1. Background
Suicide is a preventable public health problem across the globe; however, it is still underattended by stakeholders (1-3). Suicide kills nearly 1 million people globally and is one of the three leading causes of death (1). If the current trend continues, it will kill approximately 1.53 million people in 2020, as stated by the World Health Organization (WHO) (1-4). Therefore, WHO focuses on suicide prevention and has called on countries to devise national suicide prevention strategies (1-4). Means restriction is one of the few promising strategies of suicide prevention, which showed effectiveness in declining the rate of suicide (5-8). It ranges from complete restriction of lethal methods to the promotion of educational and social interventions to make apart lethal means from risky persons (6-8). The choice of method depends on availability, accessibility, and perceived lethality of the method, intensity of intent to die, and other related socio-cultural factors (1, 9, 10). When intention is severe, means substitution can eventually happen (6-8). Unusual to very unusual means or methods have been used when intention to die is severe (6, 10). Uncommon methods with strong intention for suicide turn the suicides unpreventable (9, 10). The author aimed to review the reported suicide attempts with uncommon methods so that suicides by unusual modes will be paid adequate attention in suicide prevention.
2. Methods
Articles were searched in PubMed, PubMed Central, Google, Google Scholar, and BanglaJOL with key search words (unusual suicide, unusual mode of suicide, unusual methods of suicide, uncommon methods of suicide) between 2000 and 2017. Articles in the English language and articles focusing the suicide methods were considered as inclusion criteria. Unusual aspects of suicide other than methods, such as unusual suicidal notes, articles on topics other than suicidal topics, such as accidental death were excluded from the review. All studies identified through the search strategy were assessed by their titles and abstracts to help ascertain their suitability against the inclusion and exclusion criteria. If it was not clear from the article title or abstract whether they met the inclusion criteria, a full version of the text was then acquired. Next, screening was conducted and exclusion of duplicate articles was done. After considering the inclusion and exclusion criteria, eventually, 23 articles were selected for the current review.
3. Results
The list of articles is presented in Table 1.
| SL. | Year | Author | Mode | Method | Country | Highlights |
|---|---|---|---|---|---|---|
| 1 | 2018 | Arafat (10) | Poisoning | Kerosene IV | Bangladesh | Case report of suicide by IV kerosene |
| 2 | 2017 | Zengin Eroglu et al. (11) | Asphyxia | Hanging | Turkey | Unplanned complex suicide |
| 3 | 2016 | Hasan et al. (12) | Poisoning | Kerosene IV | Bangladesh | Suicide attempt using IV kerosene |
| 4 | 2016 | Bidaki et al. (13) | Poisoning | Gasoline SC | Iran | Suicide attempt by SC Gasoline |
| 5 | 2016 | Zribi et al. (14) | Poisoning | Para phenylene diamine | Tunisia | Combination of complex suicide |
| 6 | 2016 | Misiak et al. (15) | Violent | Stabbing | Poland | Suicidal attempt by stabbing |
| 7 | 2016 | Rishi et al. (16) | Violent | Stabbing | USA | Suicide attempt with a kitchen knife |
| 8 | 2015 | Behera et al. (17) | Insulin | IV cannula | India | Suicide by IV insulin |
| 9 | 2015 | Zribi et al. (18) | Violent | Electric saw | Tunisia | Suicide by electric saw |
| 10 | 2013 | Jayaprasad & Metikurke (19) | Poisoning | Kerosene IV | India | Suicidal attempt using IV kerosene |
| 11 | 2013 | Rossi et al. (20) | Asphyxia | Methane gas | Italy | Suicide by asphyxia by Methane Gas |
| 12 | 2012 | Vapa et al. (21) | Asphyxia | Chocking & hanging | Serbia | Suicide by combination of choking and hanging |
| 13 | 2012 | Austin & Byard (22) | Violent | Head impalement | Australia | Suicide by head impalement |
| 14 | 2011 | Senthilkumaran et al. (23) | Poisoning | Parathion | India | Suicidal attempt by per rectal parathion |
| 15 | 2011 | Schyma et al. (24) | Violent | Explosion | Germany | Suicide by head explosion |
| 16 | 2011 | Findikcioglu & Findikcioglu (25) | Poisoning | Paint thinner | Turkey | Suicidal attempt with injection of paint thinner |
| 17 | 2009 | Asamura et al. (26) | Asphyxsia | Wrapped tape and electrical cord | Japan | Suicide by combination of asphyxia |
| 18 | 2009 | Viel et al. (27) | Violent | Stabbing | Italy | Suicide by sharp force |
| 19 | 2009 | Salem et al. (28) | Violent | Multiple | Romania | Atypical suicidal methods |
| 20 | 2008 | Tournel et al. (29) | Violent | Chainsaw | France | Suicide with a chainsaw |
| 21 | 2007 | Behera et al. (30) | Poisoning | Copper Sulphate IV | India | Suicide with parenteral copper sulphate |
| 22 | 2004 | Rautji et al. (31) | Violent | Cutting razor blade | India | Suicide with a safety razor blade |
| 23 | 2003 | Rautji et al. (32) | Violent | Stabbing | India | Suicide by Stabbing |
List of Articles
Table 2 reveals the demographic variables and risk factor distributions. The mean age was 39.96 years, ranging from 17 to 80 years, with 68% (17) being male. A total of 72% (18) of the respondents died by the act, 28% had a nonfatal attempt; 36% were found to have mental disorders, where among them, 28% had depression, 4% had schizophrenia, and 4% had bipolar 1 disorder (Table 2). Seven cases had notable risk factors and two had a previous attempt. Nine cases were reported as poisoning, eight as violent attempts, four as stabbing, and four as asphyxia.
| No. | Age (Y) | Gender | Nuptiality | Mode | Country | Suicide/Attempt | Mental Disorder | Risk Factors | Previous Attempt |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 30 | Female | Single | Poisoning | Bangladesh | Suicide | Depression | Few friends | No |
| 2 | 43 | Male | Divorced | Hanging | Turkey | Attempt | Depression | Yes | |
| 3 | 17 | Male | Poisoning | Iran | Attempt | Cluster B personality | Yes | ||
| 4 | 23 | Female | Single | Poisoning | Tunisia | Suicide | No | No | |
| 5 | 48 | Female | Stabbing | Poland | Attempt | ||||
| 6 | 67 | Male | Stabbing | USA | Attempt | ||||
| 7 | 30 | Female | Married | Poisoning | India | Suicide | Depression | Marital discord | |
| 8 | 30 | Male | Single | Violent | Tunisia | Suicide | No | No | No |
| 9 | 34 | Male | Poisoning | India | Attempt | Family disharmony + alcoholic | No | ||
| 10 | 35 | Male | Asphyxia | Italy | Suicide | ||||
| 11 | 40 | Male | Asphyxia & Choking | Serbia | Suicide | Prisoner & criminality | |||
| 12 | 80 | Male | Violent | Australia | Suicide | Depression & Pancreatic Cancer | |||
| 13 | 35 | Male | Poisoning | India | Attempt | Hypertension | |||
| 14 | 57 | Male | Violent | Germany | Suicide | No | No | No | |
| 15 | 55 | Female | Poisoning | Turkey | Attempt | Bipolar 1 | |||
| 16 | 52 | Male | Asphyxia | Japan | Suicide | Financial | |||
| 17 | 43 | Female | Stabbing | Italy | Suicide | ||||
| 18 | 32 | Female | Violent | France | Suicide | Schizophrenia | |||
| 19 | 22 | Male | Single | Poisoning | India | Suicide | Depression | Financial | |
| 20 | 29 | Male | Cutting | India | Suicide | Depression | No | ||
| 21 | 50 | Male | Married | Stabbing | India | Suicide | No | No | |
| 22 | 22 | Male | Violent | Romania | Suicide | ||||
| 23 | 19 | Male | Violent | Romania | Suicide | ||||
| 24 | 30 | Female | Poisoning | Romania | Suicide | ||||
| 25 | 76 | Male | Violent | Romania | Suicide | Depression |
Demographic Variable and Risk Factor Distribution of the Victims
Figure 1 reveals the distributions of gender and unusual methods. Males chose more violent methods and females chose unusual poisoning patterns.
Cross-tabulation with gender and mode
3.1. Unusual Asphyxia
In Japan, a very uncommon suicide was reported by asphyxia of a 52-year-old man who was financially burdened (26). It was a suicide by a combination of suffocation by adherent tape wrapped around the head to cover the airway and ligature strangulation by an electrical cord (26). In Italy, a 35-year-old man was found dead at home with his mouth containing a tube linked to the domestic methane gas system originating from the wall, which was sealed with packing tape (20). In Serbia, a 40-year-old prisoner died by suicide by a combination of asphyxia and choking (21).
3.2. Unusual Poisoning
Suicide by intravenous kerosene was reported in Bangladesh, India (10, 12, 19). A 30-year-old female physician injected kerosene into her own vein, which is quite unusual. The lady had no previous history of suicide attempts or even intentions (10). In 2016, a suicide attempt of a 17-year-old boy with subcutaneous injection of gasoline was reported in Iran (13). The boy had cluster B personality traits and had a history of multiple suicide attempts. Suicide of a 22-year-old painter who was suffering from depression, intravenously injected 2 cc copper sulfate was reported in India (30). In 2015, Behera et al. (17), again reported the suicide of a 30-year-old married female physician who used Insulin Lispro with the help of an intravenous cannula in India. The lady was reportedly found to be depressed before the suicide. Senthilkumaran et al. (23), reported a suicide attempt of a 35-year-old male who introduced parathion (organophosphorus compound) rectally. A very uncommon suicide attempt was reported for a 53-year-old female bipolar patient who injected paint thinner into the dorsum of her hand (25).
3.3. Suicide by Violent Methods
In France, suicide via chainsaw of a 32-year-old female engineer who was suffering from schizophrenia was found (29). Suicide of a cobbler by violent stabbing of his own chest was reported in India (32), suicide by power or electricity of a 30-year-old single male carpenter was reported in Tunisia (18), a 48-year-old female’s suicide attempt by stabbing a kitchen knife in her throat was reported in Poland (15), and suicide attempt by stabbing with a kitchen knife was also reported (16, 27). Suicide by cutting of the neck with a razor blade was found in a 29-year-old unemployed, depressed man in India (31) and Schyma et al. (21), reported suicide by head explosion via an explosive. The 57-year-old man was an electrician and had no previous history of any physical or mental disorders. Suicide by violent head impalement was found in an 80-year-old man with pancreatic cancer and depression (22). Salem et al. (28), reported in Romania the suicide of a 76-year-old male who drilled his own chest using a drill borer. When two or more methods are applied either simultaneously or one after another in a suicide, it is called complex suicide (11, 14, 33). Complex suicides were reported in Turkey (11), Tunisia (14), and Romania (28).
4. Discussion
The choice of method for suicide depends on the availability and accessibility of the method; the victim’s knowledge of the lethality of the method, age, sex, ethnicity, culture, religion, personal beliefs, occupation, educational status, media influence, and so on (1, 9, 10, 22). Among the methods investigated here, nine were reported as poisoning, eight as violent deaths, four as stabbing, and others as different forms of asphyxia (Figure 1). Atypical poisoning was more common in south Asia than in other parts of the world (Table 2). Violent methods were used more by males than by females, and females used atypical poisoning more often. Similar findings were also reported in cases of typical suicides (7, 34-37). The mean age was about 40 years, with a range of 17-80 years. Therefore, no report was found for any individual under the age of 17. Similar findings were also found in the review conducted by Arun et al. (33), in 2010. The male-female ratio was 2.1:1. As usual, more suicides were committed by males than by females, however, the ratio was smaller in Asia than in the Western part of the world (1-3, 34, 36). Among 25 suicides, nine (36%) of the individuals were found to have psychiatric disorders (seven with depression, one with schizophrenia, and one with bipolar disorder), four were mentioned as having no morbidities, and others had no cue on their comorbidity status (Table 2). Previous reviews revealed that approximately 90% of suicide victims were found to have had at least one axis 1 psychiatric comorbidity (3, 5, 9). Though more severe psychiatric morbidities are supposed to be present among the individuals who have died by unusual methods, this review finding does not support such notion (28). Seven (28%) victims had notable risk factors such as financial burdens (2), personality domains (2), marital and family discord (2), and imprisonment (1).
Suicide is the end result of combination of complex factors (9, 10, 37). Prevention strategies have been formulated and implemented focusing the major chunk of the suicide. Eventually, it is very challenging to prevent suicides by unusual means; however, few patterns were also prevailed. For example, intentional poisoning in its unusual form was more common in Asia and violence in its unusual form were found to be more common in the west.
4.1. Conclusions
Adult males are more prone to use unusual methods of suicide than females, with males using violent methods more often and females using unusual poisoning methods more often. Asians and south Asians used poisoning methods more often than individuals from other parts of the world. Review of articles of relatively short duration, few number database inclusion, and only English articles would preclude the generalization. Further large-scale reviews should explore these issues more vigorously.
