dispute with the spouse/marital disharmony (30%). Nine had psychiatric illnesses (6%): of these, three were suffering from schizophrenia while six had an affective disorder – depression, anxiety state or bipolar disorder (Table 7). Only two victims had sought the help of psychiatricservices around the time of death, while another two had doneso during the previous year. Another two victims had done somore than one year previously. Only 14 victims (9 men and 5women) had written a suicide note.



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Table 7 Reason given at the inquest for committing suicide





Discussion

TOP

Abstract

Introduction

Method

Results

Discussion
ACKNOWLEDGEMENTS

REFERENCES

 

Suicide is the result of multiple precipitating factors, althoughone factor is eventually identified as the main causative factor.

In 2006, 3558 men (79%) and 946 women (total 4504) committed suicide in Sri Lanka, according to the Annual Report of the Police.2 The male-to-female ratio was 5:1. The present study also showed that nearly two-thirds of victims (62%) were below the age of 40 years. A rising trend of suicide in young men is observed worldwide, especially among the 15–19-year age group.3

In our study the victims of suicide were mostly young, marriedmen who had interpersonal problems with their families whichthey could not handle. However, the male-to-female ratio showsthat a significant number of women too had committed suicide.

Most of the victims were of a low socioeconomic status: 34%were unemployed and 53% had been working as skilled, semiskilledor unskilled workers. Only 6% were involved in administrative,managerial, professional, technical or clerical occupations,indicating that the pressures were commoner among the lowersocioeconomic class.

Sri Lanka has a high literacy rate, with only 7.9% not attending school, 29.9% having primary education, 41% having secondary education and 21.2% having tertiary education.4 In this study,6% of the victims had no education at all and most of thosewho committed suicide (48%) had been schooled up to year 6–11(secondary education). Only 22 (15%) had studied up to advancedlevel or had a higher education.

In 2006, poisoning accounted for 2787 (62%) deaths in Sri Lanka. Of these, 2467 (88.5%) died from pesticide ingestion. In the present study, pesticide ingestion was the commonest method of self-poisoning, amounting to 72% of poisoning deaths. Since the first case of pesticide poisoning was reported in Sri Lanka in 1962,5 pesticide poisoning reached epidemic proportions in the 1990s. Acute pesticide poisoning is a major health problem and in several agricultural districts it is the principal cause of death in hospitals.6

In one study of suicide in Jaffna, the capital city of the Northern Province of Sri Lanka, pesticides were found to be responsible for 91% of self-poisoning cases, while in another study in Kandy District of the Central Province pesticides were responsible for 77% of cases.7,8 Pesticide poisoning has a very high death rate, 21.8%, in some hospitals in Sri Lanka.9

As Sri Lanka is a predominantly agricultural country, pesticides are easily available. They can be purchased from shops without any difficulty and even stored in households of many small-scale farmers. Action has been taken to ban some of the very toxic pesticides in Sri Lanka. Considering the high death rate from pesticide poisoning in Sri Lanka and other countries in the region, a regional information network for pesticide poisoning has been suggested.10

Self-immolation was the second leading method for committing suicide documented in the present study. According to the Annual Report of the Police,2 178 people (130 women and 48 men) committed suicide by deliberate self-burning in Sri Lanka during 2006. The present study has documented 29% of these deaths. Self-immolation constitutes a considerable proportion of major burns admitted to burns units. The pain, suffering and socioeconomic costs of this problem are significant.11

Self-immolation is common among women. Easy availability of kerosene in households of low socioeconomic groups contributes to this. A study in Batticaloa, a district in the Eastern Province of Sri Lanka, has shown that there were 5.8 cases of self-immolation/100,000 inhabitants annually.12 It is one of the most acute in the world, the victims being mostly young women.13 The present study alsoshowed a female-to-male ratio of 3.25:1, and 55 victims werebelow the age of 39 years.

Marital disharmony was the main reason for committing suicide (30%). Psychiatric illnesses were responsible for only 6% of suicides. A study of 168 parasuicides in Sri Lanka has shown that only 20% had a psychiatric illness and the rest were considered to have ‘impulsive personalities’.14 The findingin our study that only 14 (9.3%) had left suicide notes alsosuggests that the majority of suicide attempts were due to suddenimpulse.

The present study showed that psychiatric reasons are not themain reason for suicide, unlike in many developed countries.However, this may not be accurate as the relations and/or friendsattending the inquest might not divulge if a psychiatric illnesswas present, due to the stigma attached.

In 29 (19%) no definite reason for suicide was determined. Itis possible that some of them were suffering from a psychiatricillness. Alcohol and drug dependence were the other psychiatricproblems seen among those who had committed suicide.

Altogether 70 (46%) had committed suicide due to dispute withfamily members, marital disharmony and disputes in love affairs.This indicates the major influence the family context has uponan individual’s social and personal life within Sri Lanka. Themajority of victims (75%) were living with their family at thetime of committing suicide which correlates with the above fact.Social make-up and poor problem-solving abilities may be contributingfactors.

After a psychosocial assessment, only a minority of self-harmvictims are amenable to psychiatric intervention. In a countrylike Sri Lanka, where there are only a few specialist psychiatrists,it is not possible to have specialist psychosocial assessmentfor every patient presenting with self-harm. The first lineof assessment has to be the general practitioners and non-specialistmedical officers managing these patients.

Since 1995, a significant reduction in the number of suicides has been achieved. Although self-harm from pesticide poisoning is still very common, more patients who ingest pesticides now survive because of the import controls of the most toxic pesticides, such as endosulphan, monocrotophos and methamidophos by the Registrar of Pesticides (Table 8). Integrated pest management practices by farmers and improved management of poisoning cases may have been the major contributory factors for the reduction of suicides in Sri Lanka.15



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Table 8 Hospital admissions and deaths from poisoning in 2006

 

One reason for improved hospital management of poisoning cases is the establishment of more intensive care units in state hospitals. A study of admissions to an intensive care unit in a teaching hospital has shown that 10.2% of total admissions were due to suicidal self-poisoning.16 Other reasons for the reduction ofincidence of suicide are awareness programmes conducted forvarious stakeholders by the National Poisons Information Centreand some restrictions on reporting of suicides in the media.

A further reduction of the suicide rate requires a multifunctionalresponse by several stakeholders. For example, community interventionsto prevent easy access to toxic pesticides can reduce suicideby pesticide poisoning. Future interventional activities shouldinclude secure access and restriction of the availability ofpesticides and drugs, empowering people to manage anger andconflicts, recognize and treat alcoholism and psychiatric illnesses.

 

 

 

 

 

 

 

 




ACKNOWLEDGEMENTS

TOP

Abstract

Introduction

Method

Results

Discussion

ACKNOWLEDGEMENTS
REFERENCES

 

We are grateful to Edward Ahangama and Ashroff Rumy, the Inquirersinto Sudden Deaths, City of Colombo, for granting permissionto perform this study; Chandrani Wijegoonewardane for secretarialassistance; and the South Asia Clinical Toxicology ResearchCollaboration (SACTRC), funded by the Wellcome Trust/NationalHealth and Medical Research Council International CollaborativeResearch Grant 071669MA, for financial assistance.




REFERENCES

TOP

Abstract

Introduction

Method

Results

Discussion

ACKNOWLEDGEMENTS

REFERENCES

 

  1. Fernando R. A study of the investigation of death (Coroner system) in Sri Lanka. Med Sci Law 2003;43:236–40[Abstract/Free Full Text]
  2. Sri Lanka Police Service. Annual Report of the Police, 2006. http://www.police.lk/divisions/crime/mode_of_suicide_2006.html (last checked 12 January 2010)
  3. Wassermann D, Cheng Q, Jiang GX. Global suicide rates among young people aged 15–19. World Psychiatry 2005;4:114–20[Medline]
  4. Sri Lanka Socio Economic Data 2007. Colombo: Central Bank of Sri Lanka, 2007:22
  5. Vethanayagam AVA. Folidol poisoning. Ceylon Med J 1962;7:209–11[Medline]
  6. Van de Hoek W, Konradson F, Athukorala K, Wanigadeera T. Pesticide poisoning: a major heath problem in Sri Lanka. Soc Sci Med 1998;46:495–504[Medline]
  7. Ganesvaran T, Subramaniam S, Mahadeva K. Suicide in a northern town of Sri Lanka. Acta Psychiatr Scand 1984;69:420–5[Medline]
  8. Hettiarachchi J, Kodituwakku GCS, Chandrasiri N. Suicide in Southern Sri Lanka. Med Sci Law 1988;28:248–51[Medline]
  9. Senanayake N, Peiris H. Mortality due to poisoning in a developing agricultural country: trends over 20 years. Hum Exp Toxicol 1995;14:808–11[Abstract/Free Full Text]
  10. Fernando R. Pesticide poisoning in the Asia Pacific region and the role of a regional information network. J Toxicol Clin Toxicol 1995;33:677–82[Medline]
  11. Cameron DR, Pegg SP, Muller M. Self-inflicted burns. Burns 1997;23:519–21[Medline]
  12. Laloe V, Ganeson M. Self-immolation a common suicidal behaviour in eastern Sri Lanka. Burns 2002;28:475–8[Medline]
  13. Laloe V. Patterns of deliberate self burning in various part of the world. – a review. Burns 2004;30:2007–15
  14. Seneviratne SL, Warnasooriya WM, Gunatilake SB, Fonseka MM, Gunawardena MK, de Silva HJ. Serum cholesterol concentration in para-suicide. Ceylon Med J 1999;44:11–3[Medline]
  15. Gunnell D, Fernando R, Hewagama M, Priyangika WD, Konradsen F, Eddleston M. The impact of pesticide regulations on suicide in Sri Lanka. Int J Epidemiol 2007;36:1235–42[Abstract/Free Full Text]
  16. Gunawardane RH, Abeywarna C. Intensive care utilization following attempted suicide through self poisoning. Ceylon Med J 1997;42:18–20[Medline]

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Articles by Karunaratne, S.
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