By Kasun Kodituwakku –
Over 800,000 suicide deaths are reported every year, 75% of these origination from the lower and middle-income countries predominantly within Asia.
Sri Lanka was listed as having the 4th highest suicide rate in the WHO report of 2014. The conflict-ridden history of the country has meant that suicide has been a major burden of the previous three decades, nevertheless the measures and interventions implemented by the governing body has shown to positively impact suicide mortality rates, particularly legislations on pesticides. But the numbers of attempted suicides continue to increase, highlighting the inadequate attention given to the central determinants of suicidal behaviour. Means restriction and addressing social and economic factors whilst providing mental support via a robust healthcare system have shown to be key in tackling suicide.
This report explores the dynamics of suicidal behaviour in Sri Lanka and the interplaying factors that contribute to the persistent national burden. It investigates the education and employment systems as well as assessing successfulness of interventions and policies implemented by the governing body.
Burden of Suicide
Suicide is a complex multifaceted behaviour, which is induced by various stresses and predispositions. It accounts for millions of non-fatal hospital admissions and over 800,000 deaths annually, a life every 40 seconds.1 Projections estimate mortalities to almost double to 1.53 million by 2025; with a further 15 to 30 million cases of attempted suicide, thereby demonstrating the major global health burden that suicide represents.2
Over 90% of suicides have been related to psychiatric illness in high-income countries (HIC)3, in which bipolar and major depressive disorders account for almost 60%.4
In the WHO 2014 report5, the overall suicide rate was marginally higher in HIC than low and middle-income countries (LMIC), 12.7 per 100,000 and 11.2 per 100,000 respectively. But the sheer population that reside in LMIC meant that it accounted for 75% of all suicides.
Sri Lanka is a small densely populated island located just off the southeast shores of the Indian subcontinent6. It’s regarded as a lower-middle income country7 with a relatively low expenditure on health – $89 per capita 8, 3.4% of the GDP6,9. But the widespread basic healthcare system available in Sri Lanka is admirable considering its economic profile. An extensive network of government funded public health units exists alongside a robust private sector providing basic health care to the majority10. Communicable diseases remain endemic in Sri Lanka; vector-borne diseases like dengue fever along with diarrhoeal diseases and hepatitis A pose the greatest threats6. Sri Lanka, like many LMIC, is facing the double burden of disease, today non-communicable diseases account for over 70% of mortalities, cardiovascular disease, chronic respiratory diseases and diabetes are extremely prevalent10,11. Mental health was previously a neglected topic, but in recent years especially post-conflict (1983-2009) there has been a greater focus on such conditions by the Ministry of Health. This resulted in the introduction of mental health policies and interventions to tackle the health burden; nevertheless only 1.6% of the total health budget is invested on mental health12.
A History of Suicide
A civil war that spanned over 25 years (1983-2009) left the country in social disintegration with an estimated 100,000 lives lost. Suicide rates were highest during the war and a significant reduction was established in post-conflict Sri Lanka. Financial hardship and loss of livelihoods was repeatedly affected families especially in the northern provinces, numerous individuals suffered from depression and posttraumatic stress disorder (PTSD) and many more resorted to suicide.13
During 1985 and 1989 male suicide rates were second highest in the world14, many studies fail to address a major contributory factor, the 1987-99 JVP Insurrection(15). The government faced a youth rebellion from the People’s Liberation Front aka JVP. In retaliation the government captured, tortured and killed the whole JVP politburo and an estimated 30,000 civilian supporters16. Many were thought to have committed suicide to evade capture or developed PTSD but due to the circumstances data is unavailable.17
Conflict has now diminished and Sri Lanka is at peace, but yet suicide rates still prevail. Since the 1970s Sri Lanka has endured extremely high suicide rates, peaking in the 1995 where it had one of the highest suicide rates in the world, 47/100,00018,19. A steady decline has been apparent in the past two decades but in 2014 the WHO listed it as having the 4th highest suicide rate globally, 28.8/100,0005. On average there are over 6,000 mortalities and almost 100,000 individuals attempt suicide annually20.
This essay will focus on contributory factors associated with suicide in Sri Lanka, exploring the suicide mortality control mechanisms, psychosocial determinants and investigating mental health policy and possible approaches of delivering primary care.
Controlling Suicide Mortality
Targeting the means of suicide have shown to be effective in reducing mortality, in the UK legislation on the sale quantities of paracetamol have shown to lessen hospitalisations and case fatalities due to overdose21. In contrast LMIC especially in rural Asia face a sever issue with impulsive self-poisoning due to the easy accessibility of highly toxic pesticides19,22.
Studies have estimated the suicide by pesticide ingestion accounts for up to 300,000 deaths globally per year23-25. The agricultural sector in Sri Lanka represents 31.8% of the national labour force6; they are often subjected to many stressful situations due to finance, weather, workload and farm related disputes26. Suicide amongst farmers is a global phenomenon and agriculture has the highest rate of mortalities amongst all industries27.
Prior reports have shown that pesticides were accountable for two thirds of all suicides in Sri Lanka25,28; such alarming statistics provoked the government to introduce laws prohibiting import of highly toxic organophosphate compounds in 1995 and chlorinated hydrocarbon insecticides like endosulfans in 199829. This directly coincided with a ~50% reduction in suicide mortality rates from 1995 and 2005, as shown in Figure.125. This study did lack data from the northern provinces in which 1.5% of the population reside and nonetheless the evidence presented was deemed to be conclusive.
The pesticide burden remained relatively high and therefore initiatives encouraging the safe storage of pesticides, provided a practical measure. Hawton et al30 demonstrated the effects of providing farming households with lockable boxes for pesticide storage in two villages. Each box displayed a message for anyone with the intention of suicide, encouraging them to seek counselling from close friends. This approach was widely accepted but the study did show that over 25% of the boxes were just left unlocked after an 18-month follow-up. The study lacked generalizability due to the small sample size used but it was able to demonstrate the general acceptability of the intervention. Other similar studies31,32 found alike results and therefore introducing these lockable storage facilities would reduce accessibility to pesticides in the domestic environment. None of these trials addressed the knock-on effect on other forms of self-poisoning such as the ingestion of the widely available poisonous seeds from the yellow oleander tree – a factor associated with many sucides.14
Safe storage and prohibitions on highly toxic pesticides may have positively impacted mortality rates nonetheless the self-poisoning related hospital admissions continue to increase29. Repeat admissions are likely but it demonstrates that the pesticide interventions represent a distal approach as it had little effect on suicidal behaviour.
Moreover Figure.2 displays an increase in male and female suicide rates through hanging following the pesticide accessibility restrictions enforced by the government19, thereby highlighting means substitution due to the lack of attention given to the proximal determinants of suicidal behaviour.
Risks and Determinants of Suicidal Behaviour
HICs generally tend to have suicide rates directly linked to the increasing prevalence of mental illnesses with age, peaking in the middle aged and elderly. In contrast the majority of suicides in Sri Lanka are not associated with mental illness, therefore HIC suicide preventive strategies cannot be effectively applied. Interventions addressing central causes of suicidal behaviour are essential.
Underlying determinants of suicide
A mental health stigma still exists in Sri Lankan society. Patients are subjected to discrimination, especially by employers, which have only proven to exacerbate the condition. Self-stigmatisation has led to significant delays in seeking aid; patients were often withdrawn opting for secrecy rather than disclose any emotions33. Fernando et al stated that doctors have also shown to have stigmatising attitudes towards depression and alcohol and drug addiction patients.
Sexuality plays an undeniable part in suicide. Homophobia is common amongst families, they disown and force out homosexuals, who then face a lot of discrimination by relatives and society in general, and many have opted for suicide due to the constant torment and mental stress34. Engaging in homosexual acts is currently against the law35 and is punishable by up to 10 years in jail34. Even today private clinics exist with the sole aim of ‘curing’ homosexuality.
Such findings call for anti-stigma campaigns for the LGBT community and certain mental health disorders. General education for the public is vital and also efforts must be made to reduce poor attitude towards mental health disorders in medical education.
Education and Unemployment
National statistics shown in Figure.3 no correlation between unemployment rates and the suicide rate, the unemployment rates have decreased even during the peak in suicide rates in 1995. But youth unemployment has always been a huge burden in Sri Lanka and is a considerable suicide factor.
The education system in Sri Lanka is highly competitive and it often criticised for being overly academic orientated. Efforts have been made to modernize the program by offering apprenticeships and career opportunities36. Nevertheless over 20% of the youth remain unemployed. The highly competitive nature of education alongside deteriorating relations with parents and the desire to prove one’s self-worthiness has shown to be detrimental on the mental health of the youth37. Therefore psychosocial support and services focusing these matters are essential in tackling youth suicide rates, which are prevalent in both sexes – demonstrated in Figure.2.
Low skilled workers are often subjected to financial hardships due to the minimum wage system adopted by the government, which organises minimal pay according to the industry of occupation. Private sector employees have to be legally paid just $62/month, in a country where at least $100-$150 is deemed adequate for a very basic living with minimal food security38.
Mental Health Policy & Providing Primary Care
Neuropsychiatric diseases are estimated to account for 11.5% of the national disease burden. In 2005 an official mental health policy was approved to combat the previously neglected burden of mental health39.
Funding was allocated from the general health budget and an effort was made to decentralise the delivery of mental health care from hospitals to community based mental health facilities. Focusing on refining stewardship functions at the central level has shown to provide a better delivery of the decentralised healthcare systems in smaller districts40. Yet, in 2011 there were only 1,538 beds in 278 facilities across the country with a lack of facilities in rural regions, therefore demonstrating the inadequateness of the current facilities39.
Recruitment and task shifting
Training was given to the majority of primary health care professionals and an official referral procedure was enforced to integrate mental health services into primary care delivery39. Jenkins et al12 found that a short 40 hour training programme for psychiatrists, medical officers and practitioners had positive impacts on patient assessments and treatment. Nevertheless a considerable deficit of healthcare professionals exists across the board, especially psychiatrists and psychologists as shown in Figure.4. Currently there are only 58 medical officers and 56 nurses trained in mental health in Sri Lanka – approximately 2 per district. In comparison Thailand has almost double the mental health care professionals41. Therefore further recruitment and training of healthcare workers is essential, but the stigma surrounding mental health often deters many medical students and even doctors42. Further education interventions aiming to improve and progress knowledge and attitudes toward mental health is paramount in order to increase human resources.
However alternatively other studies have suggested a task shifting approach43. Here tasks are delegated to less or narrowly trained individuals and can encompass a wide range of cadres, examples of this include:
- Non-specialist physicians and nurses with minimal training are able to diagnose and treat moderate cases of mental health
- Supporting community health workers in basic care
- Collaborate with education professionals to increase awareness and involve them in the detection of mental disorders
Currently nurses in Sri Lanka are not independently allowed to diagnose or prescribe any psychotherapeutic medication, as doctors are the only authoritative figures empowered to do so39. Such hierarchical attitude is precautionary but with the correct training procedure allowing nurses to act independently would allow for a wider delivery of mental health care.
Emigration of healthcare professionals from rural to urban region or even abroad in search of better career opportunities poses an issue to the human resource availability in rural regions44. Thus it may be favourable to provide financial incentives to manage attrition and achieve a reasonable distribution of professionals.
Other possible interventions
Cognitive behavioural therapy (CBT)
CBT is a common treatment approach for many mental disorders anxiety, depression, and suicidal thoughts and behaviour. A current trial is being carried out by Kings College London45 in southern province in Sri Lanka, here a culturally appropriate manual for CBT is being used. A pilot randomized control trial of CBT46 in active suicidal ideation found that such intervention was having a positive impact on the target population. Thus training lay community health workers in CBT delivery provides another option to tackle suicide rates.
The media is an influential role on suicide, it can be aid in the public awareness of suicide and mental health or it can promote suicide by portraying it as a means of escaping hardship and suffering. Journalists must adopt a sensitive approach when reporting on suicide cases as they have shown to be highly influential on the younger generation who are able to relate to the situation47.
Dubbed Indian soap operas have been associated with promoting domestic abuse towards women in Sri Lanka48, often these dramas depict gender inequality and women are subjected to physical and psychological torture. Plots where women have been forced to commit suicide by relatives due to marital disputes been broadcasted. The impact of such shows is immeasurable on the suicide burden.
Prevention programmes run by NGOs are increasing. Sumithrayo is the principal organisation involved in Sri Lanka. They aim to provide confidential emotional support for anyone suffering from distresses that may progress to suicidal thoughts49. Sumithrayo continues to raise awareness through education programs in schools. Their rural program covers over 80 suicide prone villages and here they are issuing lockable storage boxes for pesticides in an attempt to actively prevent self-poisoning related deaths18. The work of NGOs continues to positively impacting suicide rates.
A conflict-ridden history has meant that suicide has become a common method to escape a distressed and psychologically unbearable life. Tackling suicide in Sri Lanka necessitates a multifaceted approach.
Means restriction has proven to be extremely effective; the introduction of legislation prohibiting the most toxic of pesticides greatly impacted suicide mortality. Lockable safe storage of pesticides represents another effective strategy but these distal interventions have shown to potentiate means substitution. Therefore tackling the proximal determinants of suicidal behaviour is paramount.
However the current understanding of these factors is limited, the rising cost of living and the social stresses due to education and employment have shown to be contributory to the suicide burden. Cultural ideology and stigma surrounding aspects such as mental health and sexuality have shown to hinder progress. A lack of public awareness and understanding exacerbates the issue; therefore public education campaigns are vital interventions.
Current governmental mental health policies are commendable but a lack of human resources is apparent. Task shifting provides a potential alternative but the social hierarchy and attitude towards delegation of authoritative figure roles to less qualified individuals proves to be a major barrier.
The task at hand is vast, as it essentially requires a social revolution, but the combined efforts of the government, the general public and NGOs would positively impact the persistent suicide problem in Sri Lanka.____________________________________________________________________References
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