G. Hassan¹ Waseem Qureshi², Kadri S.M.³, G.Q. Khan⁴, D.C. Kundal⁵, Qureshi K.A.⁶, Manish Kak⁷, Manzoor Ahmad⁸, H. Arshid⁹, Maajid¹⁰ Nazir A. Khan¹¹

1Registrar, Department of Medicine, Government Medical College, Srinagar, India.
2. Medical Superintendent, Government Medical College associated SMHS Hospital, Srinagar, Kashmir, India.
3. Trainer, Regional Institute of Health & Family Welfare, Directorate of Health Services, Srinagar, Kashmir, India.
4. Professor and Head, Department of Medicine, Government Medical College, Srinagar, Kashmir, India.
5. Registrar, Department of Medicine, Government Medical College, Srinagar, Kashmir, India.
6. Faculty Member, Department of Social and Preventive Medicine, Government Medical College, Srinagar, Kashmir, India.
7,8 MBBS postgraduate Scholars, Department of Medicine, Government Medical College, Srinagar, Kashmir, India.
9,10 Registrar, Department of Psychiatry, Government Medical College, Srinagar, Kashmir, India.
11 Causality Medical Officer, Government Medical College associated SMHS Hospital, Srinagar, Kashmir, India.

Correspondence:
Dr SM Kadri
PO Box 1143, GPO, Srinagar-190001, Kashmir, India
E-mail: kadrism@gmail.com, kadrism@hotmail.com

INTRODUCTION

Around one million people die from suicide and at least 10 times more attempt suicide worldwide every year¹. A review of the world literature shows that attempted suicide rates vary from 100 and 300 per 100,000 with a preponderance of females². In the United States, around 5 million poison exposures occur yearly and up to 30% of psychiatric admissions are prompted by attempted suicidal poisoning³. In India, no nation-wide epidemiological studies have been undertaken, so it is not possible to know about the extent of the problem and change in pattern over the years⁴. However, an unprecedented increase in the number of suicides has recently been observed in Kashmir, and poisoning is the commonest mode of such incidents^1,5,6. In a recent study of 364 poisoning cases by Khan G Q et al, 83.5% cases were found to be suicidal in nature, and similar results were found by Malik G M et al from Kashmir valley^5,6. The incidence of suicidal poisoning is alarmingly increasing in Kashmir valley because of the existing turmoil since 1989 and the resultant social, mental and physical stress. In view of this threatening situation, we studied the total number of suicidal poisoning cases during the turmoil period (i.e. 1989 onwards) and compared the same retrospectively with the pre-turmoil period, at the SMHS hospital of the Government Medical College, Srinagar - a tertiary care health institution of the valley.

Study population
This study included the patients of attempted suicidal poisoning who were referred to the Department of Medicine of the SMHS Hospital Srinagar for emergency treatment from the peripheral primary and secondary health care institutions from January 1989 to December 2004. The study population mainly comprised permanent residents of the Kashmir Valley, and also includes a few security personnel and labourers from different parts of India working in Kashmir. Patients were of both sexes and of different age groups belonging to different religions.
The data of patients from January 1985 to December 1998 was collected from the Medical records Department and studied retrospectively.

Methods
Brief socio-medical history was obtained from the patients, their attendants and the accompanying policemen. This included nature of poison, amount consumed, time duration since intake and the circumstances which prompted the patients to take the poison. Containers of poisons like bottles, strips of tablets and sachets etc were searched, examined and sent for chemical analysis whereever possible. After a brief history and clinical examination, priority was given to the immediate treatment of the patients and included gastric lavage (whenever indicated), maintenance of, and patency of airways and intravenous line and subsequent supportive treatment, till the patient was stabilized. All gastric contents and blood and urine samples were preserved for chemical analysis. During hospitalization all patients were subjected to investigations like Haemogram, Urine analysis, Biochemical tests, Electrocardiograph and Chest radiographs.

Exclusion Criteria
The following cases were excluded from the study:

• Doubtful history of ingestion of poisons.
  
• Patients with accidental exposure to poisons
  
• Poor level of cooperation.
  
• Patients leaving hospital against medical advice
  

Psychiatric Evaluation
Following stabilization of the general condition, the selected patients were subjected to detailed psychiatric evaluation by the experienced psychiatrist.

All the data obtained from history, examination, investigations, psychiatric evaluation and/or mortality findings were recorded in the proforma for every patient.

Despite energetic and aggressive treatment by highly trained staff, 724 (6.12%) victims died during the period. These were the people who either had consumed ahuge quantity of Organophosphorus compounds or reported late to the hospital. Of the victims who had consumed other substances for poisoning, no death was observed. All the saved victims were discharged in s stable condition and we advised regular psychiatristic follow-up.

The study included a total of 13,157 cases of suicidal poisoning, of which 11,829 cases were studied over a period of 16 years viz.1989 to 2004 whereas the data of the previous 4 years (1985 to 1988) was obtained for comparison, retrospectively. The present turmoil in Kashmir valley came into existence in 1989; as such the present study is mainly concerned with 11,829 cases of this period. The study group comprised 5,543 (46.85%) males and 6286 (53.15%) females having the age of 14 to 89 (mean # SD) years. The majority of these 10,823 (91.49%) belonged to Muslim religion; others were Hindus, Sikhs and Christians. Among the six districts of Kashmir valley, Pulwama dominated the others while the least number of cases were noted from the Anantnag district (Table 1). The majority of the cases (82.43 %) belonged to the rural population. Females 6286 (53.15%) dominated the males.

The yearly number of cases during the turmoil period showed a progressive trend compared to the pre turmoil period (Table 2, Figure 1) and female victims dominated over the males. Among the substances implicated for the suicidal purposes, organophosphorus compounds were the most commonly used by 6,813 (57.59%) cases. The other substances includes rodenticides in 2,482 (20.99%), drugs like benzodiazepines, acids, antihistamines in 1893 (16.0%) cases and the other substances like dhatura and alcohol were used by 641 (5.42%) victims.

While analyzing the various precipitating factors for suicidal poisoning it was found that loss of lives, property/business and torture of innocent people and eventually adverse effects, was the leading cause of suicidal attempts. Other factors include events like poverty, failure in love affairs, divorce, drug abuse and strained social relations unrelated to the turmoil (Table 3).

+, loss of property, parents/siblings, loneliness, torture by security forces and militants, and unmarried pregnancies.
++, poverty, failure in love affairs, divorce, drug abuse, and strained social relations.

Analysis of selected groups (8,984) by psychiatrists revealed that depression with post traumatic disorder provoked by the existing turmoil, was the main psychiatric ailment in the poisoning victims. In addition several other disorders where found in the remaining cases and we attributed these to the untoward circumstances created by the turmoil (Table 4).

Excluding 279 cases who had psychiatric illness like major depression, manic depressive psychosis and schizophrenia January 1985 to December 1988.

This study showed an alarming increasing rate of poisoning in the Kashmir valley attributed mainly to the existing turmoil for the last 16 years now, as is well known to the whole world. Thousands of lives were lost, parents, siblings, property and business with eventual decline of economy, creation of a frightful environment and increase of mental stress. Several others lost their lives because they could not reach the available medical facility due to unavoidable circumstances, adding further to the bad situation. The present study is fairly accurate because almost all victims with history of intake of poisons are immediately referred to our tertiary care centre from the primary and secondary care levels. Although early published studies^5,6,8 signifying the impact of the turmoil on increasing attempted suicidal poisoning, such observations involved small samples at the same place within only a few years. We studied the data in detail and compared the observation with the retrospective observations of the pre turmoil era. The study showed the increased rate of attempting suicidal poisoning among young adults, predominantly females with the majority belonging to the rural areas. These findings are consistent with previous literature.

Mostly Muslims are involved, being the majority of the population of this region; most of the non-Muslims having migrated to other places of India. Several security personnel also became the culprit of attempting suicide in view of performing their jobs in stressful circumstances. Organophosphorus compounds were mostly used for suicidal attempts. It is because of free availability of such products in the valley, being used as pesticides and fungicides in apple orchids and agriculture, the main source of income in the valley. Similarly, Organophosphorus has been found as the most used substance for suicidal poisoning by several other observers^5,6,11-13.

Stressful situations and psychiatric disorders are the known risk factors for attempting suicidal poisoning and unemployment has been associated with increasing the same^2,9,11. Unemployment, poverty and low literacy are directly related to the presently existing turmoil. Occurrence of frequent bandhs, hartals, crack downs and firing episodes led to the closure of industrial units, malfunction of educational institutions, tourism failure due to the kidnappings and killings, and overall deterioration of economy, education and social environment, with creation of a stressful atmosphere. This has lead to increased incidence of psychiatric ailments with eventual increase in the incidence of suicidal poisoning. The present study revealed mortality of 6.1% however; varying figures were found by Pichot MH¹⁴ (14%), Nordstrom P¹⁰ (6-11%) and Kumar S¹⁵ (8.1%). While compiling the data from the preturmoil period we found an increase in incidence of suicidal poisoning by (260%) and the picture is showing a progressively increasing trend. This may causea dangerous deterioration if proper effective measures are not instituted.

1. Margoob M.A., Hussain A., Malik J.A., Zargar M.A., Zaffer Abass, Dhuha M, et al. Serum Cholesterol level and suicidal attempts kashmir scenario. JK Practitioner 2004, 11: 171-7 (www.jkpractitioner net).
   
2. Roy a. suicide In: Sadock BJ, Sadock VA, editors. Kaplan & Sadock's comprehensive Text book of psychiatry, philadelphia, Lippincott Williams and Wilkims; 2000. P. 2031-35.
   
3. Liden CH, Burns MJ, Poisoning and over dosage. In : Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison's Principles of Internal Medicine. New York: Mc Graw Hill; 2005. P. 2580-93.
   
4. Avasthi G, Mahajan R,Avasthi R. changing profile of acute poisoning in India. In Das S editor, Medicine Update Association of Physicians India. Mumbai : API; 2003. P 913-917.
   
5. Malik GM, Mubarik M,Romshoo GJ. Organophosphorus poisoning in Kashmir Valley. New England J Med 1998; 338: 1078-79.
   
6. Khan GQ, Romshoo GJ,Hassan G. Profile of acute poisoning in turmoil affected Kashmir Valley. J Assoc. Physicians India 2001; 49: 192.
   
7. American Psychiatric Association, Multiaxial Assessment edition I (India): 2000.P. 27-37.
   
8. Kashmir conflict takes suicide toll. BBC News, September 17 2004 (htt://news.bbc.co.uk/1/hi/world/south asia/3656048.stm)
   
9. Bille U.Attempted Suicide in Denmark.Acta Psychiatr Scand 1985,71:217-26.
   
10. Nordstorm P. Survival analysis of suicide after attempted suicide Acta Psychiatr Scand 1995; 91: 336-40.
    
11. Basu D. The profile of acute poisoning in a teaching hospital at Calcutta J Assoc Physicians India 1999; 47: 831-32.
    
12. Satoh T, Hosskawa M. Organophosphates and their impact on the global environment. Neurotoxicology 2000, 21: 223-27.
    
13. Serinivas VR. A profile of acute poisoning. J Assoc Physicians India 2000; 48; 140.
    
14. Pichot MH. Auzepy P, Richard C. Acute drug poisoning in suicidal elderly patients 70 years old and ove : 92 cases in a medical ICU. Ann Intern Med 1990; 14: 429 -30.
    
15. Shivkumar S. Profile of acute poisoning in Chennai : A two years experience in Stanley Medical College and Hospital (1999-2000). J Assoc Physicians India 2000; 50:206.