Suicide and deliberate self-harm represent significant health and social crises in Sri Lanka, placing extraordinary burdens on individuals, families, communities, and public services. By the final decade of the 20th century, the Sri Lankan suicide rate was one of the highest in the world; since then the rate has dropped, but rates of deliberate self-harm have significantly increased. The cause of the fall in the suicide rate was mainly the result of means restrictions – banning the most toxic pesticides used in self-harm – and improved health services implemented from the late 1990s, as well as an apparently spontaneous shift to medicinal drugs as a popular method of self-harm, which have a lower fatality rate. This briefing note aims to provide an overview of suicide and self-harm in Sri Lanka in relation to rates, demographic and social patterns, causes, and interventions.
The Sri Lankan suicide rate is currently around 20 per 100,000 in the population; anything above 16 per 100,000 – the global average – is considered ‘high’ by the WHO. In 1996 the suicide rate peaked at 47 per 100,000, but since then has declined rapidly. Official suicide data are compiled from police reports kept at local level. Widger has observed that these data are unlikely to be accurate due to a number of reporting biases, including underreporting of suicides by methods ‘easy’ to classify as accident (e.g. drowning, falling, vehicular, and burning).
There is no national protocol to record deliberate self-harm hospital admissions. There is a national protocol to record poisonings, including self-poisonings, through the National Poisons Information Centre (NPIC). However, the reliability of reporting procedures from local to national levels is questionable; for example, not all hospitals maintain records on patient admissions. The NPIC also does not collect data from private hospitals and only limited data from the north and east of Sri Lanka. Although limited, NPIC figures suggest that the self-harm rate is potentially many times larger than the suicide rate: in 2006, 4,504 people committed suicide but 93,733 people were admitted to hospital for poisoning.
Fragmentary evidence suggests rates of deliberate self-harm are rising. The UN Office for the Coordination of Humanitarian Affairs suggests that over the past 20 years there has been a 300% increase in patient admissions to state hospitals for self-poisoning. Using data collected from a base hospital in southern Sri Lanka, Senadheera suggests that admissions for self-poisonings in children and youth rose by 54% between 2006 and 2010. Unpublished data collected by the South Asian Clinical Toxicology Research Collaboration (SACTRC) for the Anuradhapura District also suggests rising levels of self-harm.
Patterns of suicide and self-harm vary by gender, age, ethnicity, religion, and geographical location. In summary, quantitative and qualitative studies suggest:
• Geographical location: District-level data has long suggested an urban/rural and north-eastern/south-western divide in Sri Lankan suicide rates. Areas with the highest rates include Vavuniya, Jaffna, and Polonnaruwa, and the lowest include Kegalle, Gampaha, and Colombo.
• Sex: Men commit suicide at a greater rate – around three times – than that of women. The sex ratio has tended to be much closer amongst self-harmers, with most studies reporting either gender parity or a male: female ratio of no greater than 2: 1.
• Age: Suicide has been a leading cause of death in the 16 to 24 years age group. The suicide rate falls for both women and men after 30 years, before rising again from around 50 years onwards amongst males. Self-harm is highest in the 16 to 24 years age group.
• Ethnicity & Religion: Sinhala and Tamil populations report the highest suicide rates, and Muslims and Burghers the lowest rates. Suicide rates are also highest in Buddhist and Hindu communities, and lowest in Christian and Muslim communities.
• Socio-economic status: There is only limited data on this issue, but most observers agree that suicide and self-harm are higher in low-income, low status communities, and amongst those with limited education (up to GCE level). International migration is also thought to be a risk factor associated with suicide.
• Marital status: Again there is only limited data available, but most observers agree that self-harm is highest in the unmarried and recently married, and suicide is highest in the married, recently separated, and recently widowed.
Research into the causes of suicide has been conducted by sociologists, anthropologists, and health scientists. Although the field does reflect a diversity of opinions, there is general disagreement over the likely causes of Sri Lanka’s suicide and self-harm epidemics. On the one hand are the health professionals, some of whom argue that suicide is primarily caused by depression and others argue that depression accounts for only a small number of cases. On the other hand are the social scientists, some of whom have argued that suicide is caused by macro-level economic, social, and political turbulence, and some of whom argue that suicide is a culturally-embedded response to interpersonal disputes. While it seems very likely that psychological, sociological, and cultural factors are all important, it seems equally unlikely that psychiatric disease classifications can provide a legitimate evaluation framework in most cases. This is because of the lack of such classifications in Sri Lankan culture, where understandings of mental and psychosocial health derive from different medical and social traditions. Widger , for example, has argued for the development of an ethnopsychological framework based on classifications used by suicidal people themselves.
While convincing ‘ultimate’ explanations still seem a long way off, there is more agreement over the ‘proximate’ causes. These include a range of family and interpersonal disputes, for example arguments between spouses, parents and children, and some extended kin. Failed love affairs, extra-marital affairs, and failed examinations and job opportunities are also frequently cited. In many cases, shame (läjja) is recognised as a leading cause of suicide; self-harm or suicide may be committed to escape shame or to cause shame for another person. In many cases, self-harm or suicide arise because they are felt to provide an appropriate response: in children and young women, for example, self-harm exists as an alternative to public expressions of anger. There appears to be an important relationship between self-harm, suicide, and gender and other forms of relational inequality. Finally, many acts of self-harm are also said to arise ‘impulsively,’ as a sudden and unplanned response to particular problems. Very few cases arise after an extended period of contemplation, which makes the efficacy of psychosocial preventions designed in Euro-American contexts unlikely.
Interventions can be divided into two kinds: research and prevention. As yet there has been no national research programme, severely restricting the development of evidence-based policy. There have been a number of academic research programmes, and also some NGO-based research activities. These have tended to be fragmentary and aside from NGO research, not conducted with the intention of developing policy/practice outputs. An important exception is the South Asian Clinical Toxicology Research Collaboration (SACTRC), which has conducted research into rates and causes, as well as trials of poison antidotes and lock-up boxes for pesticides.
Prevention programmes have also been fragmentary and largely not based on evidence. In 1996 a Presidential Commission was convened to find solutions to the escalating suicide rate. Six recommendations were proposed by a group of experts, although only one of those – restricting access to pesticides – was implemented. This had a significant impact of the suicide death rate, but made no difference to the self-harm rate, which continued to spiral. The report of the Presidential Commission remains the only national-level government strategy concerned with suicide in Sri Lanka, and there are growing calls for the development of a new strategy. The strategy itself is hard to find, and several key national stakeholders have admitted they cannot find a copy! Recent government programmes include life skills training for youth and care-givers. An initiative is about to be launched in the Kurunegala District, where the effects of life-skills training on local self-harm and suicide rates will be monitored.
NGO prevention programmes are mushrooming. Sumithrayo is Sri Lanka’s oldest and largest suicide prevention organisation, and is affiliated with Befrienders Worldwide. Volunteer-run, Sumithrayo operates out of 10 offices around the western, central, and southern provinces, and is currently seeking to establish a presence in Jaffna. Sumithrayo offers in-person and telephone befriending services to suicidal and distressed people, and although limited evidence suggests it can be effective in the local communities where it works, is too small to make any overall impact. Sumithrayo admits that its telephone service is largely unused, because there is no culture of seeking help in that manner. CCCLine, a recent initiative of the CCC Foundation, also offers telephone counselling. Like Sumithrayo, it struggles to attract callers. Many observers question the likely effectiveness of telephone counselling, given the contexts under which suicidal acts occur.
By and large, prevention programmes have been based on those designed in and for Euro-American contexts, where practices of self-harm and suicide are very different to those in Sri Lanka. There is a large ‘cultural gap’ between the kinds of suicide they have been designed to prevent, and the kinds of suicide found in Sri Lanka. This significantly complicates their likely efficacy and efficiency.
Rates of suicide and self-harm remain at crisis levels in Sri Lanka. Means restriction strategies have reduced the death rate and provided breathing space, but self-harm continues to rise. As yet, psychosocial interventions have failed to demonstrate efficacy or efficiency, largely because they are culturally inappropriate and have not been developed on the basis of sound evidence. However, the continuing crisis calls for urgent action in several key areas:
• A renewed Presidential commitment to suicide and self-harm prevention as a priority issue
• The establishment of a national forum or network for research and prevention stakeholders
• A national, interdisciplinary research programme to inform the development of policy and practice
• A new national suicide and self-harm prevention strategy, based on sound research and including impact monitoring
About the author
Tom Widger has been closely involved in the study of suicide in Sri Lanka for the past 13 years. His PhD thesis (LSE, 2009) was titled Self-harm and self-inflicted death in Sri Lanka: an ethnographic study, and in 2011 he was awarded an ESRC Post-Doctoral Fellowship for a new project: The sociality of suicide in Sri Lanka and comparative settings. Tom is the author of several academic articles on suicide in Sri Lanka and is co-editor of Ethnographies of Suicide, a special issue of Culture, Medicine and Psychiatry. His first book, Suicide in Sri Lanka: An Ethnographic Study, is due to be published by Routledge.