UM Commentary: Hanging to commit suicide in the developing world

Introduction

Seventy-nine percent of suicides occur in developing countries and hanging is the second most likely method of suicide attempt in developing countries^1,2. Efforts to prevent hanging are hindered by the social stigma of depression and suicide and the lack of an effective prevention strategy. In this mini-review, we discuss the current epidemiology and prevention strategies of hanging as a suicide attempt in the developing world, discuss the physiology of hanging and near hanging and describe the results of our recently published protocol for the initial management of near-hanging patients.

Rates of Hanging as Suicide

Geographic location is a strong predictor of suicide method. According to the World Health Organization (WHO), hanging is the most likely method of suicide worldwide^3,4. However, many developing countries lack the resources to accurately track suicide statistics. In addition, there is a cultural stigma to mental illness and suicide that limits accurate reporting.  Furthermore, in many developing countries, laws exist prohibiting suicide and attempted suicide which leads to fear of criminal retribution for survivors of hanging attempts5. Despite a lack of comprehensive records, suicide rates are increasing globally, most prominently in India and China^2,6. In non-European countries, pesticides and hangings are the most common methods of suicide, with pesticides contributing to approximately 49% of all suicides and hangings to an additional 35%³. Compared to the United States, firearms are less commonly used methods of suicide in developing countries³.

Prevention

Population-level suicide prevention strategies include strengthening firearm regulations, restricting pesticide and poison sales, mandating safe storage of toxins and applying thoughtful design to buildings and bridges. In developing countries, the implementation of many of these strategies is challenging due to a lack of infrastructure and economic constraints. However, local regulations may have the potential to decrease rates of suicide by firearms and pesticides, but have shown no impact on the rate of hanging attempts³. In addition to the challenges of specifically preventing hangings, many developing countries lack adequate resources to provide mental health services⁷. The most promising prevention strategies include initiatives that focus on increasing community awareness of suicide risk factors and providing mental health training to local providers⁷. Suicide clusters have been reported after media coverage of an initial suicide^7-9. Therefore, another proposed prevention strategy includes recommendations that media outlets focus on publicizing suicide prevention strategies and mental health resources rather than providing case-specific details.

Physiology of Hanging and Near Hanging

The term hanging refers to any method where external pressure is placed on the neck by a ligature in a suspended or partially suspended individual¹⁰. The term near-hanging refers to those who survive an episode long enough to present to the hospital. Death due to self-hanging are typically secondary to vascular occlusion leading to cerebral vascular congestion. Once unconscious, the patient’s muscle tone is lost, resulting in arterial occlusion and cerebral anoxia^10,11. While it is believed that in judicial hangings, in which a person is dropped 4-6 feet, death results from C2 fracture^11,12.

For patients who present to the hospital, survival rates are reportedly as high as 88-90%^13,14. Near-hanging patients who require CPR or present with a low Glasgow Coma Scale have a significantly higher mortality rate¹⁵.  In addition to anoxic brain injuries, patients presenting with near-hanging may have laryngotracheal fractures, cervical spine injuries, vascular dissections or lacerations. Contusions or abrasions of the neck are the most commonly identified injuries, while cervical fractures and spinal injuries are exceptionally rare^13-16. Patients who may initially present asymptomatic are at risk for delayed cerebral injury and pulmonary edema¹¹.

Early Management Protocol

Our recent publication, “Reducing mortality in near-hanging patients with a novel early management protocol” describes the largest published case series on near-hanging and the first attempt to establish guidelines for the initial management of the near-hanging patient in India. By implementing a protocol using early intubation, strict blood pressure control, and targeted temperature management, near hanging patients demonstrated significant reductions in mortality (10/27 (37%) versus 2/38 (5%), p<.05) and significantly higher rates of discharge without neurologic deficits (10/27 (37%) versus 35/38 (92%), p<.05)¹⁷.

Working with EMS providers

A significant caveat when considering the promising results of the aforementioned study is the differences in time to ED presentation.  Prior to implementation of the ED protocol, the time to ED presentation was 216 minutes, whereas the time to presentation Post-Implementation was 164 minutes. It is possible that the earlier transport time is associated with improved clinical benefit. There is significant variation in the implementation of pre-hospital care throughout the developing world, with a mixture of government and community organizations providing transport.  However, the vast majority of patients arrive at the hospital without formal prehospital care or transport. In most systems, ambulances are utilized purely for the transport of the sick and injured, without a major focus on treatment¹⁸. Many programs are fragmented and uncoordinated, although more successful systems provide care comparable to the United States. Pakistan’s Rescue 1122 is one such system providing BLS level care with physician oversight and training. Rescue 1122 responds to approximately 430,000 emergencies each year in Pakistan’s Punjab Province, with an average response time of only 7 minutes¹⁹. Across India, there is a wide variety of approaches to EMS, with both public and private sector EMS services providing a varying level of care in each state²⁰.

Looking Forward

Hanging continues to be a common method of suicide worldwide. Suicide prevention in developing countries is limited by cultural stigma, legal implications and a lack of resources. Applying a simple early management protocol has been shown to significantly improve outcomes in patients with near-hanging. Hospitals in developing countries should consider implementing a similar strategy to improve the care of these patients.

Conflict of Interest: The above authors certify that they have no affiliations or financial interest in the subject matter or materials discussed.

References:

1. Tingle J. Preventing suicides: developing a strategy. Br J Nurs 2015;24:592-3. doi:10.12968/bjon.2015.24.11.592
2. Suicide Fact Sheet. 2018. at http://www.who.int/news-room/fact-sheets/detail/suicide.
3. Ajdacic-Gross V, Weiss MG, Ring M, et al. Methods of suicide: international suicide patterns derived from the WHO mortality database. Bull World Health Organ 2008;86:726-32. doi:10.2471/BLT.07.043489
4. Gunnell D, Bennewith O, Hawton K, Simkin S, Kapur N. The epidemiology and prevention of suicide by hanging: a systematic review. International Journal of Epidemiology 2005;34:433-42. doi:10.1093/ije/dyh398
5. Khan MM, Hyder AA. Suicides in the developing world: case study from Pakistan. Suicide Life Threat Behav 2006;36:76-81. doi:10.1521/suli.2006.36.1.76
6. Varnik P. Suicide in the world. Int J Environ Res Public Health 2012;9:760-71. doi:10.3390/ijerph9030760
7. Hawton K, van Heeringen K. Suicide. Lancet 2009;373:1372-81. doi:10.1016/S0140-6736(09)60372-X
8. Hawton K, Harriss L, Simkin S, et al. Effect of death of Diana, Princess of Wales on suicide and deliberate self-harm. Br J Psychiatry 2000;177:463-6. doi:10.1192/bjp.177.5.463
9. Biddle L, Donovan J, Hawton K, Kapur N, Gunnell D. Suicide and the internet. BMJ 2008;336:800-2. doi:10.1136/bmj.39525.442674.AD
10. Gandhi R, Taneja N, Mazumder P. Near hanging: Early intervention can save lives. Indian J Anaesth 2011;55:388-91. doi:10.4103/0019-5049.84863
11. Tintinalli JE, Stapczynski JS, Ma OJ, Cline D, Meckler GD, Yealy DM. Tintinalli's emergency medicine: a comprehensive study guide: New York: McGraw-Hill Education, 2016.
12. Hellier C, Connolly R. Cause of death in judicial hanging: a review and case study. Med Sci Law 2009;49:18-26. doi:
    
    10.1258/rsmmsl.49.1.18
13. Penney DJ, Stewart AH, Parr MJ. Prognostic outcome indicators following hanging injuries. Resuscitation 2002;54:27-9. doi:
    
    10.1016/s0300-9572(02)00050-3
14. Salim A, Martin M, Sangthong B, Brown C, Rhee P, Demetriades D. Near-hanging injuries: a 10-year experience. Injury 2006;37:435-9. doi:10.1016/j.injury.2005.12.013
15. Nichols SD, McCarthy MC, Ekeh AP, Woods RJ, Walusimbi MS, Saxe JM. Outcome of cervical near-hanging injuries. J Trauma 2009;66:174-8. doi:10.1097/TA.0b013e31817f2c57
16. Aufderheide TP, Aprahamian C, Mateer JR, et al. Emergency airway management in hanging victims. Ann Emerg Med 1994;24:879-84. doi:10.1016/S0196-0644(94)70206-3
17. Tharmarajah M, Ijaz H, Vallabhai M, et al. Reducing mortality in near-hanging patients with a novel early management protocol. Am J Emerg Med 2018;36:2050-3. doi:10.1016/j.ajem.2018.08.003
18. Suryanto, Plummer V, Boyle M. EMS Systems in Lower-Middle Income Countries: A Literature Review. Prehosp Disaster Med 2017;32:64-70. doi:10.1017/S1049023X1600114X
19. Sriram VM, Naseer R, Hyder AA. Provision of prehospital emergency medical services in Punjab, Pakistan: Case study of a public sector provider. Surgery 2017;162:S12-S23. doi:10.1016/j.surg.2017.02.015
20. Sriram V, Gururaj G, Razzak JA, Naseer R, Hyder AA. Comparative analysis of three prehospital emergency medical services organizations in India and Pakistan. Public Health 2016;137:169-75. doi:10.1016/j.puhe.2016.02.022

Evan Kuhl RES '19, MD is a GW Emergency Medicine residency alumnus and current faculty member.

Joanna Cohen, MD is a GW Pediatrics faculty member and ultrasound fellowship alumnus.

Katherine Douglass, MD is a GW Emergency Medicine faculty member and section chief of Injury Prevention.

Maxine LeSaux is a former Clinical Research Study Coordinator with Emergency Medicine and currently an associate with Audacious Inquiry.

Andrew Meltzer, MD, MS is a GW Emergency Medicine faculty member, co-chief of Research and director of Urgent Matters.