79 Prevention of metropolitan and railway suicide

Railway suicides account for a minority of <10 per cent of all suicides, although they are considered a major public health issue because of their tremendous consequences on functioning of the transportation system and their deteriorating impact on the mental health of staff and bystanders. Railway suicide is a particularly violent method, and case fatality is 90 per cent of all attempts. However, case fatality in metro systems of >60 per cent are rare. More men than women choose the track as a means of suicide with a trend towards a balanced distribution in metro systems. Victims are predominately young with a median age stratum in the range of 25–34 years. For men, a prevalence peak in April and a low in December has been observed. The weekly distribution shows a peak at the beginning of the week and a low on weekends. Railway suicide behaviour patterns include jumping, lying and wandering, some individuals present deviant behaviour prodromal to the attempt. Attractiveness of the method derives from high levels of opportunity and low levels of self-perceived costs.

Prevention may rely on a package of different structural and communicative tools. Inhibiting access to the track, by providing barriers at places of advanced risk and surveillance systems, are among structural means. Inhibiting media coverage and education of gatekeepers to increase awareness and skilfulness in contact with potentially vulnerable subjects on station platforms are among communicative tools. Railway suicide prevention is a realistic option: however, enhancement of research in this field is urgently needed.

The first steam engine—critical to the invention of the modern railroad and trains—dates back to the very beginning of the nineteenth century. In 1825, Locomotion No.1 was the first steam locomotive engine for railways that carried both goods and passengers on regular schedules in England. The success of this and other early local railway experiences influenced the development of railways elsewhere in Britain and abroad, leading to a first trunk line, opening in 1837, which connected the rapidly industrializing towns in England (for details see Evans and Gough 2003).

The Victorian railway rapidly acquired a double-edged perception in the view of the public: as ‘a vast, dramatic, and highly visible expression of technology triumphant’ but with the railway accident ‘as a uniquely sensational and public demonstration of the price which that triumph demanded—violence, destruction, terror and trauma’ (Harrington 2003, p. 203). In validation of Emile Durkheim's prediction stating that ‘the more the land is covered in railroads, the more general becomes the habit of seeking death by throwing one's self under a train’ (cited by Clarke 1994, p. 401), the development of the railroad network apparently reached a critical density in a short time to become a suicide mean: the first railway suicide to be officially recorded in the reports of the British Registrar General was a male subject in the year 1852 (Clarke 1994). More than 10 years later, in 1864, the first female suicide was recorded but female incidences in that year mounted quickly to five cases.

Since then, the railroad system, including metropolitan railways built under the ground in large cities, has become one of the most prominent transportation means in industrialized and emerging countries, carrying millions of passengers every day. Among critical incidences with involvement of damage to persons, suicide acts on the track nowadays hold the most prominent position (Rådbo et al. 2005). Each railway suicide is an individual tragedy, but is often also a cause of trauma amongst train drivers, employees, emergency personal and bystanders who witness the event or deal with the aftermath of the incident, including removing the body. The British Rail Safety and Standards Board estimates the total cost of suicides (trackside and at stations) to the industry in 2003 was more than £61 000 per suicide and accounted for several million pounds per year. This includes delay to trains, lost working time as a result of trauma suffered by staff and the equivalent value of trauma as a minor injury (Samaritans 2008).

Suicides on railway or subway tracks are classified in the mortality recording in accordance with the tenth revision of the International Classification of Diseases (ICD-10) category as ‘intentional self-harm by jumping or lying in front of a moving object’ (code X81). In principle, there are no basic differences in terms of suicidal behaviour between railway systems that serve as urban underground transportation (metro) and those who provide long-distance transportation, especially if the suicide attempt is accomplished within the railway station or along the platform. Nevertheless, several specific aspects have to be taken into consideration, which will be addressed in the following.

Railway suicide is considered as a particularly serious ‘hard’ suicide method, which does not allow ambivalent behaviour, and no control over the effects of the attempt is available once the suicidal act is initiated. In contrast to less violent suicide methods (e.g. self-poisoning), it is largely impossible to solicit help after initiating a suicide attempt on the track (Veress and Szabo 1980; Deisenhammer et al. 1997; Erazo et al. 2005).

However, epidemiological reports from different European countries elucidate a stable proportion of survivors on the overground railway track in the range between 6–13 per cent (Veress and Szabo 1980; Lindekilde and Wang 1985; Schmidtke 1994; Deisenhammer et al. 1997; Kerkhof 2003; Erazo et al. 2005). The case fatality of urban metro suicides is even lower. In the international comparison study of O'Donnell and Farmer (1992), case fatality rates of metro suicides greater than 60 per cent were rare. Case fatality in London was 55 per cent (O'Donnell and Farmer 1994) while in the Munich subway study, the overall case fatality rate reached 66 per cent (Ladwig and Baumert 2004). Survivors generally sustain severe injury, such as major head injuries or amputation of upper and lower extremities (Maclean et al. 2006; Guth et al. 2006). An evanescent minority receives little, if any, injury irrespective of the mode of the railway system (Guggenheim and Weisman 1972).

Epidemiological evidence concerning railway prevalence from populations in Europe and elsewhere are scarce. No data on this topic from the USA have been published so far. Limited and mostly outdated data from Hungary in the 1960s (Veress and Szabo 1980) pointed to a proportion of 2.7 per cent of all suicides, 3.1 per cent in Denmark (Lindekilde and Wang 1985), and 2.5 per cent in Brisbane, Australia (Emmerson and Cantor 1993). Schmidtke (1994) analysed 6090 cases of railway suicides in Germany in the study period of 1976–1984, revealing a proportion of 5.7 per cent in males and 4.2 per cent in females of all suicides. In Austria, Deisenhammer et al. (1997) analysed data from 552 cases in the years 1990–1994, and found a proportion of 5.7 per cent of all suicides. Van Houwelingen and Beersma (2001) analysing the study period of 1980 to 1994 reported an excess annual ratio of 10–14 per cent of railway-to-all-suicides for The Netherlands. Baumert et al. (2006) registered 8653 fatal railway suicide attempts over a 10-year observation period on the German railway net, which accounted for an average of 7.0 per cent of all suicides in the German population. This proportion, reflecting an average of three fatal railway suicide attempts per day, underscores that railway suicides are of major public concern. Around 80 per cent of 80–100 fatalities occurring on the Swedish railroad each year are considered suicides, which account for about 5 per cent of all suicides in Sweden (Rådbo et al. 2005).

International comparisons of prevalence figures of metro suicides are compromised by major differences in track length and number of passengers using the transportation system. Ladwig and Baumert (2004) assessed incidence of subway suicides relative to total mortality in 1999 (0.8 per cent) and its relative proportion to all suicides (4.1 per cent). In general, rates within cities appear to be independent of national rates of all suicide methods (Ranayake et al. 2007).

The British SOVRN Project (Abbott et al. 2003) observed a steady increase of suicide numbers from 1996–1997 (153 cases) to 2000–2001 (203 cases) on the British East Coast Main Line (ECML) connecting London with Scotland. During the 1990s, suicide deaths in Japan on just one rail network, operated by the East Japan Railway Company, increased from 81 per year at the start of the decade to 212 in 1999 (Fernandes 2003). Based on the grounds of 10-year representative central critical incidence registry (1991–2000) of all person accidents for the German railway system, Baumert et al. (2006) revealed an average annual percentage change of +1.8 (95 per cent CI 0.1 to 3.4) for subjects younger than 65 years. Contrary to a substantial decrease of all suicides over the same observation period, these findings translate into an approximately 20 per cent increase of railway suicides among this age group within this timeframe. In contrast, the incidence of fatal railway suicide attempts for subjects aged >65 years exhibited a favourable decrease, on average by −6.2 per cent per year. As for underground railways, O'Donnell and Farmer (1994) found an increase in mean annual numbers from 36.1 (1940–1949) to 94.1 (1980–1989). Ladwig and Baumert (2004) determined a stable incidence of subway suicides in Munich over a 20-year observation period, again despite a pronounced decline in total suicide mortality in the Munich population.

In the general population, substantially more men than women commit suicides with a male:female ratio of 3.2:1 within European countries (Schmidtke 1997). Erazo et al. (2004b) analysed 4003 fatal railway suicides over a 6-year period (1997–2002) and revealed a male:female ratio of 2.70:1 (p >0.0001), which was almost identical with the sex ratio of railway suicides revealed by Schmidtke (1994) more than a decade before. The excess railway suicide risk of males was also confirmed in the SOVRN Project (Abbott et al. 2003). Apparently, these figures mirror to some extent the general sex distribution of fatal suicides in Western societies. However, in contrast to these findings, the sex ratio of suicide victims in subway systems differs considerably. Here, Ladwig and Baumert (2004) observed a near to equal sex distribution, which is supported by findings from O'Donnell and Farmer (1992, 1994) and Sonneck et al. (1994). Interestingly, when analysing sex differences in fatal railway suicides (after stratifying by open track and station area), it appears that the striking male preponderance of railway suicides decreases from 1:2.85 to 1:2.46 (Erazo et al. 2005).

Elderly people are known to have the highest suicide risk (Conwell and Brent 1995). In contrast, O'Donnell and Farmer (1992) in their multinational approach and Sonneck et al. (1994) in their analysis of the Vienna subway system, report that the majority of metro suicides were committed by 20–29-year-olds. Furthermore, O'Donnell and Farmer (1994) identified a peak age group in the London study of 25–34 years, which was exactly the case in the Munich study (Ladwig and Baumert 2004). In the SOVRN Project (Abbott et al. 2003), suicide deaths in overground railway suicides peaked within the age band of 31–40 years; still, however, leaving over one quarter in the age stratum of >50 years.

Evidence from retrospective psychological autopsy studies confirmed a substantial degree of psychiatric morbidity in these patients. Mishara (1999) reanalysed patient records from 129 subjects, who committed suicide in the Montreal metro, and found 73 per cent had received inpatient psychiatric treatment (e.g. major depression, schizophrenia) at the time of death. The majority of the SOVRN patients suffered from signs of mental disorders, where many of these were present for over a year and some for more than a decade (Abbott et al. 2003, p. 51). Recently, van Houwelingen and Kerkhof (2008) revealed in a study of 57 train suicides in The Netherlands that 53 per cent received psychiatric care at the time of suicide, with 49 per cent of them being inpatients. Compared to general suicides, functional non-affective psychoses were over-represented. However, loneliness and sudden ending of an intimate relationship are also possible triggers (O'Donnell et al. 1996).

Seasonality is often seen in violent methods of deliberate self-harm (Maes et al. 1993; Hakko et al. 1998), especially in males (Meares et al. 1981; Micciolo et al. 1991), and was confirmed by railway track suicides revealing a prevalence peak in April and September followed by a low in December for men (Schmidtke et al. 1994; Deisenhammer et al. 1997; Erazo et al. 2004b). Concerning the weekly distribution, studies indicate a peak at the beginning of the week and a low on weekends (Angermeyer and Massing 1995; Schmidtke et al. 1994; Deisenhammer et al. 1997; van Houwelingen and Beersma 2001; Erazo et al. 2004b). Apparently for subjects at risk the beginning of the working week triggers feeling of personal failure and isolation.

As for circadian patterns, it is generally believed that suicides by all means are largely restricted to daytime (Barraclough 1976). In an analysis of 4003 railway suicide cases, Erazo et al. (2004b) looked two-dimensionally at clock time and time of the year, and found that peaks of the summer half year compared to those in the winter half year were clearly shifting to earlier and later clock times, respectively, corresponding to time of sunrise and sunset. In the male subgroup, a pronounced late evening peak after sunset was observed, whereas the female subgroup was characterized by a single morning peak and no evening peak. These findings support previous analyses of sex-specific interaction patterns of season and clock time of excess railway suicide risk (Schmidtke et al. 1994; van Houwelingen and Beersma 2001).

Guggenheim and Weisman (1972) were the first to describe four distinct patterns of suicidal behaviour on railway tracks. People who manifest these behaviours were termed jumpers, liers, touchers and wanderers. Accordingly, jumpers are those who leap or tumble directly in front of an oncoming train in the presence of passengers and other bystanders. Liers, seldom observed entering the pit, lie down across the tracks, generally in a prone position, and await the approach of a train or for the train to start. Decapitation, in the latter cases, is not a rare event. Touchers get into contact with the electrical sources by being killed through electrocution from a high-volt electrical conductor. Wanderers walk along the pit and are hit by the collision with the train in a walking position. Subway drivers often experience suicides by wanderers as particularly traumatogenic, because they may be exposed to a ‘final’ look from the suicidal person. Analysing suicide data for the German Railway Suicide Project, we additionally identified some rare cases of ‘chaired suicides’ (one incidence with wheelchair bound persons, several incidences with couples). In one case, a young mother had committed suicide on the track with two infants in her arms.

Relevant indicators of suicidal intent may be removal of shoes (O'Donnell et al. 1996), sudden dropping of belongings as the train approaches, possession of items that ordinarily would be left home (e.g. framed family pictures), erratic behaviour, possibly with indications of alcohol/drug intoxication, or conversely over-deliberate moves, faces hidden, avoidance of eye contact (Clarke and Poyner 1994; Gaylord and Lester 1994). Interestingly, in China, departing from ordinary dress to clothing in traditional ethic fashion alerts subway staff (Gaylord and Lester 1994).

Key factors presumed to influence railway track method choice remain largely speculative. It is also most likely that the different behavioural patterns (jumpers, liers, etc.) bear different choice-structuring properties. Intuitively, suicide death on the open track, accomplished by wanderers or liers and not witnessed by the public, point to a more thoughtful and hopeless ‘accounting balance’ consideration than is the case with a public death in the metro system with numerous bystanders. Accordingly, Guggenheim and Weisman (1972) learnt from jumper survivors to be well aware of the public nature of their attempt. They reported feeling ‘full of hate for everyone’ and wanting ‘to punish the whole world’.

Mishara (2007) interviewed Metro suicide attempters in a hospital emergency room and revealed as omnipresent belief that suicide on the track results in a certain and painless death. According to the SOVRN project, railway suiciders choose places near their vicinity—the ‘proximity factor’. The choice-structuring concept presented by Carke and Lester (1989) underscores, first of all, the complexity of the cognitive progression from ideation to action (Cantor and Baume 1998) and, by applying the concept on railway suicides, the fatal attractiveness of the method. As illustrated in Table 79.1, opportunities are high—no knowledge and skills are required to reliably produce the desired result—costs may in some cases be even of benefit (inconvenience to others), and among other issues, misperception (certainty of death) may be widespread.

Current knowledge of predictors of suicidal behaviour is largely unable to anticipate concrete individual acting (Mann et al. 2005). Nevertheless, primary and secondary suicide prevention for railway and metro systems is possible (O'Donnell et al. 1994; Mishara 2007), even though it should rely on the synergistic effect of a package of different structural and communicational means, each of which has a very limited individual influence.

Undoubtedly, ‘closing the access’ by inhibiting access to the track is by far the most effective method to prevent track-related suicide behaviour. However, extensive track length (e.g. currently more than 36,000 km in Germany) impedes complete fencing-in, and makes this approach financially untenable as is the case with installing secure barriers with automatic doors in metro systems (Mishara 2007). However, the French TGF (Train à Grande Vitesse) fast track railway system is hermetically sealed, thus successfully inhibiting suicides (personal communication).

A realistic alternative is to provide barriers at places of advanced risk—hotspots. Erazo et al. (2004a) identified clusters of increased suicide prevalence analysing 5731 railway suicides in Germany over a 5-year observation period. Of these, >75 per cent were in the proximity of psychiatric hospitals. It is most likely that specific approaches in these risk areas are more feasible and may substantially contribute to suicide prevention. However, with the passage of time new hotspots emerge, and a special task force and surveillance is needed as a continuous effort. More awareness is warranted when planning psychiatric hospitals in the proximity of railway lines. Planning and development of psychiatric facilities at a distance within a circle of about 2–3 miles from a railway line should be prevented by law. Visibility of railway tracks from psychiatric facilities should be strictly inhibited.

Further structural means refer to the installation of mirrors, flash lights, warning signals and television surveillance systems, mainly for platforms on railway and metro stations. Success in the east Japanese metro system, however, was not convincing (personal communication 2005). The same holds true for tools to mitigate the collision with the body (e.g. airbags, baskets) on the train. Drainage pits in metro systems, however, may be successful in decreasing mortality, due to a gap of space below the track, which prevents an attempter from making bodily contact with the train (Clarke and Poyner 1994; Coats and Walter 1999; Ratnayake et al. 2007).

Railway and metro suicides have often led to extensive media coverage in the past. Media effects on suicides have been convincingly evaluated in the pioneering work of Schmidke and Häffner (1988), which showed that a fictional television drama of the intentional death of a male student on the railway track led to a substantial increased in the subsequent incidences of railway suicides for male subjects in the same age group. Etzersdorfer and Sonnek (1998) showed by their experience in Vienna that it is possible to prevent imitative suicides by influencing mass media to limit reports and depictions of railway and metro suicides as much as possible.

Automatically transmitted announcements in trains, and on station platforms along trunk lines, may reach tens of thousands of passengers simultaneously. Thus, railway companies are advised to design announcement protocols that inform passengers and bystanders about a critical incident leading to a breakdown of railway traffic but avoid promotion and further implementation of railway suicide into the subconscious of the passengers (e.g., the German Railway Company now uses the wording ‘due to a medical rescue operation underway’ as standard operation procedure).

Poster campaigns addressing help for high-risk subjects may, under defined circumstances, be a prevention option: to avoid counterproductive promotion of suicidal ideation and fantasies dealing with the railway as a concrete suicide mean, nationwide poster campaigns in railway stations targeted at persons with increased suicidal risk should focus solely on addressing concrete help (telephone hotline, Samaritans) for those who feel hopeless and desperate. Under no circumstances should the campaign address concrete suicide means and it should also avoid mentioning any understanding of the motives of suicidal plans.

Once a psychiatric facility has been ‘infected’ by imitation behaviour with a high degree of virulence (Hazell 1993), going back to normal is unethical, and specific approaches to avoid in-hospital psychiatric suicides are warranted (Vogel et al. 2001).

Taking the German railway company as an example for a transportation system typical in highly developed countries, one will come across several tens of thousands of employers who are working on a daily schedule in the proximity of station platforms. Additionally, some thousands of persons are engaged as police force in this particular setting, as are Samaritans and railway chaplains. All these specialists may serve as ‘organizational gatekeepers whose contact with potentially vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment’ (Mann et al. 2005, p. 2067). Advanced vocational training in these subjects should include basic knowledge and skills in approaching persons at risk (see Table 79.2). Awareness programmes for railway staff members have led to successful primary interventions (for example in the Montreal metro system) resulting in a substantial number of people being intercepted' before a possible suicide attempt (Mishara 1999).

Suicides on the track of metro and railway systems are perceived as serious public health issues around the world. This has been proven in particular for metro suicides, including analyses from the Far East (Hong Kong, Tokio), Middle- (Mexico City) and South America (Caracas) and the USA (San Francisco) (see O'Donnell and Farmer 1992; Ratnayake et al. 2007). Nevertheless, data on prevalence, case fatality and patient characteristics remain scarce, especially for railway suicides (Mishara 2007). At present, most epidemiological findings are available from European countries (Austria, England, Germany, Sweden, The Netherlands). However, findings from India (Chowdhury et al. 2000) elucidate that railway suicides are also a reality in developing countries. Surprisingly, to date, no reports on railway suicides are available from Australia (except one report by Emmerson and Cantor 1993), USA, or Middle- and South America—although indirect evidence and anecdotal reports prove that railway track suicides occur in the USA (Guth et al. 2006) and in Brazil (Fernandes 2003).