A review of the changing patterns of suicide and deliberate self-harm in Sri Lanka

The fall in suicide rates in Sri Lanka is a positive outcome of preventive measures taken, including restriction of access to toxic pesticides. These need to be continued, together with increased focus on management of psychological contributory factors, such as depression and alcohol use disorders. At the same time, innovative and culturally appropriate preventive strategies are needed to address the increasing public health problem of attempted selfpoisoning.


Introduction
In 1995, Sri Lanka claimed the dubious distinction of having the second highest suicide rate in the world.The most common method of suicide was by self-poisoning, most often by ingestion of pesticides, which carried a high case fatality (1).From a high of 47.0 per 100,000 in 1995, the rate of suicide in Sri Lanka has gradually declined to 14.58 per 100,000 in 2015 and in 2016 (2).Almost parallel to this drop in suicide rates, there have been reports of increasing numbers of hospital admissions for attempted or non-fatal self-poisoning (3).Thus since 1995, Sri Lanka has seen significant patterns of change in the rates of both suicide and selfharm; which is likely to have important lessons for health care planners.Mapped district-level suicide rates for 1955, 1972, 1980 and 2011 and investigated associations between district level suicide rates and census-driven measures of rurality.
Found that increasing population density was inversely associated with suicide rates, and this association was strongest when pesticides were the most common method of suicide (in 1980) compared to 1950.Age-standardised overall, sex-specific, and method-specific suicide rates were calculated using data from the Sri Lankan police data .
Overall suicide mortality dropped by 21% between 2011 and 2015, from 18.3 to 14.3 per 100,000.There was a large decline in suicides due to pesticide ingestion, during this period.Persons admitted to hospital for medical management of attempted self-poisoning were reassessed after one year.
Repetition of self-harm (by any method) at 12 month follow-up was 2.5%.

Rates of suicide
Six studies included in the review commented on the rates of suicides in Sri Lanka since 1995 (2,(4)(5)(6)(7)(8).A common theme reported in all six articles was the decline of overall suicide rates in Sri Lanka during the past two decades.De Silva et al reported that the annual suicide rate had reduced from 47.0 per 100,000 in 1995 to 19.6 per 100,000 in 2009, with an absolute reduction of 27.4 suicides per 100,000 (2).A time trend analysis of the suicide rate showed an exponential decline; the trend was Y t = 41.61 x 0,947 t where Y t was the annual incidence of suicide and t was the time elapsed (2).

Suicide rates by age and gender
Knipe et al examined the rates of suicide in Sri Lanka by age and gender; and reported that similar to the overall patterns of suicide, among males there has been a rapid decline in all age-specific suicide rates since 1995 onwards (6).In the mid-1980s suicide rates among males were higher in the 17-25 year age group than among older males (aged >35 years), but since 1999 this has changed, with the risk of suicide in males increasing with age (6).
Similar to suicide rates in the males, among females too there has been a linear decline in suicide rates across all ages, since 1995 to 2011 (9).However in contrast to the males, throughout the past three decades, among females, suicide rates have remained highest among younger females (<35 years) compared to older females.This difference in female suicide rates between the youngest and oldest age groups was most marked in the pre-1987 era (upto a 5 fold difference); and despite the decline in overall female suicide rates, the higher rates among younger females has persisted (6,10).For instance, by 2011, among females, the highest suicide rate was in the 20-29 year age group (13.98/100,000); while the lowest rate was seen in the 40-49 year age group (5.29/100,000) (9).

Comparison of suicide rates among males and females
In keeping with patterns of suicide internationally, the rate of suicide in Sri Lanka during the period 1995 to 2016 was higher among males than that in females (9,11,12).The reported suicide rate among males was 2.92 times that of females in 1995; by 2011 the rate in males was 3.77 times that of females (9).When age specific suicide rates were compared, higher suicide rates were seen in males in all age groups except the youngest age group (10-19 years); in this 10-19 year age group category the rate of suicide in females is slightly higher compared to males (9).

Modes of suicide
Overall to date, the most common method of suicide in Sri Lanka has been by self-poisoning, most often by pesticide ingestion (6).This despite the fact that from 1995 onwards, rates of suicides by self-poisoning have declined in both genders; the rate of suicide by selfpoisoning fell from 42/100,000 (79% of all suicides) in 1994-96 to 11/100,000 (48% of all suicides) in by 2010-2012 (2,6).The second most common method of suicide has been hanging; this has shown some increase among both genders -from an overall rate of 3/100,000 in 1975-77 (13% of all suicides) to 8/100,000 in 2010-12 (36% of all suicides) (6).

Title, and authors Main outcomes of interest and findings
A review of the changing patterns of suicide and deliberate self-harm in Sri Lanka

Trends in attempted or non-fatal selfpoisoning
Almost all studies on non-fatal self-harm in Sri Lanka have been carried out based on examination of those admitted to hospital due to attempted or non-fatal selfpoisoning (Table 1).Data on other methods of self-harm are minimal.Nine studies included in this review commented on non-fatal self-poisoning in Sri Lanka.Reported rates of hospital admissions for selfpoisoning included 315/100,000 in 2002 (in Southern Sri Lanka), an average of 318/100,000 from 1992-2002 (again in Southern Sri Lanka) and 406/100,000 from Ampara, for three months in 2009 (13)(14)(15).
Three studies had examined changes in rates of hospital admissions for self-poisoning with time (2,3,13).The common theme reported was an increasing rate of hospital admissions for self-poisoning, characterised by increased ingestion of drugs, medicaments and other biological substances.

Repetition risk after self-harm
Data on rates of repetition of self-harm in Sri Lanka is limited; two studies in this review prospectively examined the rates of repetition following non-fatal self-poisoning, and reported repetition rates of 4% and 2.7% at 18 month and 12 month follow-up, respectively (16,17).

Discussion
Since 1995 onwards the suicide rates in Sri Lanka show a significant decline, in both genders, and across all age groups.Measures taken to restrict access of toxic pesticides in Sri Lanka, from the mid 1990s onwards appears to be one of the most significant factors contributing to this drop in rate of suicides (5,8).It is notable that pesticide poisoning has continued to decline after the turn of the century, though no major restrictions to pesticide availability have been applied.This may be due to the ongoing shift towards increasing use of medication overdoses, with it's lower associated case fatality (2).Other factors, such as improved and more accessible medical care following poisoning, may also have contributed to the overall fall in suicide rates.It has been suggested that the period of the civil war may have affected suicide rates, but overall evidence is inconclusive (7,8,18).
Reduction of suicide rates by restriction of a particular mode of suicide, does give rise to the possibility of method substitution -or the increase of suicide by adoption of different methods.In keeping with this, the rates of suicide in Sri Lanka by hanging have increased from 13% in 1975-77 to 36% of all suicides in 2010-12 (6).However this increase in rates of hanging over the past decades has been much less than the fall in rates of suicides due to pesticide ingestion (5,6).Thus overall Sri Lanka can report a success story with regards to the reduction of rates of suicide by means restriction, which has important implications for future policy makers (8,19).However, we still need to be aware of the possible increase of suicide rates in future by other methods such as hanging, and to monitor for possible emergence of this phenomenon.
Overall rates of suicide in Sri Lanka throughout the past decades has been more among males than females, which is in keeping with patterns of suicide throughout the world (11).However a key finding is that when considering the younger age group (10-19 years), rates of suicide in Sri Lanka are higher among females than males (9,10).And while the risk of suicide among males in Sri Lanka is now associated with increased age, the rates of suicide in females still remain highest among the younger age groups (6).Similar patterns of female suicides have been reported in other South Asian countries, and in the past, from China (20,21).This suggests that restriction alone is not enough to address the issue of young female suicides in this country.There is a need to examine the gender specific socio-cultural as well psychological factors that maybe contributing to this phenomenon in Sri Lanka (10).
Although the suicide rates have declined since 1995, the rates of hospital admissions for attempted or nonfatal self-poisoning in Sri Lanka have increased (2).This appears to represent a true increase, though other factors, such as reduced lethality of substances ingested, and greater accessibility of hospital services in recent years, may also influence these findings.
Since the mid-1990s, patterns of non-fatal self-harm have shifted to resemble patterns seen in the West, with increasing medicinal overdoses, and higher rates of nonfatal self-poisoning in young females compared to males (2,22).The high rate of hospital admissions due to non-fatal poisoning by medication and other biological substances has now become an important public health challenge, associated with significant individual distress as well economic cost to the country (23).
Interpersonal conflict is a commonly reported proximal trigger which appears to precipitate the act of non-fatal self-poisoning; similar coping patterns have been described from other countries in South-Asia (24)(25)(26).Difficulty in tolerating acute emotional distress associated with interpersonal conflict, feelings of shame, and distress, and patterns of learnt behaviour against a background of socio-economic difficulties, may contribute towards this self-harm behaviour (24).Depression and alcohol use disorders also play a significant role, especially with regards to non-fatal self-poisoning behaviour in older males (27,28).
In Sri Lanka, the reported rate of repetition following an attempt of self poisoning, is lower than rates of repetition reported from the West (29).However similar low rates of repetition have been reported from other parts of Asia (29,30).Further research is needed to explore whether this is indeed a true difference, and possible contributory factors.

Limitations
This review was limited to English language articles published in indexed journals listed in Pubmed, and there was no search of the grey literature; this may have led to the inadvertent omission of relevant articles, although every effort was made to minimise this by searching bibliographies of the articles included.Many articles included in the review based their findings on data from the Sri Lanka Police and the Ministry of Health, and any inaccuracies in the original data may also have biased the findings.

Conclusions
The fall in rates of suicide over the past two decades, is a very positive and important outcome of measures taken to reduce suicide, including restriction of access to toxic pesticides.These measures need to be continued, while monitoring for increase of suicide rates by other methods, such as by hanging.There is now also a need to focus on other psychological factors influencing suicide and self-harm -such as increased awareness and management of depression and alcohol use disorders.The increased occurrence of suicide among older males and younger females should also be areas of future focus.
On the other hand, rates of attempted or non-fatal selfpoisoning appear to be increasing, with a shift towards Western patterns of more medicinal overdoses; now a key public health problem.Exploration of innovative and culturally appropriate preventive strategies is needed to address this issue.

Table 1 .
Articles included in the review

Table 1 .
Articles included in the review(Continued) Between 1996-2008, the annual incidence of hospital admissions due to poisoning by a medicinal or biological substance increased exponentially from 48.2 to 115.4 admissions per 100,000 population.The annual incidence of suicide decreased exponentially from 47.0 per 100,000 in 1995 to 19.6 per 100,000 in 2009.(Continued) Figure 1.Flow diagram for literature search.(Continued)6 Suicide in Sri Lanka 1975-2012: age, period and cohort analysis of police and hospital data Knipe DW, Metcalf C, Fernando R, Pearson M, Konradsen F, Eddleston M, Gunnell M BMC Public Health 2014; 14: 839 (6) Reports changes in age and gender patterns of suicide since the 1980s.Examined admissions to hospitals in Ampara after selfpoisoning, during 3 months (in 2009).Included 230 admissions, with a rate of self-poisoning of 406 per 100,000 per year 8 Analysis of 8000 hospital admissions for acute poisoning in a rural area in Sri Lanka Van der Hoek W, Konradsen F Clin Toxicol 2006; 44(3): 225-31 (13) Examined incidence of acute poisoning, based on retrospective examination of hospital records of six hospitals in southern Sri Lanka from 1990-2002.Average incidence of poisoning over the study period was 318/100,000.9Demographic risk factors in pesticide related suicides in Sri Lanka; research letter.Desapriya EBR, Joshi P, Han G, Rajabali F Injury Prevention 2004; 10: 125-127 (12) Examined pesticide related deaths in 2002 in Sri Lanka, based on data extracted from the Department of Police in Colombo, Sri Lanka, and population health data from the Ministry of Health.All districts except Kilinochchi and Mullativu showed an increase in rates of admissions due to poisoning with drugs, medicaments and biological substances.

Table 1 .
Articles included in the review(Continued)