Suicide and Self-harm in Sri Lanka 1975-2010:

Age, gender and method time-trend analysis of Police data

Dee Knipe

Overview

• Background

– Context

• Aims

• Methods

• Results

• Conclusion

Context - Sri Lanka

• Population ~ 20.3 Million • 24,954 square miles • 1/3 population employed in

agriculture • Widespread use of high yielding

crops – agrochemicals heavily marketed

• Has one of the highest suicide rates worldwide

Epidemiology • “Two peaks” in risk by

age (young and elderly)

• >50% acts of pesticide related suicide occur within 30min of initial thought*

• Case fatality = 15% (compared to <1% from medicine)

*Eddleston, M., A. Karunaratne, et al. (2006). "Choice of poison for intentional self-poisoning in rural Sri Lanka." Clin Toxicol (Phila) 44(3): 283-286 ** Gunnell DJ, Eddleston M: Suicide by intentional ingestion of pesticides: A continuing tragedy in developing countries. Int J Epidemiol 2003, 32(6):902-909.

England

Sri Lanka

Hospital Admissions for Self poisoning

Suicide Rates

**

Suicide rates in Sri Lanka 1940–2005.

Gunnell D et al. Int. J. Epidemiol. 2007;36:1235-1242

Green Revolution

Pesticide Bans

Open Economy

Aims

• Identify time-trends of method specific rates by age and gender

Methods

DATA • Suicide Data: Police data* from

1975-2010 • Population Data: Census data

for 1971,1981 and 2001 obtained and calculated mid-year estimates

ANALYSIS • Calculate age-standardised rates • Graphical presentation of trends * From the Department of Police, Division of Statistics, Sri Lanka

Results

1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

0

20

40

60

80

100

120

140

Su

icid

e r

ate

pe

r 1

00

,00

0

a) Male 17-25 26-35

36-55 55+

Open Economy

Civil War Begins

All Class I banned**

Civil War Ends

Endosulphan Import Ban

First Class I ban*

* Class I Organophosphate - methylparathion and parathion ** All remaining Class I pesticides (monocrotphos and methamidophos)

Results

1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

0

20

40

60

80

100

120

140

Su

icid

e r

ate

pe

r 1

00

,00

0

b) Female

17-25 26-35

36-55 55+

Endosulphan Ban

Civil War Ends Open Economy

Civil War Begins

All Class I banned** First Class I ban*

* Class I Organophosphate - methylparathion and parathion ** All remaining Class I pesticides (monocrotphos and methamidophos)

Pre* and Post** Pesticide Regulation

17-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61+

0

50

100

150

200

250

300

350

Su

icid

e r

ate

pe

r 100,0

00

a) 1979-81*

M F 17-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61+

0

50

100

150

200

250

300

350

Su

icid

e r

ate

pe

r 100,0

00

b) 2008 -10**

M F

Method Specific Rates – the highlights

1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

0

5

10

15

20

25

30

35

40

Su

icid

e R

ate

Per

100,0

00

Method-specific suicides combining poisoning and other methods: Sri Lanka 1975-2009

Hanging

Jumping in front of train

Drowning

Burning

Shooting

Sharp cutting instruments

Self-poisoning and "other" methods

Strengths/Limitations

Strengths

• Uniquely rich data by age/gender/method

• Spans several years

Limitations

• Missing data for some of the north

• Potential underreporting

Conclusion

• Dramatic change to age/gender/method specific trends

• Age/gender suicide patterning (post regulations) similar to pattern in the west, but only in men

• Still a high risk group in young women

• Some evidence of method substitution

Acknowledgements

Prof David Gunnell Dr Chris Metcalfe Dr Ravindra Fernando (University of Colombo) Dr Michael Eddleston (University of Edinburgh) Registrar General for Sri Lanka With special thanks to: S.A.S .Bandulasena (Dept. of Census and Statistics) Ms Pushpa Gunasekara (Medical Statistics Unit, Sri Lanka)

Questions?

Suicide and Self-harm in Sri Lanka 1975-2010:

Age, method, period and cohort analysis of Police data

Dee Knipe