Abstract
Around a million people commit suicide, and at least 10 times this number attempt suicide, worldwide every year. No nationwide epidemiological studies have been undertaken in India but a significant rise in suicides has been observed in Kashmir in recent years. This study was carried out on patients reporting to the Government SMHS Hospital in Srinagar with a history of suicidal poisoning.
Introduction
Worldwide, around a million people die from suicide, and at least 10 times this number attempt suicide. 1 A review of the literature shows that attempted suicide rates vary from100 to 300 per 100,000 people per year, the greatest number of whom are women. 2 In the USA, around five million poison exposures occur yearly and up to 30% of psychiatric admissions are prompted by suicidal poisoning. 3 In India, no nationwide epidemiological studies have been undertaken, so it is not possible to know the extent of the problem and the change in pattern over the years. 4 However, a significant rise in suicides has been observed in Kashmir in recent times and poisoning is the most common method employed. 1,5,6 In a recent study of 364 poisoning cases by Khan et al. 83.5% were found to be suicidal in nature. 5,6 Similar results were described by Malik et al. 6 There has been an alarming increase of suicidal poisoning in Kashmir mostly as a result of the presiding insurgency. This study was conducted in order to examine the rise in suicidal poisoning in the area and to compare it with the pre-turmoil data.
Material and methods
This study was carried out on patients reporting to the Government SMHS Hospital in Srinagar with a history of suicidal poisoning. The cases were referred to our hospital for emergency treatment from peripheral primary and secondary health-care institutions from January 1989 to December 2004. The study population mainly included the civilian population of the Kashmir state and a few members of the armed forces. The data of poisoning cases during in the pre-turmoil period from January 1985 to December 1998 was collected from the medical records department and studied retrospectively for comparison.
The sociomedical history was obtained from the patients, their attendants and the accompanying legal administrators. These included the nature of the poison, the amount consumed, the time since intake and the circumstances that prompted the suicide attempt. Containers of poisons (e.g. bottles, strips of tablets and sachets) were searched, examined and sent for chemical analysis whenever possible. After a brief history and clinical examination, treatment was instituted. Gastric lavage, antidotes, supportive therapy and other required measures were taken. All gastric contents, blood and urine samples were preserved and sent for chemical analysis.
Exclusion criteria
Patients with a doubtful history of ingestion, accidental exposure, poor cooperation and patients leaving the hospital against medical advice were excluded from the study.
After stabilization the patients were subjected to a detailed psychiatric evaluation to try and pin point the basic precipitating causes and counselling was given to the patient.
All the data obtained from the history, examination, investigations, psychiatric evaluation, as well as the death, were recorded for each patient.
Results
The study included a total of 13,157 cases of suicidal poisoning, of which 11,829 were studied over a period of 16 years (1989–2004). The data of the pre-turmoil period was studied retrospectively. The present insurgency in the Kashmir valley came into being in 1989. The post insurgency cases comprised 5543 men (46.85%) and 6286 women (53.15%). Of these cases, the majority (10,823 [91.49%]) were Muslims and 82.43% came from a rural background.
Data of poisoning cases from January 1985 to December 2004
The various precipitating factors for suicidal poisoning were loss of a loved one, loss of property, torture, witnessing a death and violence. Analysis of selected groups of patients by psychiatrists revealed that depression, with a post-traumatic disorder provoked by the existing turmoil, was the main cause among poison victims (89.91%). Generalized anxiety disorders and panic disorders, along with impulse control disorders and bipolar affective disorders, were included in this group. Personality disorders and mental retardation was found in 10%.
Despite the energetic attempts by the trained staff, 724 (6.12%) victims died during this period. These were people who had consumed huge quantities of organophosphorous compounds and had reported late to the hospital.
During the insurgency period the yearly number of poisoning cases reporting to our hospital was over 739. Of these cases, 69.94% were directly precipitated by insurgency related factors. Only 332 cases reported yearly to our hospital in the pre-turmoil period and none of them was caused by violence-related factors.
Discussion
The insurgency in Kashmir has so far lasted 18 years. Thousands of lives have been lost, property and businesses have been damaged, the economy has declined and the stress levels in the area have been extremely high. Due to the tenuous nature of our medical resources sometimes trivial injuries cause death due to the delay in intervention, adding to an already stressful environment.
Earlier studies have been published which have shown the turmoil to be the cause of the increased poisoning rates. However, the study groups have been much smaller than that of our study. 5,6 A vicious circle of violence, decline of economy, unemployment, recruitment to the armed factions and more violence has provided a very fertile and tragic ground for attempted suicide. Muslims are mainly represented among the patient population as they are the major community in the affected areas. Some people from the armed forces were included in the study group and they had been affected by the stressful atmosphere of their occupation. Our study revealed that organophosphorous compounds were mainly used because they were easy available in the rural setting. This is in agreement with other studies carried out elsewhere. 5–12 Suicidal poisoning has been related to several preexisting factors in other studies – including stressful circumstances, unemployment, poverty, low literacy and psychiatric morbidity. 2,9,11
Our study revealed a mortality rate of 6.1%. Pichot reported a mortality of 14%, Nordstrom 6–11%, and Kumar 8.1%. 10,13,14 During the period of turmoil a 222% increase in the rate of yearly suicidal poisoning was observed. It is therefore imperative that in areas where there are insurgencies doctors be trained in the treatment of poisoning in order to cope with an expected increase in the number of such cases. In an atmosphere of violence it is expected that a whole range of poisons might be encountered and manuals should be present in all emergency casualty departments to enable staff to cope with all the eventualities. Tighter legislation regarding organophosphorous might also be introduced in order to make this compound harder to procure – the mortality encountered in poisoning is largely due to this compound. The role of the psychiatrist is re-emphasized as the possibility of repeated attempts is high.