Suicide contagion and psychosocial risks among Nepali youth through a near-hanging case study

Introduction

Suicide contagion is a phenomenon resulting from exposure to suicide or suicidal behaviours and is a genuine concern^{1 –3} and creates a situation where knowledge of suicide death triggers similar behaviour in others. ¹ Such contagion may be due to exposure to the suicide of a famous personality or a close loved one.^{1 –3} It is noteworthy that suicide can be socially contagious, affecting individuals within their family or peer group, or through media reports.^1,2,4 Studies indicate that both direct and indirect exposure to suicidal behaviour increases suicidal ideation, with individuals such as adolescents and young adults particularly at risk. ¹ Therefore, it can be argued that suicide is contagious under certain circumstances. We present a case where the victim attempted suicide following his girlfriend’s suicidal death the previous day.

Case presentation

Following an attempted hanging, an 11th grade student from a remote mountain community was brought to our Emergency Department. The patient's friend found him hanging from the ceiling fan with a grey muffler and promptly released him. There was history of loss of consciousness but, when seen in the Emergency Department, he was conscious with his vitals within normal limits. Physical examination revealed a ligature mark on the neck and the presence of laryngeal crepitation. Computed tomography (CT) scan of the head and neck region revealed a normal brain, oedematous pharyngeal mucosal space, and bilateral aryepiglottic folds with minimal air compression. There was no evidence of subcutaneous emphysema, and the laryngeal framework was intact. Laboratory values for blood tests were within the normal limits. The patient was then admitted and treated at the intensive care unit (ICU). He recovered completely clinically without any neurological deficit by the third day and was transferred to the psychiatry ward.

On day 3, medico-legal consultation took place. Physical examination revealed an incomplete and oblique pressure abrasion on the right side of the neck, directed upwards and backwards, measuring 9 cm in length at the level of the thyroid (Figure 1). Upon inquiry, the patient had no recollection of his own suicide attempt; however, he admitted being in love with a female classmate who had hanged herself the previous day.

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Figure 1.

Pressure abrasion seen over the left side of the neck.

During the psychiatric consultation, the patient presented with excellent hygiene and proper attire, normal posture and gait, and maintained eye contact throughout. He spoke comprehensively and spontaneously, demonstrating clear perception with no illusions, hallucinations or misinterpretations. His subjective mood was, “I am fine,” and objective mood was euthymic. Cognition was oriented to time, place and person, and he exhibited no tangentiality, delusions or phobias. The patient had average intelligence with intact judgment and insight.

The patient was studying in class 11. He was from a remote village. However, for his education he had rented a room and shared it with his friend near to his school. He said he had been in love with “Miss X” of his class for the past six months and they used to have online chats and conversation through social media networks until recently, when her family found about it. They beat her up, seized her mobile and forbade her from going to school. Two days prior to the incident, she had called him from an unknown number and detailed to him what had happened. The same evening, she committed suicide by hanging. Although his roommate knew of the incident, he did not inform him nor any of his friends. He only knew of it the following day because the school was called off. He was disturbed and upset by her death. Alone in his room, he could not think of anything but her. He could not sleep the whole night. Next morning, when his friend went to buy milk, he felt life was not worth living alone and attempted to hang himself. During the session, the patient expressed despair and loneliness. The patient gave no history of substance abuse, chronic illness, or surgical intervention, and was neither a smoker nor an alcoholic. The patient reported normal sleep, appetite, bowel and bladder habits and was discharged on advice on day 5.

Discussion

The management of near hanging requires a multidisciplinary approach involving emergency medicine, otorhinolaryngology, general medicine, psychiatry and forensic medicine. In this particular case, the emergency physician provided initial stabilisation followed by ongoing care by an otorhinolaryngologist and physician. The forensic medicine team was consulted given the medico-legal nature of the case. Psychiatry also played a crucial role in counselling to help prevent future suicide attempts.

The case illuminates the complex interplay between predisposing and precipitating factors in suicidal behaviour. Predisposing factors like genetic, biological and social elements can make certain individuals prone to suicidal tendencies. ¹ Meanwhile, precipitating factors can trigger psychological changes like isolation and hopelessness that lead to suicidal acts. ¹ The interaction between predisposing and precipitating factors depends on the individual's resilience level. ¹ For vulnerable individuals, exposure to another’s suicide can strongly precipitate their own attempts at suicide. ¹ Specifically, young depressed individuals, or those who identify with the deceased, face higher risk from suicide stories.^{1 –3}

Suicide contagion refers to the phenomenon where exposure to suicidal behaviours, plans to end life, attempts to commit suicide, or others actually committing suicide makes copycat behaviour more acceptable and feasible for individuals. ² A PubMed search with the keywords “suicide AND contagion” on 6 March 2024 revealed 218 results with articles published from 1983 to 2024. Suicide contagion is a global phenomenon with prevalence among adolescents as observed in the PubMed search. The three bodies of research supporting this notion encompass studies on the impact of media reporting, suicide clusters, and the influence of exposure to suicidal peers. ³ This impact is massive among adolescents due to their susceptibility to social influence and their awareness of societal norms. ² Gender differences were observed, with women exhibiting more suicidal behaviour than men due to distinct risk factors and socialisation strategies. Same-sex friendships among women frequently include greater intimacy and personal disclosure, increasing the likelihood of suicide risk within their social circles. ²

Support from families, community organisations and government bodies at the local and national levels can help prevent suicide and reduce the risk of mimicking behaviour, especially among vulnerable adolescents and young adults. ¹ It is important to be aware that suicide contagion can profoundly impact people beyond close family members and may influence neighbours, classmates and acquaintances of the deceased. ¹ Adolescents who are exposed to suicidal people apart from their family, including friends, classmates or acquaintances, have a higher risk of suicide, which may be attributed to the phenomenon of imitation. ⁴ These exposed adolescents are vulnerable due to the fact that they experience greater pain and stress because of the loss of a loved one. ⁴ Exposure to real-life suicidal behaviours increases the risk of suicidal ideation in adolescents, suggesting that real-life suicidal behaviours may contribute more than media exposure. ⁴ A look at media reporting of celebrity suicides in India and Bangladesh confirmed low compliance with guidelines, along with presenting immoderate information about the deceased and insufficient attention to education. ⁵ The analysis revealed differences across gender, life events and photographs indicating an urgent need for better, culturally-adapted reporting standards to mitigate the public health impact of unbalanced coverage. ⁵

Recent studies have shed light on psychosocial and economic factors associated with suicide in Nepal. For Nepali women, interpersonal conflict, marital issues, abuse, relationship difficulties and financial difficulties are associated with self-harm and suicide. ⁶ Several socio-cultural and economic factors, such as gender inequality, traditional/cultural and patriarchal norms, and social exclusion, render Nepali women particularly vulnerable. ⁶ As per the victim’s narrative, it was revealed that his girlfriend committed suicide as her relationship with him was not accepted by her family. There is a culture of silence regarding incidents of domestic violence which contributes to the underreporting of suicides and suicide attempts in Nepal.^6,7 More studies are needed on male suicides and unreported cases of suicide in the Nepali scenario. ⁷

Losing a loved one is a highly stressful experience, causing at least six people to experience intense grief for every suicide. ⁸ In the present case we could not provide psychiatric counselling to the roommate of the patient who rescued him. Intervention in the form of psychological support for the friends and family of the patient is crucial to prevent suicide contagion. ⁸

For male adolescents like the victim in this case, it is important to provide emotional support and safe avenues for processing psychological trauma. Expecting teenage boys to suppress emotions and maintain constant strength in the face of traumatic events can contribute to suicidal ideation. ⁷ Dealing with psychological trauma, particularly among male adolescents, can be a challenging feat and may even contribute to the tragic decision of suicide. Traumatic life events, particularly those of an interpersonal nature, have the strongest association with suicidality, especially among men. ⁹

Conclusion

Suicide contagion and psychosocial factors may contribute to suicide or suicide attempts, as seen in the case of a young student from Nepal. There is an imperative need for further research to identify the key risk factors contributing to suicide contagion in the Nepali scenario and elsewhere. Furthermore, it is important to identify vulnerable people and deal with social and cultural issues that contribute to their vulnerability. This case highlights how complex suicide behaviour can be, emphasising the need for education, preventive strategies, early intervention and more research to better understand the phenomenon of suicide contagion.