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EDITORIALS: Sundararajan Rajagopal Suicide pacts and the internet BMJ 2004; 329: 1298-1299 [Full text]

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Suicide is a burning public health issue in Japan

Ediriweera B.R., Desapriya   (4 December 2004)

Internet suicide pact, and charcoal burning

Kathy PM Chan, Paul SF Yip, Director, Centre of Suicide Research and Prevention, University of Hong Kong, and Dominic TS Lee, Professor, Department of Psychiatry, Chinese University of Hong Kong; Lecturer, Department of Social Medicine, Harvard Medical School.   (16 December 2004)

Suicide is a burning public health issue in Japan 4 December 2004
Ediriweera B.R., Desapriya, Research Associate-Department of Pediatrics Department od Pediatrics, University of British Columbia-V6H 3V4 Send response to journal: Re: Suicide is a burning public health issue in Japan	Year 2003 was the sixth in which more than 30 000 Japanese killed themselves leaving Japan with by far the highest suicide rate in the industrial countries. Nearly 100 people commit suicide everyday in Japan three times of annual traffic fatalities. Economic cycles have a close correlation with suicides in Japan, which has one of the highest suicide rates in the world. Attention to suicide prevention in Japan has unfortunately not been adequate. Introduction: Premature death by suicide is estimated to be the tenth leading cause of mortality in the world; just as common as the number of deaths in road-traffic accidents (1). Suicide is a leading cause of death among the young as well as a major factor in all age-groups. In 1998 an estimated 2.3 million people worldwide died as a result of violence. Approximately 42% of these 2.3 million deaths were suicides, 32% were homicides, and 26% were war related (2). Suicide is a public health problem that requires an evidence- based approach to prevention. The need to implement proper policies is urgent. Unless we do so, significant gains made over the last 40 years in reducing child and maternal mortality, increasing life expectancy, and lowering the burden of infectious diseases will be off set by the growth of intentional and unintentional injuries, mental and behavioral problems. In 2003 thus becoming the sixth consecutive year where death by suicide had exceeded the 30,000 barrier. The 25 per 100,000 in Japan easily outstrips the 7.4 per 100,000 in the UK, 12 in the US and 15.8 in Germany. Elsewhere in Asia 14.7 per 100000 Hong Kong residents kill themselves while the figure is 9.5 in Singapore (3). .More people die of suicide than from homicide in Japan. In 2000 there were 15 suicides for every homicides committed in Japan. Guns are highly restricted in Japan and only 0.2% of people used guns as methods of suicide.¡¡ Suicide victims are young adults at their most economically productive age and these tragic losses hold serious consequences to the economy. Among young adults (15-24 years of age), suicide was the second leading cause of death, accounting for 26.7% of all deaths. Among the young middle-aged group (25-39 years of age), suicide was the leading cause of death, accounting for 31% of the complete toll. Among middle-aged adults (40-54 years of age), suicide was the second leading cause of death, accounting for 14.2% of all deaths (3). . The rate in middle-aged men (40-54 years) was five times higher than in women, mainly due to suicides associated with unemployment and economic recession (4). In 2002, the unemployment rate leapt to 5.4% from 3.1% in the year 1995. Table 1- Leading causes of mortality and -2000 (3) Rank Cause of death Death rates per 100000 pop.(1) Proportion of all deaths (2) 1 Malignant neoplasms 231.6 (1) 29.6 (2) 2 Heart disease 120.4 (1) 15.4 (2) 3 C.V.D. 110.8 (1) 14.2 (2) 4 Pneumonia 74.9 (1) 9.6 (2) 5 Accidents 32 (1) 4.1 (20 6 Suicide and self-inflicted injury 25(1) 3.2(2) 7 Sanility 18.2 (1) 2.3 (2) 8 Renal failure 14.1(1) 1.8 (2) 9 Diseases of the liver 13.2(1) 1.7(2) 10 Chronic obstructive pulmonary disease 10.4(1) 1.3(2) All other causes 132.4(1) 16.8 (2) Total 782.9 (1) 100 (2) Source: Vital statistics-2000 (3) Graph 1 ¨C Suicide and transport attributed death rates per 100,000 population in Japan Source: Vital statistics-2000 (3) Discussion: Suicide is a public health problem that requires an evidence- based approach to prevention (5). The efficacy of primary care has been shown for the treatment of depression, and effective interventions include psychotropic drugs and interpersonal and cognitive behavioral therapy. Mental health practitioners in Japan should acquire the skills and knowledge that would enable them to deliver culturally effective evidence-based interventions. Development of a culturally valid, evidence-based action plan should be implemented immediately with the assessment of current utilization of mental health services in prefectural level. The stigma associated with suicide and mental illness, gives the view that these are shameful and/or sinful acts or conditions. This is also a barrier to treatment for persons with suicidal desires or who have attempted suicide in the past (6). Furthermore, attitudes to mental health care may need to be overcome in Japan, such as fear of the mental health care system attributable to its use for long term confinement of patients, stigma and community rejection of vulnerable groups Research has shown that many suicides are preventable; however, effective suicide prevention programs require commitment and resources (7). References 1 Murray CJL, Lopez AD. Global health statistics: a compendium of incidence, prevalence, and mortality estimates for over 200 conditions. Cambridge (USA): Harvard University Press 1996. 2. WHO Mortality Database, Geneva, Switzerland, World Health Organization, 1998 3. Vital Statistics 2000.Ministry of Health and Welfare, Tokyo- Japan. 4. Takei, N., Kawai, M., Mori, N., Sluggish economic affects health of Japanese business warriors. Bri. J. Psychiatry 2000; 176: 494-495 5. De Leo, D., Struggling against suicide: the need for an integrative approach. Crisis 2002:23; 23-31 6. Desapriya, E.B.R and Nobutada Iwase. Stigma of mental illness in Japan. Lancet 2002:359;1866-1867 7. Maris RW, Berman AL, Silverman, MM. Treatment and prevention of suicide. Comprehensive text book of suicidology. New York: Guilford, 2000: 509-35. Competing interests: None declared
Internet suicide pact, and charcoal burning 16 December 2004
Kathy PM Chan, Senior Medical Officer Kwai Chung Hospital, Kwai Chung, NT, Hong Kong SAR, Paul SF Yip, Director, Centre of Suicide Research and Prevention, University of Hong Kong, and Dominic TS Lee, Professor, Department of Psychiatry, Chinese University of Hong Kong; Lecturer, Department of Social Medicine, Harvard Medical School. Send response to journal: Re: Internet suicide pact, and charcoal burning	We read with interests Rajagopal's editorial on suicide pacts and the internet (1), and would like to enrich the discussion by pointing out that the 2 cited Japanese suicide pacts both used a new suicide method, charcoal burning, to kill themselves. These two widely publicized pacts were followed by four additional pacts (13 deaths) and a murder-suicide of a family of four, all of whom used charcoal burning (October to December 2004). In Hong Kong, we had also observed that suicide pacts and family murder-suicide commonly used charcoal burning to institute death. Charcoal burning involves smoldering barbecue coal within a small and sealed environment, like a bedroom (2,3). The setup is conceptually similar to diverting exhaust fumes to the inside of a car, both of which aim to produce carbon monoxide chamber within a short time. Rajagopal pointed out that vehicle exhaust fumes poisoning was the most commonly used method among suicide pacts in UK. We have also observed that the emergence of charcoal burning was associated with a sharp rise in the number of suicide pacts in Hong Kong. Based on Coroner Court data, suicide pact used to be rare, accounting for fewer than 1% of suicide deaths locally (Coroner Court, 1991-1997). Since the popularisation of charcoal burning suicide, the rate of suicide pact climbed up to 2.3% of all suicide deaths in 2002. In 2002 and 2003, out of the 22 suicide pacts, 20 pacts (91%) used charcoal burning. It is of note that of all charcoal burning suicide deaths happened during the same period, 7% were suicide pacts. Charcoal burning has several characteristics that are desired by people who want to commit suicide together. Unlike other methods of suicide, such as jumping and hanging, charcoal burning is a method that can be easily shared. Charcoal burning, like other means of carbon monoxide poisoning, is often portrayed as non-disfiguring and painless. In our ethnographic study of people surviving serious attempts of charcoal burning, many informants perceived the process as painless and comfortable, like "going to sleep" (4). Hence, partners in suicide pacts could be more easily lured into the act. Apart from spouses and lovers, the coerced "partners" can also be children who are not mature enough to defend themselves. Here in Hong Kong, charcoal burning was involved in three of the nine murder-suicide cases involving children in 2002 (Coroner Court data). The Internet media, apart from connecting otherwise isolated anomies in forming suicide pacts, has played an important role in spreading new suicide method across countries and societies. Since the emergence of charcoal burning suicides in Hong Kong, the method has spread to Macau, Mainland China, Taiwan, Japan, New Zealand, and recently the United States. The first charcoal burning suicide victim in Taiwan explicitly stated he learnt of the method from Hong Kong Newspaper website (2). When we first started our research on charcoal burning suicides in 2002, there was only one website that described the method (4). Now, a search on the Google returned with 87,900 hits! Charcoal burning suicide is a local problem no more. Charcoal burning suicide can pose serious public health threat for several reasons. The method has demonstrated its ability to spread from one society to another. The novelty and misguided glamour entailed can lead to rapid proliferation of the method within a society. Once an "outbreak" begins, it is hard to stop. This is because barbeque is a common leisure activity, and charcoal is widely available in supermarkets and convenience stores. Restricting availability of means, often regarded as too intrusive by the public, is very hard to achieve. However, with the progressive spread and plague of charcoal burning suicides in Hong Kong, Taiwan and Japan, it is high time to re-examine the issue more critically, and to ask how charcoal can be made less accessible, at least to the vulnerable population (5). Charcoal burning and cyber-suicide pacts are examples of how globalization and cyber-era are creating new challenges for global health. Joint effort and expertise of the international community are urgently called for. Reference : 1. Rajagopal S. Suicide pacts and the internet: Complete strangers may take cyberspace pacts. BMJ 2004; 329:1298-1299 2. Lee DTS, Chan KPM, Lee S & Yip, PSF. Burning charcoal: A novel and contagious method of suicide in Asia. Arch Gen Psychiatry 2002; 59:293 -294 3. Chan KPM, Lee DTS, Lee S & Yip, PSF. Media¡¦s role is double edged. BMJ 2003; 326:499 4. Chan KPM, Yip PSF, Au J & Lee DTS. Charcoal burning suicide in post-transition Hong Kong. Br J Psychiatry Jan 1, 2005; 186(1) 5. Yip, PSF. Should charcoal sales be banned except near barbeque sites? South China Morning Post 2004, Oct 13. Competing interests: None declared