Suicide due to sulfuric acid ingestion in a case of major depressive disorder.

A case of Sulphuric acid ingestion with an intention to commit suicide in a patient of Major Depressive Disorder which resulted in death is reported. Aspects of this mode of suicide and legal issues concerning suicide in mentally ill patient have been discussed.

INTRODUCTION

Suicide in psychiatric patients using caustic substances though rare, is not unknown. In this case report, death due to Sulphuric acid ingestion in a patient having Major Depressive Disorder is being reported for three reasons; 1) rarity of this mode of suicide 2) factors influencing the mode of suicide 3) legal issues concerning suicide in mental illness.

CASE REPORT

An 18 year old, unmarried male gold smith was brought to psychiatry out patient of a general hospital by his relatives. The patient had strong ideas of suicide and had made repeated attempts of suicide by hanging, drowning and consumption of large number of sedative tablets. On further enquiry he was found to have symptoms of sadness, easy fatigability, lack of concentration, sleeplessness, lack of appetite, loss of interest in work and daily activities of three weeks duration. Physical examination was unremarkable. Thus, on clinical evaluation a diagnosis of severe Major Depressive Disorder was arrived at. Considering the strong suicidal intensions in the patient and as he was nil per orally overnight, emergency Electro Convulsive Therapy (ECT) was planned. While making arrangements for administration of ECT he was made to wait in the reception area along with his relatives. After about half an hour he was taken on to ECT table. On ECT table pungent odor emanating from the patient was recognized. Hence, administration of ECT was withheld and observation was continued. Patient became increasingly restless and was clutching his upper abdomen. On enquiry he complained of burning pain in the chest and upper abdomen. His blood pressure was 130/70 mm of Hg, pulse was 120 beats per minute, pupils were of midsize and non reactive to light. At this stage a tentative diagnosis of acid poisoning was made. He was given albumin of 2 eggs and 3 bananas. Patient was shifted to emergency ward. As the patient developed difficulty in breathing and became semiconscious he was put on assisted breathing. The patient's condition gradually deteriorated and he died after 2 hours. An autopsy was performed 6 hours after the death. The autopsy confirmed death due to sulfuric acid ingestion. Detailed autopsy findings have been reported elsewhere.[1]

DISCUSSION

Mode of suicide

In a review article citing 22 Indian studies many modes of suicide have been recorded. But, there is no mention of suicide by acid ingestion[2] probably due to its rarity. The article further emphasizes that methods employed for suicide usually reflect easy availability of the means; for example use of fire arms is based more on prevailing legislation rather than the nature of behavior per se and easy availability of pesticide is the main reason for chemical poisoning in farmers as a means of suicide in both developed and developing countries.[2] Behre & Bhise in their study of suicides in Maharashtra have also observed that farmers who commit suicide tend to use methods to which they had easy access. They also have alluded to the point that in UK a decline in farmer's suicide was recorded after legislation on purchase, storage and registration of fire arms.[3]

In western literature Gimmon et al.[4] have reported that acid ingestion as a mode of suicide is common among children and psychotics. Within adult population too, suicidal intentions are recognized as one of the commonest cause of Sulphuric acid ingestion.[5]

The patient referred to in this article had easy access to sulphuric acid as he was a goldsmith by occupation. Recently there was a report in newspaper that a family of jewelers committed suicide by consuming potassium cyanide which is used in cleaning jewellery.[6] Thus one's occupation can have a bearing on the mode of suicide. In this context it is felt that there should be regulation of sale and storage of hazardous materials by the state. However, recently the Supreme Court of India has directed Indian government to regulate sale of acids in a different context, i.e; acid attacks on women. As a consequence of which it has been proposed to ban over-the-counter sale of at least a dozen acids and bring the sale of acid under “The Poisons Possession And Sales Rules 2013”.[7] There have also been suggestions to control the sale, proper precautions in storage and usage of pesticides.

Legal issues concerning attempt of suicide in a mentally ill patient

Section 309 of IPC (Indian Penal Code) deals with the offence of attempting suicide. However to avoid any entanglement with the law, many suicidal attempters give a false account or concoct the incident as accidental. Section 84 of IPC protects mentally ill from provisions of Sec 309 of IPC This section is usually not invoked in many cases as the onus of proving unsoundness is on the survivors of suicide. Sections 305 and 306 of IPC deal with abetment of suicide; the former in relation to suicide of a child or insane person and the latter with other persons. Because of these sections the relatives or guardians of mentally ill may have an unexpected and unfair chance of getting charged under these sections. Section.304 B of IPC also deals with abetment of suicide relating to dowry death in women within seven years of her marriage.

Section 39 of CrPC, 1973 specifies that knowledge of crimes under various sections of IPC are to be informed to magistrate or police by the public. However under this Section IPC 309 is not included therefore it is not mandatory to inform about attempt of suicide to legal authorities unless one is absolutely certain the said act is related to suicide. But, in practice all cases of suicide are reported to police.

In day to day practice it has been observed that both police and legal authorities are reasonable, compassionate and humane when dealing with cases of attempted suicide in mentally ill patients. The absurdity of suicide as a punishable crime has been debated both in legal and medical circles with arguments for and against. Mental health professionals have been advocating an expansion of immunities extended to the persons with psychiatric illness.[8] Punishing attempted suicide has been viewed as anachronism of twentieth century.[9] Finally, legal opinion has held firm that no one has right to end anyone's life even if the life happens to be one's own. The repeal provision of IPC in cases of suicide has been refused even in psychiatric cases fearing misuse of provisions. The supreme court of India in a ruling given in 1996 stated that a person with any mental disorder may be detained in a psychiatric hospital for treatment under Mental Health Act 1987, but may not escape punishment for attempted suicide.[10] Scrutiny of every case of suicide and suicidal attempt has been recommended to ensure missing out on any foul play. However, in a recent development efforts are on to repeal section 309.

Most of the mentally ill and their attendants are not aware of the legal issues concerning suicide. They do not recognize that the attempt of suicide as wrong or contrary to law. In addition many patients and their relatives do not prefer to invoke legal provision fearing unknown legal hassles. The psychiatrist should be aware of legal provisions to educate and defend their patients in case of such unfortunate occurrence.