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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 102-104

Can chronic heart disease lead to active suicidal ideation? – A case report of a planned suicide


Department of Forensic Medicine, Tomo Riba Institute of Health and Medical Sciences, Naharlagun, Arunachal Pradesh, India

Date of Submission04-Jun-2020
Date of Decision15-Jul-2020
Date of Acceptance10-Sep-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Samarendra Barman
Department of Forensic Medicine, Tomo Riba Institute of Health and Medical Sciences, Naharlagun - 791 110, Arunachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_30_20

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  Abstract 


The link between chronic illness and depression is complex but indisputable. Individuals with depression may resort to suicide to end their suffering, especially if they have an intractable and incurable illness. Evidence suggests that young people with chronic illness are more likely than older individuals to experience concomitant mental illnesses and thus have an increased risk of suicide attempts. Determined suicidal individuals may use either multiple, potentially fatal, methods in a single event or a single, excessively fatal method to ensure that they do not survive. This may happen in cases where an individual attempts suicide for the first time. In these circumstances, determining the cause of suicide is of paramount importance for future risk assessment and prevention. This report describes the case of a patient with known heart disease who self-inflicted multiple, sharp force injuries on his neck and wrists to end his life.

Keywords: Chronic illness, depression, heart disease, sharp force injuries, suicide


How to cite this article:
Barman S. Can chronic heart disease lead to active suicidal ideation? – A case report of a planned suicide. J Forensic Sci Med 2020;6:102-4

How to cite this URL:
Barman S. Can chronic heart disease lead to active suicidal ideation? – A case report of a planned suicide. J Forensic Sci Med [serial online] 2020 [cited 2020 Nov 24];6:102-4. Available from: https://www.jfsmonline.com/text.asp?2020/6/3/102/296570




  Introduction Top


Suicide is a major cause of death in India. The National Crime Record Bureau survey shows total number of suicides in India in 2015 was 133,623, i.e., 10.6/100,000 populations.[1] Poisoning, hanging, drowning are the leading methods of suicide in India. Suicide by hard and violent methods, for example, firearms or sharp weapons is infrequent.[2] Individuals with violent suicidal ideations are often more socially distant and psychiatrically ill, and have a shorter time between the decision and execution of suicide.[3] Suicidal risk increases to many fold when individuals with psychiatric conditions also suffer from physical illnesses, such as heart disease.[4]


  Case Report Top


On December 15, 2018, a 27-year-old male was found nearly dead lying prone on a pool of blood in the bathroom by his brother. The bathroom door had been bolted from the inside and had to be broken to gain access. He was rushed to a nearby hospital but could not be revived. It was presumed that he succumb to his injuries just before reaching the hospital.

The deceased's brother, married sister, uncle, a colleague, a close friend and the investigating officer were interviewed on separate occasions. Details regarding the incident, for example, description of the scene, method of death, deceased's behavior, social connections, interpersonal conflicts with other family members, and medical conditions were obtained.

The deceased was unmarried and worked as a medical representative. He lived with his financially well to do joint family. He was a soft-spoken introverted guy, and had few friends both in his personal and professional lives. He was not in a relationship with a member of the opposite sex. The deceased would often spend time alone at home and in the office. At home, he was distant with little to no interaction with other family members. He was previously diagnosed with valvular heart disease and was on maintenance medications. The patient had no history of drug or alcohol abuse or any psychological condition. There was no history of previous suicide attempts. However, his brother stated that, for several nights before the incident, the deceased would wake up in the middle of the night and lock himself inside the bathroom for several hours. There was no history of any family disputes. The deceased was right-handed and took his life using a razor blade. No suicide note was discovered at the crime scene.

On autopsy, the deceased was found to be thin built with a body length 168 cm and weight 53 kg. His clothing was in order. A scar from his previous open-heart surgery was observed on the anterior chest wall [Figure 1]. The primary fatal wound was an incision wound at the front of the neck [Figure 2]a and [Figure 2]b with clean-cut margins, a length of 25 cm, and a maximum breadth of 5 cm, and was deep up to the anterior surface of the trachea. This wound was associated with three hesitation cuts – two above the main wound and one below. These cuts were superficial and ran parallel to the main wound before trailing off toward the right side of the neck. The deceased also had a single incision wound on both wrists [Figure 3] and [Figure 4] that were bone-deep with exposed muscles and tendons. There were no hesitation cut marks on the wrists. A superficial, 6 cm long, tentative cut mark was observed running across the sagittal suture over the frontal region of the scalp before tailing toward the right side [Figure 5]. There was no evidence of defensive injuries or injuries on inaccessible parts of the body.
Figure 1: Old scar mark of previous heart surgery

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Figure 2: (a) Multiple sharp force injuries on the neck with hesitation marks (anterior view), (b) multiple sharp force injuries on the neck with hesitation marks (lateral view)

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Figure 3: Sharp force injury on the right wrist

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Figure 4: Sharp force injury on the left wrist

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Figure 5: Incised wound on the frontal region of the scalp

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On internal examination, his organs were found to be pale but healthy. An artificial mechanical valve was attached to the mitral valve area of the heart. The toxicology report on blood, organ, tissue, and gastric contents was negative.

The autopsy report concluded that death was due to hemorrhagic shock as a result of self-inflicted sharp force injuries on the neck and wrists.


  Discussion Top


Cases of sharp force injuries to the throat or wrist are often self-inflicted. In this case, meticulous questioning, circumstantial evidence, and autopsy findings pointed toward the suicidal nature of the injuries. According to the police report, suicide privacy was maintained at the scene as the room was bolted from the inside. The offending weapon was recovered in the bathroom near the right hand of the deceased. Forensic fingerprint analysis revealed a positive match between the fingerprints of the deceased and those present on the weapon. There were no signs of a struggle or drag marks to suggest homicide. There were no other scars on the body to suggest previous suicide attempts using sharp objects. Multiple hesitation cut marks near the main fatal wound indicate self-inflicted injury which is evident in this case also.[5],[6] The presence of a superficial tentative cut mark on the scalp of the deceased might be caused by his desire to experience pain and gather sufficient courage before inflicting wounds on vital body parts.

A suicidal individual's decision on what method to use is often guided by that method's likelihood of lethality. There are records of cases where individuals employed a single, excessively fatal method or multiple, potentially fatal methods in a single event with a progressive conversion from less lethal to more lethal methods. This so-called “overkill” is most likely associated with the pain, anguish, and frustration experienced by the victim and is usually favored by severely mentally ill patients, which is evident in this case.

Previous studies have found a strong link between heart disease and depression.[7] Having one of these diseases can increase the risk of developing the other.[8] Intractable heart disease can incapacitate an individual, decrease his self-esteem, and influence his outlook about the future.[9] Conversely, when people are anxious, stressed, or socially disconnected, they are less likely to follow healthy lifestyle practices which predisposes them to cardiovascular diseases. Although depression is an independent risk factor for the development of heart disease, it is still unclear whether it is associated with valvular heart disease.

In this case, the deceased underwent open-heart surgery in 2011 for valvular heart disease. Although he had no prior psychiatric consults or a history of depression, his relatives and colleagues mentioned that he became more socially disconnected after his diagnosis. At that time, they failed to perceive the severity of his mental condition. Furthermore, his mother, who suffered from major depression, killed herself by jumping off a cliff in 1993. It is well-known that a family history of depression and suicidal ideation can predispose succeeding generations to develop these as well.[10] Hence, it is likely that the diagnosis of valvular heart disease increased the likelihood of developing major depressive illness in the victim who was already at high risk.


  Conclusion Top


In investigating any alleged suicide case, meticulous postmortem examination and careful questioning of the relatives are essential as these provide valuable insight on the deceased's state of mind prior to attempting suicide. As depression is a major cause of suicidal ideation, determining its cause is important for successfully closing the investigation and for future risk assessment. This is a key preventive strategy which identifies high-risk members of the population and allows for timely medical intervention and psychological counseling.

Acknowledgment

The author is thankful to Professor Prateek Rastogi, Dr Ashim Misra and Dr Karma M Bhutia for their valuable suggestions and guidance.

Declaration of patient consent

All procedures undertaken in this study involving human body was in accordance with the ethical standards of the institutional and national research committee, and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent from the deceased's legal guardian had been obtained for publication of the information in journal under condition of keeping the identity of the victim anonymous.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Accidental Deaths and Suicides in India. National Crime Records Bureau. New Delhi: Government of India; 2015.  Back to cited text no. 1
    
2.
Kumar S, Rathore S. Trends in rates and methods of suicide in India. Egypt J Forensic Sci 2013;3:75-80.  Back to cited text no. 2
    
3.
Denning DG, Conwell Y, King D, Cox C. Method choice, intent, and gender in completed suicide. Suicide Life Threat Behav 2000;30:282-8.  Back to cited text no. 3
    
4.
Ferro MA, Rhodes AE, Kimber M, Duncan L, Boyle MH, Georgiades K, et al. Suicidal behaviour among adolescents and young adults with self-reported chronic illness. Can J Psychiatry 2017;62:845-53.  Back to cited text no. 4
    
5.
Solarino B, Buschmann CT, Tsokos M. Suicidal cut-throat and stab fatalities: Three case reports. Rom J Legal Med 2011;19:161-6.  Back to cited text no. 5
    
6.
Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force: Typical and atypical features. Int J Legal Med 2000;113:259-62.  Back to cited text no. 6
    
7.
Berge T, Finset A, Fjerstad E, Lise Sovde H, Hyldmo I, Lang N, et al. Screening for symptoms of depression associated with heart disease. Norwegian J Clin Nurs 2017; doi: 10.4220/Sykepleienf. 2017.60372en.   Back to cited text no. 7
    
8.
Lippi G, Montagnana M, Favaloro EJ, Franchini M. Mental depression and cardiovascular disease: A multifaceted, bidirectional association. Semin Thromb Hemost 2009;35:325-36.  Back to cited text no. 8
    
9.
Cohen M, Mansoor D, Langut H, Lorber A. Quality of life, depressed mood, and self-esteem in adolescents with heart disease. Psychosom Med 2007;69:313-8.  Back to cited text no. 9
    
10.
Currier D, Mann JJ. Stress, genes and the biology of suicidal behavior. Psychiatr Clin North Am 2008;31:247-69.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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