The first COVID-19 triadic (homicide!)-suicide pact: Do economic distress, disability, sickness, and treatment negligence matter?

INTRODUCTION: Dyadic suicide-pact is rare but possible incidence in the COVID-19 time. No prior evidences available on triadic suicide-pact, which is presented herein for the first-time. CASE
PRESENTATION: An Indian family consisting of three members, committed suicide. There is no evidence of homicide-suicide, which suggests the cases to be mutual suicide-pact. However, the suicide risk factors can be evidently noted as (i) economic distress, (ii) feeling burden of disability and sick people, and (iii) being stubborn as of not getting hospital treatment. Poisoning is reported for the suicide method; besides, the victims left a suicide note. PRACTICAL IMPLICATIONS: The present case highlights the possibilities of further suicide-pacts in economically unprivileged family, whereas having disabled and/or sick people may add extra burdens in taking such extreme decision.

INTRODUCTION

Now‐a‐days, mental health problems are the emerging issue because of the ongoing COVID‐19 pandemic across the world. Evidences suggest that social distancing, isolation, quarantine, economic distress, and misinformation, and so forth, being originated from the pandemic, are contributing factors to greater mental health sufferings.1, 2, 3 It is reported that people are at greater risk of developing common mental disorders, such as depression, anxiety, sleep disturbances, stress, traumatic symptoms, and so forth.2, 4, 5, 6, 7 However, these mental health problems are the main culprit of suicidal thoughts and actual suicide completion.8, 9 For instance, about 90% of the suicide occurrences are supposed to be incident because of psychiatric problems.10, 11 Consequently, likely other stressful live events, suicide rate increment is being reported in the current COVID‐19 pandemic.10, 12

There are plenty of research addressing the COVID‐19 suicide cases or case‐series across the world. For instance, Bhuiyan et al. reported the Bangladeshi general people's suicides, whereas Mamun and Ullah and Dsouza et al. respectively, investigated the Pakistani and Indian cases. Off these case studies, Dsouza et al, the Indian study, which was compromised with a total of 69 suicide cases (the largest case series in the COVID‐19 context) reported the prominent suicide risk factors to befear of COVID‐19 infection in a total of 21 cases. Whereas, other causalties were noted as financial crisis (n = 19), being tested positive with COVID‐19, social negligence and boycott suspecting the victim COVID‐19 infected, being at pressure to be quarantined of the suspected cases, missing family and loneliness due to the lockdown, work‐related stress in managing COVID‐19 workplace, unavailability of alcohol, feeling distressed because of exam postponement, and so forth. Although these risk factors were reported for general people suicidality in India, Mamun et al. recently demonstrated the Indian celebrity suicide occurrences because of depression.

Besides, there are three studies assessing the suicide pact (i.e., suicides of one more people) in the COVID‐19 period. For instance, Griffiths and Mamun observed a total six global couple suicidality pacts from Bangladesh, India, Malaysia, and the United States. The suicide‐pact causalities were reported to be (i) fear of infection, (ii) financial distress, (iii) social boycott, (iv) being unable to return home from abroad among the couple. An unusual suicide‐pact case (considering the victim and preparators’ relationship, that is, among mother‐adult son) was also reported as of online schooling‐related quarrel leading family conflict in Bangladesh. Besides, another exceptional case relating to infanticide suicide pact of a 30‐year‐old Indian woman and her 6‐month‐old infant was reported in Saudi Arabia. The woman's husband was recently retrenched from his job and was infected with COVID‐19 before 4 days of the incident. However, the probable fear of COVID‐19 infection of the infant along with ongoing familiar economic crisis, the infant was deliberately killed before the woman committing suicide.

Dyadic suicide cases are reported in the COVID‐19 context although, there is lack of evidence on triadic suicide pact. And, thus, the present report tries to document a rare (but possible) suicide pact of three persons from South Kolkata, India. The case is presented based on the press media reports, a well‐established retrospective suicide method that is widely used in the non‐COVID‐1919, 20 and COVID‐1912, 13, 21, 22 periods.

CASE PRESENTATION

On June 9, three people of the same family living in Satyanarayana Palli, Thakurpukur police station area of South Kolkata, committed suicide. According to the press media and police source, the triadic suicide‐pact victims were an 80‐year‐old man named Govinda Karmakar, his 70‐year‐old sick wife Ranu Karmakar and 47‐year‐old disabled son Bula Karmakar Debashis.

Debashis was crippled since birth, with paralyzed lower back and was supposed to perform everything by other's help, especially his mother, Ranu. The woman had a cerebral stroke a month ago. Due to financial constraints, she was treated by the support of her father in Hugli. They returned home 2 days back committing suicide from Hugli. That returning day, the old‐man went out to the neighborhood and swept off his feet. Neighbors grabbed him and brought him home. Then, he went out again and fall down. As of 2‐day uneaten, the old‐man became heavily debilitated. Then, the locals called the police, and they were taken to Vidyasagar Hospital for the probable COVID‐19 test. The doctors informed that the old man was having high body temperature and suggested that he should be taken to other hospitals. He was taken to Bangur Hospital, then, Medical Hospital, and later on, Nilratan Government Hospital; but as of not getting him admitted, the police dropped them in their home.

According to Mr. Karmakar's suicide note, it seemed that without him, his wife and son would be in a tragic situation, whereas he wanted to save them. The experience of walking from hospital to hospital might have made him even more stubborn. And the result of that zeal was to leave the world together with everyone. The locals could not accept the fact and felt that the hospital admission could have saved their lives. However, Debashis and his mother were lying dead on the bed, while Govinda was lying on the floor with his head toward the door. On the cement floor, 'all three of us are dead' was written, and near to the cup with a paper found to be noted as “no one will touch the cup, there is poison.”

DISCUSSION

When two persons' deaths occur because of either (i) killing one by a perpetrator and committing suicide himself, or (ii) committing suicide on mutual understanding at the same given time and place is referred as dyadic deaths.24, 25 The examples of dyadic deaths can be noted as murder‐suicide or homicide‐suicide, child homicide‐suicide, suicide pact, and so forth.15, 24, 26 Usually these suicides occur in the family context, and account for a very minor portion of the total suicide rate. However, the homicide‐suicide rate is reported to be yearly 0.06 per 100,000 persons in England and Wales, whereas 0.11 in Australia, 0.38 in Japan, 0.07 in New Zealand, 0.21 in the United States, and so forth.

Being married, socially isolated, having a serious health suffering in one or both partners are the accountable risk mediators of couple suicide pact.25, 26 Besides, premarriage relationship complexities, being unable to have children, financial difficulty, and so forth, can also be reasons for suicide pact.25, 26 For the child‐homicide suicide, there are two aspects leading the incidence occurrence; (i) motivational sources (i.e., altruistic, acutely psychotic, unwanted child, accidental, and spouse revenge) and (ii) origin of the stimulus (i.e., battering mothers, mentally ill mothers, retaliating mothers, unwanted children, and mercy killing). Issues like frequent depression, psychosis, and suicidal behaviors, prior mental health treatment, and so forth, along with chronic physical sufferings, unhealthy familiar environments consisting with violence, abuse, and so forth, aggravate the child‐homicide suicide incidence.27, 28

The COVID‐19 recession, is a major global financial recession, which began with the great lockdown across the entire world. It was first manifested by the 2020 stock market crash on February 20, of that 2 months back, the first‐ever COVID‐19 case was reported in China. To suppress the infection rate, extreme social movement restriction measures like lockdown was placed in almost all countries.2, 12 As a consequence, severe economic repercussions along with stagnation of stock markets and consumer activity globally during the ongoing pandemic is being reported. The International Monetary Fund projected that the COVID‐19 recession to be the most severe global economic shutdown since the Great Depression of 1930s, as well as the Great Recession of 2008–2009. Evidence suggests that the role of economic fallout and crisis turn people to face psychological vulnerabilities.30, 31, 32 In the extreme cases, people do commit suicide. A recent systematic review observing a total 38 papers found that economic distress and suicide rate was significantly correlated with 31 studies. Thus, the financial crisis and distress related to the COVID‐19 pandemic is taking up people's lives. For instance, Bangladesh reported all but one suicide because of economic constriction. Similarly, it was the first suicide causality in Pakistan, whereas the Indian reported it to be the second most prominent suicide factor during the COVID‐19 outbreak. Consistent with the general people suicide, the present suicide pact also reports economic sufferings.

As mentioned before, COVID‐19 turns excessive fear and worries among the people.1, 3 In  extreme psychological cases, people commit suicides. Fear of COVID‐19 infection was reported as the foremost suicide risk factor in India, whereas it was second in Pakistan. The fear also leads some avoidance behaviors among those who deal with public service during the pandemic. For instance, Mamun et al. reported Bangladeshi healthcare professionals were in excessive fear, which turned themselves to forbid treatment of a patient who was suspectedto be infected with the virus, even they also advised other patients for not getting touched with that patient. The treatment negligence and avoidance behaviors were so extreme that the patient had no option to commit suicide.34, 35 This may be an incidence herein the present case, although the press reports do not clearly indicate anything if the victims are refused for treatment by fearing them to be infected with the virus. However, being stubborn as of not getting admitted in the hospital probably makes the old‐man egotistic, which ultimately leads them to commit suicide.

Two new suicide causalities (i.e., disability and having sick family member) are identified in the present case. The incidence indicates that the old‐man is tensed at the decreased quality of life of their family members. The wife is recently treated by the support of his father‐in‐law, which reflects she is not completely recovered from the disease. Besides, the burden related to the crippled son may fuel on the old‐man's flam. Being intolerable to the family misery, he might try to escape themselves by taking their lives, and later on, committed himself suicide; although there is no clear evidence if the old‐man killed the wife and son. Hence, the present triadic suicide pact may be a mutual suicide instead of homicide‐suicide case. However, considering the homicide‐victim and preparators' relationship, homicide‐suicide is more common among the couples or person in a close relationship, which is also supported by the previous COVID‐19 suicide pact findings. For instance, out of a total eight suicidality pacts, six cases occurred in couple, whereas mother‐infant and mother‐son are the rest two cases. However, the present finding provides a new insight on triadic suicide pact victims' relationship (i.e., father‐mother‐son) with the probable mutual suicide‐pact incidence.

IMPLICATIONS FOR PSYCHIATRIC NURSING PRACTICE

The present triadic suicide pact is very uncommon case as far as reported in the COVID‐19 context. The previous all suicide pacts are reported of two decreased persons, whereas this is the first evidence providing three persons' decreasing. Besides, the suicide casualties leading the present unusual suicide pact are (i) financial distress, (ii) feeling burden of disability and sick people, and (iii) being stubborn as of not getting hospital treatment.

However, based on the present suicide pact causalities, some of the preventive approaches should be adopted for the vulnerable people. For instance, firstly, the economic wellbeing should be ensured for the unprivileged people, that may include enough reliefs to survive. Loans with no interest and optional moratorium on EMIs should be facilitated as best as possible. Besides, a moratorium up to the end of the pandemic for the previous loans should be granted (see for Bhuiyan et al ; and Mamun and Ullah for details). Second, the taking care of vulnerable cohorts, such as disable or sick people should not be avoided. There should be the government‐oriented social approaches for aiming to support the vulnerable cohorts. Third, the making ensure that the suspected people are not remaining untreated of COVID‐19. For this, uncountable cooperation of the healthcare professionals is warranted. For engaging them in the battle, dissemination of authentic, reliable, and updated COVID‐19 related information should be provided to reduce panic and fear.1, 3 Besides, the basic facilities while their family members or themselves being infected, should be provided to encourage the healthcare professionals (see Usman et al. for details). Finally, the implementation of common mental health supporting programs are highly appreciated for the general people (see Mamun and Griffiths for details).