Methods used for suicide vary between regions in the developing world

Editor—Eddleston et al point out that deliberate self harm and suicide are serious public health problems in developing countries.¹ We agree with their suggestions aimed at reducing the mortality associated with organophosphorus and pesticide poisonings, but it is important to note the considerable variation in the methods used for suicide between regions in the developing world, and even greater variations between people attempting and completing suicide.

In India self immolation and hanging remain the commonest methods for completed suicides, whereas poisoning is a common form of deliberate self harm. In Goa (a maritime state) drowning is another common method of suicide. The populations at risk also vary; for example, although most people who attempted suicide in Eddleston et al’s report were under 30, most who complete are older. Social stressors may vary as well: in Sri Lanka the civil war is an important stressor, whereas in Goa problem drinking by male relatives, harassment of women by in-laws and husbands, and loneliness due to migration of children are important.²

While discussing prevention of deliberate self harm, the authors do not deal adequately with the recognition and management of common mental disorders, such as depression in general and primary healthcare settings. Studies from south Asia show that up to half of all adult primary care attenders have a clinically important emotional disorder, most of which go undetected and treated with many drugs.²,³ In a recent study from India 18% of all adult attenders admitted to suicidal ideas in the week before interview but under a fifth had discussed these with their doctor.²

Public health initiatives to meet this challenge should include raising awareness in the community and among policymakers in the government and health funding agencies of the risks and treatments for depression and anxiety; training health workers in general and primary healthcare settings in communication skills and the recognition and appropriate management strategies of emotional disorders; setting up multidisciplinary teams to provide interventions at the community level; integrating mental health in the work of non-govermental organisations, which are playing an increasingly important part in providing health care in many developing countries; and closer research and service links between departments of psychiatry and community medicine.