The Reality of Suicide in Sri Lanka: Need for

Data-driven analysis

Featured image courtesy Sumithrayo.org

Editors Note: This post contains discussion on the topic of suicide. If you feel you
may want to take your own life, or are concerned about someone else who is likely
to attempt suicide, talk to Sumithrayo (when dialling from within Sri Lanka, phone:
011 269 6666)

NALAKA GUNAWARDENE-on 10/06/2017

The World Health Organisation (WHO) estimates that close to 800,000 people die
by suicide each year, with the majority of deaths occurring in low-income and
middle-income countries. Many more attempt suicide. Suicide accounted for 1.4%
of all deaths worldwide, making it the 17th leading cause of death in 2015. While
this makes grim news, WHO also says that effective and evidence-based
interventions can be implemented at population, sub-population and individual
levels to prevent suicide and suicide attempts.
In recent years, mainstream and social media coverage around suicide has
created an impression that Sri Lankas suicide rate is rising rapidly. Sections of the
media have begun calling Sri Lanka the suicide capital of the world. Others are
quick to blame new technologies such as social media as the cause for some
recent youth suicides, without any research to back such claims.
There is no doubt that suicides are a major issue in Lankan society. It warrants a
response at policy, institutional and community level. But first, we need to better
understand the magnitude of the problem and the factors involved.
Sadly, public discourse is dominated by media hype, activist rhetoric and
misconceptions instead of data-driven analysis. Even WHO, which sets global
standards for public health analyses and responses, has erred in this regard. In
September 2014, WHOs first global report on suicide wrongly identified Sri Lanka
has having the fourth highest suicide rate in the world (28.8 deaths per 100,000
according to them). That rate was modelled using data that was eight years out of
date, i.e. the last national data submission made in 2006.
Duleeka W. Knipe, then a PhD researcher at the University of Bristol, UK, who has
studied this topic in-depth, questioned WHOs analysis. She went in search of
actual records, and studied suicide data from Sri Lanka Police Departments
statistics division. She found that there had been 2,644 fewer suicides in 2012
than had been estimated by WHO using the 2006 data. When she used the more
recent data, it reduced the annual suicide estimate by a quarter, and the
countrys suicide rate came down to 17.1 per 100,000. That fresh analysis, which
she published in several medical journals, repositioned the island nation at 22nd
in global rankings for suicides. [Yet, regrettably, WHOs erroneous calculation
persists in the public domain and is still frequently cited by journalists and
activists.]
Today, Dr Duleeka Knipe is a mental health epidemiologist at the Bristol Medical
School, part of the University of Bristol. She has trained in public health,
pathology and microbiology. Her research work has investigated the association
between social factors and suicidal behaviour in low and middle income countries
in South and South-East Asia. She has 7 years of experience in researching suicide
and self-harm in Sri Lanka. Duleeka has published widely on the national suicide
statistics in Sri Lanka and on her work as part of a large longitudinal study
(200,000+ individuals in 54,000+ households) in the North Central Province.
In recognition of her work on suicide prevention in Sri Lanka, she has been
awarded the prestigious International Association of Suicide Prevention Andrej
Marusic Award (2017), and an Economic and Research Council Research
Fellowship to continue her work. Duleeka also chairs the University of Bristols
Suicide and Self-Harm group.
The following are excerpts from an interview, conducted via email:
Suicides are the tragic outcome of complex human, socio-economic and societal
factors. In view of this, how difficult is it to determine a specific causative
factor?
Determining what causes a specific health outcome is very difficult because it is
rare to be able to identify a single factor. This is particularly so for suicide. Usually
there is no single cause, but a cumulation of factors which increases an
individuals vulnerability to suicide. There are, however, some clearly recognised
factors that increase an individuals risk of suicide for example debt, job loss, a
relationship breakdown, bullying, and alcohol misuse. These factors may interact
with pre-existing vulnerabilities (such as mental health issues) to increase the risk
of suicide.
How do researchers deal with this multifactorial reality when they want to
discern the more probable causes or factors that triggered suicidal action in a
given case?
As researchers, we would focus on two approaches. Firstly, a multivariate
analysis, i.e. analysis that takes account of other factors to enable use to look at
the specific impact of a risk factor we are investigating. Secondly, time series
approaches, i.e. looking at the rate of suicide over time and how it changes in
response to environmental or social shocks, e.g. economic recessions, pesticide
bans or restrictions by government, etc.
If we want to investigate individual suicide deaths, then the tool most commonly
used is a psychological autopsy. Using this method we would collect information
on the deceased via interviews with family members, friends and other relevant
individuals. Where available, detailed information will also be collected from
health records. It is a comprehensive method to try to detail the factors which
would have contributed to the suicide death. This method, however, relies on
third party reports of why the deceased decided to kill themselves and therefore
might be biased (especially if there are no supporting medical records, which is
often the case in Sri Lanka).
Which official source of data is most widely used by researchers studying
suicides in Sri Lanka hospital records or police records? How comprehensive is
the recording of suicide cases in the country? Are there gaps or under-
reporting?
Suicide researchers in Sri Lanka often use the Department of Police data, as it is
collected nationally and many deaths by suicide occur in the community rather
than in hospitals (the exception is deaths by self-poisoning, but these now
comprise less than 30% of all suicide deaths). The quality of the suicide data in Sri
Lanka is unlikely to have changed over time, but to the best of my knowledge,
there have been no research studies which have explicitly investigated whether
there are cases of under-reporting in the police statistics.

Incidence of suicide in Sri Lanka, 18802015. Arrows show timing of pesticide bans
between 1984 and 2008

At national level in Sri Lanka, is there any systematic and on-going attempt to
monitor and understand the various factors that contribute to suicides? Which
institutions or individuals are involved in such monitoring?
Several studies have investigating trends (and factors influencing trends in
suicide) over the last few decades. There are several groups in Sri Lanka and in
other Universities around the world who have been investigating this. The
research in this area has involved scholars from several different disciplines,
which highlights the fact that suicide behaviour is difficult to investigate given its
complexity.
From a population health science point of view, I have been investigating the
factors that contribute to suicide in Sri Lanka for 7 years and I am continuing to
monitor the national suicide rate. In addition, by using large scale survey data
from the North Central Province, Ive been investigating the association of
different social factors with suicide behaviour.
Sri Lanka has experienced major changes in its suicide rates since the 1970s, and
by 1995 it had one of the highest rates in the world. Where does it rank today in
terms of the annual, cumulative number of suicides?
To effectively rank countries in order of their suicide rate, you would need to
have accurate data on suicide globally. This is simply not the case, especially in
low and middle income countries, where the surveillance systems for suicide are
not robust. Comparisons therefore are difficult and should be avoided given that
we are not comparing like for like.
What I can say is that Sri Lanka has made major advances in reducing its suicide
rate from the peak in the mid 1990s when there were over 8514 reported suicide
deaths (1995).
This has now come down significantly: there were 3,025 suicide deaths reported
in 2016. Compared to neighbouring South Asian countries, where there has been
little change in suicide rates, Sri Lanka has managed to reduce its crude suicide
rate by 70% during the last two decades.
This is a major public health accomplishment that is not widely known or
appreciated. What specific policy or regulatory measures helped bring down
suicide rates in Sri Lanka?
Research indicates that the major contributor to the reduction in suicide in Sri
Lanka appears to have been the removal/bans on the sale and import of the most
toxic pesticides in the country. This removal has resulted in dramatic declines in
the number of people dying by suicide.
As two fellow researchers and I wrote in The Lancet Global Health medical journal
in July 2017, Sri Lankas pesticide regulations appear to have contributed to one
of the greatest decreases in suicide rate ever seen. Having peaked at 57 per
100,000 people over 8 years in the early 1990s, its incidence is now 17 per
100,000 each year, a 70% reduction, and continuing to fall.
In that paper, we estimated that the pesticide regulatory action alone resulted in
93,000 Sri Lankan lives being saved between 1995 and 2015. The annual costs for
the Office of the Registrar of Pesticides in the early 2000s was about USD 200,000.
Considering only direct costs, each life was therefore saved at a cost of USD 43.
[Full paper: Preventing deaths from pesticide self-poisoninglearning from Sri
Lankas success. Duleeka W Knipe, David Gunnell, Michael Eddleston. The Lancet.
Volume 5, No. 7, e651e652, July
2017: http://www.thelancet.com/journals/langlo/article/PIIS2214-
109X(17)30208-5/fulltext]

Predicted versus actual suicide rates in Sri Lanka from 1983 to 2015 (suicide
deaths per 100,000 population)
What unfinished business remains on this front? I mean, what more needs to be
done by government, medical profession, community organisations and others
to further reduce suicides?
While the number of people dying by suicide has dramatically reduced in Sri
Lanka, there are still large numbers of people making suicide attempts, indicating
that there is a level of distress being experienced by the population which needs
to be addressed. In addition, Sri Lanka still has a high suicide rate in young people
(twice that of high income countries). Given that many factors contribute to
suicidal behaviour, a multisector approach is needed to counter this trend. This
approach, however, needs to properly co-ordinated. Some of my own work has
highlighted the need for developing life skills (relationship and budgeting),
reducing alcohol misuse, as well as the state and society providing improved
mental health services and better awareness.
Your research papers in recent years have concluded that The epidemiology of
suicide in Sri Lanka has changed noticeably in the last 30 years. Is this widely
known or understood by our policy makers, public health professionals or
journalists? If not, what can be done to raise awareness about changing
patterns?
Based on my dealing with policy makers and public health professional there is a
general awareness within these circles that the suicide rate in Sri Lanka has
changed over time. However, the articles I read in the Lankan media about suicide
use information and analysis that are somewhat outdated. This is partly due to
journalists and even mental health activists not always having the latest data
available to them. Part of my work over the next few months is to ensure that
relevant stakeholders (e.g. government, UN and NGOs) have the most up to date
data.
Attributing several suicides to the current prolonged drought in Sri Lanka, as
claimed by the UN Resident Coordinator, was questioned and challenged by
some of us from the moment they issued their contentious September 19
statement. UN recanted their claim on September 28 saying they (suicides)
cannot directly be attributed to the effects of the drought. We know that the
UN is not equipped to do primary research, but in this instance did they exceed
their remit?
I have no detailed specialist knowledge of the official role of the UN. However,
what is important to keep in mind is that suicide is a complex behaviour, and we
should avoid oversimplifying what causes someone to take their life. There will be
many who experience an exposure, for example the drought, who do not take
their lives. As I previously mentioned, causality is very difficult to ascertain, and
requires the right data and methods to investigate it. As far as I am aware there is
no research evidence from Sri Lanka suggesting that the drought has contributed
to an increased risk of suicide.
It is worth noting, though, that whilst there is no research evidence from Sri
Lanka, there is some work in Australia that has linked periods of drought to
increased suicide
(Example: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435226/
In your view, how best can development and humanitarian organisations
document, analyse and discuss suicides?
A better link with active researchers in the field of suicide would be of benefit to
the organisations but also to us as researchers. We are always looking for ways to
engage with organisations to make sure that accurate data are used when
reporting about suicide and in the ways that suicide is discussed. But it is also
important to note that there is strong evidence that media reporting of suicides
can, sometimes, adversely impact on suicide rates and so any discourse must be
handled carefully.
This is not the first time that a UN agency created some confusion about
suicides in Sri Lanka. In September 2014, you as a young researcher pointed
out that the calculations for Sri Lanka in WHOs first global report on suicides
were based on data that was several years outdated. What happened?
The WHO suicide prevention report is an important document and has been
useful for many who want to get an overview of suicide globally. The report
utilised data that was submitted to them by country offices to calculate the
suicide rate in 2012. If the data were out of date then WHO projected the number
of deaths they would expect to see, based on previously submitted data. Sri Lanka
had not submitted the most up to date statistics on suicide to WHO and this
resulted in an incorrect estimation.
The WHO report did caution users of the report, that the data may not be
accurate. My article pointing out the inaccuracy of the WHO reported suicide
rate was aimed at those who would use the report (i.e. media, NGOs and other
groups in Sri Lanka) to ensure that they took heed of the warning about the
accuracy of the statistics.
What are your impressions of how the Lankan media reports on suicides both
on specific incidents, as well as in discussing overall trends?
I have read numerous articles and watched several television news reports on
suicide in Sri Lanka and have been distressed by the manner in which suicide
deaths are both portrayed and reported. The media have a major role to play in
suicide prevention. Evidence has shown that certain types of media depictions of
suicide can lead to imitative behaviour and result in increases in the number of
suicides. Vulnerable people (e.g. young people, those experiencing various
difficulties) may be more likely to over-identify with the suicide victim. There is a
study that is due to come out by colleagues from the University of Copenhagen
who have recently conducted a study of media (print) reports of suicide.
As to the trends of suicide, I am disheartened to see that the media in Sri Lanka
still continue to use the above mentioned WHO report for statistics on suicide
deaths in our own country. I hope that my efforts in sharing the suicide statistics
with relevant groups in the country will help ensure more accurate reporting.
How does the media in the UK, where you live and work, observe ethical and
humane considerations when reporting on suicides? What can Lankan media
learn from this?
The media in the UK are encouraged to adhere to a set of guidelines set out by
the Samaritans, a UK charity, which are closely related to WHOs media guidelines
titled Preventing Suicide: A Resource for Media Professionals (2008). In fact, WHO
and the International Association for Suicide Prevention (IASP) have just released
a new version in October 2017. So ethical guidance is available to anyone looking
for it.
Many media outlets in the UK recognise the importance of sensitive suicide
reporting. The Sri Lankan media could adopt a similar strategy when reporting on
suicide deaths by ensuring that they adhere to a set of basic guidelines.
Posted by Thavam