Tuesday, May 24, 2011

Police suicides

Pondicherry police - kepis
Five police constables from Pune committed suicide this year. Suicide by police personnel the world over has been extensively reported. It is generally known that the occupation is stressful and associated with psychological stressors that make personnel prone to suicide. However, there is a marked variance in reported rates and stressors. Local factors may overshadow any generalisations even within the country. For instance, in the US/Europe firearms are the most common suicide method used by police (61-77%), but in Pune hanging was the only method used.

Sources of stress in police personnel

There is conflicting evidence as to the extent to which police constitute a high risk group for suicide. A study of well-being in police at Bangalore showed they were were better adjusted and had a better quality of life than comparable middle class urban factory workers (Geetha 1998). However, they had poorer social contact and support beyond the immediate family. This was attributed to their long working hours, requirement to be on duty during holidays, and the prevalent negative attitude of the public towards the police in general. Traffic policemen, personnel with higher education, and freshly recruited personnel were found to be under greater stress.

Police suicides are an interaction of personal vulnerabilities, workplace stressors, and environmental factors as is  seen with other worker groups. Two risk factors have been consistently delineated for suicide by police personnel; workplace trauma that increases vulnerability to posttraumatic stress disorders and organisational stressors that lead to burnout. Mental health interventions and organisational change are usually implemented to mitigate these factors. However, little attention is paid to the third leg of police suicide - personal factors (Stuart 2008). Personal factors had a major role to play in the Pune police suicides.

Suicide rates in police

Data on suicide rates for police in India is not available. However, the suicide rate in Pune is more than the national average. This rate is still increasing and is 17.3/100000 as of 2009.

Suicide rates in police personnel vary depending on geography. They can be higher than the general population as in Germany (25/100000 vs 20/100000), the same as the general population as in the US (14.9/100000) or half that of the comparable general population as in Canada (14.1/100000).

Suicide rates in police personnel also vary when calculated over long or short time frames, indicating the influence of clustering. This underlines the need for using longer time frames while studying this population (Loo 2003). A historical survey of police suicide from 1843-1992 in Queensland showed the rates reduced from 60/100000 to 20/100000 (Cantor 1995).

The accuracy and validity of police suicide rates are controversial. Under reporting of police suicide is significant (Violanti 2010). Up to 17% of police deaths in the US are classified as undetermined as compared to 8% for military deaths. Official police suicide rates are less accurate and less valid than suicide rates published for other working populations (Violanti 1996). We have already discussed the reasons and results of underestimating suicide rates in India.

What needs to be done

  1. Personal factors that contribute to suicide need special attention. These factors play alongside the workplace and environmental stressors in police personnel. These include psychiatric illnesses, alcoholism, physical ill health and interpersonal and marital problems. These problems are similar to those of the general population.
  2. An early warning system for stressful police events needs to be implemented. The LEOSS (Law Enforcement Officer Stress Survey) is a short 25-item questionnaire specifically designed to evaluate stress in police personnel (Van Hasselt 2003).
  3. Police personnel need easy access to mental health services. The barriers are formidable; psychiatric evaluation can result in job sanctions, reassignment, restriction of firearm privileges, missed promotions, and stigmatisation (Mazurk 2002). 
Need for more organisational change?

  1. Cantor CH, Tyman R, Slater PJ. A historical survey of police suicide in Queensland, Australia, 1843-1992. Suicide Life Threat Behav. 1995 Winter;25(4):499-507.
  2. Geetha PR, Subbakrishna DK, Channabasavanna SM. Subjecitive well being among police personnel. Indian J. Psychiat., 1998, 40(2), 172-179
  3. Loo R. A meta-analysis of police suicide rates: findings and issues. Suicide Life Threat Behav. 2003 Fall;33(3):313-25.
  4. Marzuk PM, Nock MK, Leon AC, Portera L, Tardiff K. Suicide among New York City police officers, 1977-1996. Am J Psychiatry. 2002 Dec;159(12):2069-71.
  5. Stuart H. Suicidality among police. Curr Opin Psychiatry. 2008 Sep;21(5):505-9.
  6. Van Hasselt VB, Sheehan DC, Sellers AH, Baker MT, Feiner CA. A behavioral-analytic model for assessing stress in police officers: phase I. Development of the Law Enforcement Officer Stress Survey (LEOSS). Int J Emerg Ment Health. 2003 Spring;5(2):77-84.
  7. Violanti JM, Vena JE, Marshall JR, Petralia S. A comparative evaluation of police suicide rate validity. Suicide Life Threat Behav. 1996 Spring;26(1):79-85.
  8. Violanti JM. Suicide or undetermined? A national assessment of police suicide death classification. Int J Emerg Ment Health. 2010 Spring;12(2):89-94.

Sunday, November 14, 2010

Attempted suicide prosecuted in Pune

A 21-yr woman attempted suicide by jumping from the fourth floor of the gynaecology ward she was admitted in. She could not stand the pain of complications after a Caesarean Section. Section 309 of the Indian Penal Code was slapped against her by the police. 612 people committed suicide in Pune in 2008. This gives a documented suicide rate in Pune of 16.3 persons per 100,000 population. The national suicide rate is 10.8/100,000. This data is based on police records. A verbal autopsy study (1994-99) estimated an actual suicide rate of 95.2/100 000 population —nine times the national average.

This tragic incident and its background needs further analysis

How common is attempted suicide in a 21 year old woman during and after pregnancy?
The suicide rate for 15–24 year females is 109/100000. This exceeds the male rate of 78/100 000. Suicide is responsible for 49% of all deaths in women at these ages. During pregnancy attempted suicide is about 40 per 100,000 pregnancies. Women that attempted suicide during pregnancy had increases in caesarean delivery. One percent of people who attempt suicide complete it within a year

Why are official suicide rates gross underestimates?
Attempted suicide is a symptom associated with the stigma of mental illness and also the stigma of crime. To avoid this double stigma patients and we doctors collude to label the suicide attempt as accidental. Another verbal autopsy study (1997-98) of all deaths in a rural area showed that half the deaths ascribed to injuries were actually suicides. The real suicide rates are distorted depending on the degree of under-reporting.

So what if official suicide rates are gross underestimates?
80-95% of suicide is associated with treatable physical problems (including unremitting pain) and psychiatric problems (including post partum depression). When under-reported - resources meant for treatment of psychiatric disorders, including those for knowledge dissemination and manpower, are diverted to other problems.  A California study found that a psychiatric disorder increased the risk of postpartum suicide attempts 27.4-fold. The discrimination against females with mental illness is raised to a national level. People are left unaware that the conditions resulting in suicide attempts are disorders that are treatable; doctors and paramedical staff are not trained to recognise conditions that could lead to suicide; primary care doctors are unaware of simple, effective and available psychiatric treatment options. 

Why is the suicide rate in Pune one-and-a-half times the national average?
Among the many social factors associated with suicide, addressing suicide attempts humanely would contribute more to bringing down the actual suicide rate – definitely more so than prosecution. This high suicide rate in Pune may also have a flip side – we may have a better reporting system.