Suicidal Attempts by Unusual Means and Methods: A Brief Review

AUTHORS

S.M. Yasir Arafat ORCID 1 , * , Md. Hafizur Rahman Chowdhury 1 , M A Mohit 2

1 Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

2 Department of Psychotherapy, National Institute of Mental Health, Dhaka, Bangladesh

How to Cite: Arafat S Y, Chowdhury M H R, A Mohit M. Suicidal Attempts by Unusual Means and Methods: A Brief Review, Jentashapir J Health Res. 2018 ; 9(3):e82829. doi: 10.5812/jjhr.82829.

ARTICLE INFORMATION

Jentashapir Journal of Health Research: 9 (3); e82829
Published Online: August 27, 2018
Article Type: Review Article
Received: August 1, 2018
Accepted: August 12, 2018
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Abstract

Background: When a method is unusual, the intention is very strong and then prevention becomes a big challenge; although, suicide is a preventable public health problem.

Objectives: The author aimed to look into unusual methods of suicidal attempts so that they can be considered in the formulation of prevention strategies.

Methods: A search was done in PubMed, PubMed Central, Google, Google Scholar, and BanglaJOL with specific searching key words between 2000 and 2017. Eventually, 23 articles were selected purposively for review.

Results: Nine suicide cases were reported as unusual poisoning, eight attempts were by violent methods, four by stabbing, and another four by unusual asphyxia. The mean age of the victims was 39.96 years, ranging from 17 to 80 years old, 68% being male. A total of 18 (72%) respondents died by the act, while 28% were saved from fatal attempts. Of the victims, 36% were found to have mental disorders, i.e. 28% had depression, 4% had schizophrenia, and 4% had bipolar 1 disorder. Seven cases had notable risk factors and two had a history of previous attempts.

Conclusions: Adult males are more prone to use unusual methods. Males used violent methods more than females, whereas females used more unusual poisoning methods. Asian and south Asians used more poisoning methods than those from other parts of the world.

Keywords

Unusual Suicide Unusual Mode Unusual Method

Copyright © 2018, Jentashapir Journal of Health Research. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Suicide is a preventable public health problem across the globe; however, it is still underattended by stakeholders (1-3). Suicide kills nearly 1 million people globally and is one of the three leading causes of death (1). If the current trend continues, it will kill approximately 1.53 million people in 2020, as stated by the World Health Organization (WHO) (1-4). Therefore, WHO focuses on suicide prevention and has called on countries to devise national suicide prevention strategies (1-4). Means restriction is one of the few promising strategies of suicide prevention, which showed effectiveness in declining the rate of suicide (5-8). It ranges from complete restriction of lethal methods to the promotion of educational and social interventions to make apart lethal means from risky persons (6-8). The choice of method depends on availability, accessibility, and perceived lethality of the method, intensity of intent to die, and other related socio-cultural factors (1, 9, 10). When intention is severe, means substitution can eventually happen (6-8). Unusual to very unusual means or methods have been used when intention to die is severe (6, 10). Uncommon methods with strong intention for suicide turn the suicides unpreventable (9, 10). The author aimed to review the reported suicide attempts with uncommon methods so that suicides by unusual modes will be paid adequate attention in suicide prevention.

2. Methods

Articles were searched in PubMed, PubMed Central, Google, Google Scholar, and BanglaJOL with key search words (unusual suicide, unusual mode of suicide, unusual methods of suicide, uncommon methods of suicide) between 2000 and 2017. Articles in the English language and articles focusing the suicide methods were considered as inclusion criteria. Unusual aspects of suicide other than methods, such as unusual suicidal notes, articles on topics other than suicidal topics, such as accidental death were excluded from the review. All studies identified through the search strategy were assessed by their titles and abstracts to help ascertain their suitability against the inclusion and exclusion criteria. If it was not clear from the article title or abstract whether they met the inclusion criteria, a full version of the text was then acquired. Next, screening was conducted and exclusion of duplicate articles was done. After considering the inclusion and exclusion criteria, eventually, 23 articles were selected for the current review.

3. Results

The list of articles is presented in Table 1.

Table 1. List of Articles
SL.YearAuthorModeMethodCountryHighlights
12018Arafat (10)PoisoningKerosene IVBangladeshCase report of suicide by IV kerosene
22017Zengin Eroglu et al. (11)AsphyxiaHangingTurkeyUnplanned complex suicide
32016Hasan et al. (12)PoisoningKerosene IVBangladeshSuicide attempt using IV kerosene
42016Bidaki et al. (13)PoisoningGasoline SCIranSuicide attempt by SC Gasoline
52016Zribi et al. (14)PoisoningPara phenylene diamineTunisiaCombination of complex suicide
62016Misiak et al. (15)ViolentStabbingPolandSuicidal attempt by stabbing
72016Rishi et al. (16)ViolentStabbingUSASuicide attempt with a kitchen knife
82015Behera et al. (17)InsulinIV cannulaIndiaSuicide by IV insulin
92015Zribi et al. (18)ViolentElectric sawTunisiaSuicide by electric saw
102013Jayaprasad & Metikurke (19)PoisoningKerosene IVIndiaSuicidal attempt using IV kerosene
112013Rossi et al. (20)AsphyxiaMethane gasItalySuicide by asphyxia by Methane Gas
122012Vapa et al. (21)AsphyxiaChocking & hangingSerbiaSuicide by combination of choking and hanging
132012Austin & Byard (22)ViolentHead impalementAustraliaSuicide by head impalement
142011Senthilkumaran et al. (23)PoisoningParathionIndiaSuicidal attempt by per rectal parathion
152011Schyma et al. (24)ViolentExplosionGermanySuicide by head explosion
162011Findikcioglu & Findikcioglu (25)PoisoningPaint thinnerTurkeySuicidal attempt with injection of paint thinner
172009Asamura et al. (26)AsphyxsiaWrapped tape and electrical cordJapanSuicide by combination of asphyxia
182009Viel et al. (27)ViolentStabbingItalySuicide by sharp force
192009Salem et al. (28)ViolentMultipleRomaniaAtypical suicidal methods
202008Tournel et al. (29)ViolentChainsawFranceSuicide with a chainsaw
212007Behera et al. (30)PoisoningCopper Sulphate IVIndiaSuicide with parenteral copper sulphate
222004Rautji et al. (31)ViolentCutting razor bladeIndiaSuicide with a safety razor blade
232003Rautji et al. (32)ViolentStabbingIndiaSuicide by Stabbing

z Abbreviations: IV, Intravenous; SC, Subcutaneous.

Table 2 reveals the demographic variables and risk factor distributions. The mean age was 39.96 years, ranging from 17 to 80 years, with 68% (17) being male. A total of 72% (18) of the respondents died by the act, 28% had a nonfatal attempt; 36% were found to have mental disorders, where among them, 28% had depression, 4% had schizophrenia, and 4% had bipolar 1 disorder (Table 2). Seven cases had notable risk factors and two had a previous attempt. Nine cases were reported as poisoning, eight as violent attempts, four as stabbing, and four as asphyxia.

Table 2. Demographic Variable and Risk Factor Distribution of the Victims
No.Age (Y)GenderNuptialityModeCountrySuicide/AttemptMental DisorderRisk FactorsPrevious Attempt
130FemaleSinglePoisoningBangladeshSuicideDepressionFew friendsNo
243MaleDivorcedHangingTurkeyAttemptDepressionYes
317MalePoisoningIranAttemptCluster B personalityYes
423FemaleSinglePoisoningTunisiaSuicideNoNo
548FemaleStabbingPolandAttempt
667MaleStabbingUSAAttempt
730FemaleMarriedPoisoningIndiaSuicideDepressionMarital discord
830MaleSingleViolentTunisiaSuicideNoNoNo
934MalePoisoningIndiaAttemptFamily disharmony + alcoholicNo
1035MaleAsphyxiaItalySuicide
1140MaleAsphyxia & ChokingSerbiaSuicidePrisoner & criminality
1280MaleViolentAustraliaSuicideDepression & Pancreatic Cancer
1335MalePoisoningIndiaAttemptHypertension
1457MaleViolentGermanySuicideNoNoNo
1555FemalePoisoningTurkeyAttemptBipolar 1
1652MaleAsphyxiaJapanSuicideFinancial
1743FemaleStabbingItalySuicide
1832FemaleViolentFranceSuicideSchizophrenia
1922MaleSinglePoisoningIndiaSuicideDepressionFinancial
2029MaleCuttingIndiaSuicideDepressionNo
2150MaleMarriedStabbingIndiaSuicideNoNo
2222MaleViolentRomaniaSuicide
2319MaleViolentRomaniaSuicide
2430FemalePoisoningRomaniaSuicide
2576MaleViolentRomaniaSuicideDepression

Figure 1 reveals the distributions of gender and unusual methods. Males chose more violent methods and females chose unusual poisoning patterns.

Cross-tabulation with gender and mode
Figure 1. Cross-tabulation with gender and mode

3.1. Unusual Asphyxia

In Japan, a very uncommon suicide was reported by asphyxia of a 52-year-old man who was financially burdened (26). It was a suicide by a combination of suffocation by adherent tape wrapped around the head to cover the airway and ligature strangulation by an electrical cord (26). In Italy, a 35-year-old man was found dead at home with his mouth containing a tube linked to the domestic methane gas system originating from the wall, which was sealed with packing tape (20). In Serbia, a 40-year-old prisoner died by suicide by a combination of asphyxia and choking (21).

3.2. Unusual Poisoning

Suicide by intravenous kerosene was reported in Bangladesh, India (10, 12, 19). A 30-year-old female physician injected kerosene into her own vein, which is quite unusual. The lady had no previous history of suicide attempts or even intentions (10). In 2016, a suicide attempt of a 17-year-old boy with subcutaneous injection of gasoline was reported in Iran (13). The boy had cluster B personality traits and had a history of multiple suicide attempts. Suicide of a 22-year-old painter who was suffering from depression, intravenously injected 2 cc copper sulfate was reported in India (30). In 2015, Behera et al. (17), again reported the suicide of a 30-year-old married female physician who used Insulin Lispro with the help of an intravenous cannula in India. The lady was reportedly found to be depressed before the suicide. Senthilkumaran et al. (23), reported a suicide attempt of a 35-year-old male who introduced parathion (organophosphorus compound) rectally. A very uncommon suicide attempt was reported for a 53-year-old female bipolar patient who injected paint thinner into the dorsum of her hand (25).

3.3. Suicide by Violent Methods

In France, suicide via chainsaw of a 32-year-old female engineer who was suffering from schizophrenia was found (29). Suicide of a cobbler by violent stabbing of his own chest was reported in India (32), suicide by power or electricity of a 30-year-old single male carpenter was reported in Tunisia (18), a 48-year-old female’s suicide attempt by stabbing a kitchen knife in her throat was reported in Poland (15), and suicide attempt by stabbing with a kitchen knife was also reported (16, 27). Suicide by cutting of the neck with a razor blade was found in a 29-year-old unemployed, depressed man in India (31) and Schyma et al. (21), reported suicide by head explosion via an explosive. The 57-year-old man was an electrician and had no previous history of any physical or mental disorders. Suicide by violent head impalement was found in an 80-year-old man with pancreatic cancer and depression (22). Salem et al. (28), reported in Romania the suicide of a 76-year-old male who drilled his own chest using a drill borer. When two or more methods are applied either simultaneously or one after another in a suicide, it is called complex suicide (11, 14, 33). Complex suicides were reported in Turkey (11), Tunisia (14), and Romania (28).

4. Discussion

The choice of method for suicide depends on the availability and accessibility of the method; the victim’s knowledge of the lethality of the method, age, sex, ethnicity, culture, religion, personal beliefs, occupation, educational status, media influence, and so on (1, 9, 10, 22). Among the methods investigated here, nine were reported as poisoning, eight as violent deaths, four as stabbing, and others as different forms of asphyxia (Figure 1). Atypical poisoning was more common in south Asia than in other parts of the world (Table 2). Violent methods were used more by males than by females, and females used atypical poisoning more often. Similar findings were also reported in cases of typical suicides (7, 34-37). The mean age was about 40 years, with a range of 17-80 years. Therefore, no report was found for any individual under the age of 17. Similar findings were also found in the review conducted by Arun et al. (33), in 2010. The male-female ratio was 2.1:1. As usual, more suicides were committed by males than by females, however, the ratio was smaller in Asia than in the Western part of the world (1-3, 34, 36). Among 25 suicides, nine (36%) of the individuals were found to have psychiatric disorders (seven with depression, one with schizophrenia, and one with bipolar disorder), four were mentioned as having no morbidities, and others had no cue on their comorbidity status (Table 2). Previous reviews revealed that approximately 90% of suicide victims were found to have had at least one axis 1 psychiatric comorbidity (3, 5, 9). Though more severe psychiatric morbidities are supposed to be present among the individuals who have died by unusual methods, this review finding does not support such notion (28). Seven (28%) victims had notable risk factors such as financial burdens (2), personality domains (2), marital and family discord (2), and imprisonment (1).

Suicide is the end result of combination of complex factors (9, 10, 37). Prevention strategies have been formulated and implemented focusing the major chunk of the suicide. Eventually, it is very challenging to prevent suicides by unusual means; however, few patterns were also prevailed. For example, intentional poisoning in its unusual form was more common in Asia and violence in its unusual form were found to be more common in the west.

4.1. Conclusions

Adult males are more prone to use unusual methods of suicide than females, with males using violent methods more often and females using unusual poisoning methods more often. Asians and south Asians used poisoning methods more often than individuals from other parts of the world. Review of articles of relatively short duration, few number database inclusion, and only English articles would preclude the generalization. Further large-scale reviews should explore these issues more vigorously.

Footnote

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