Final journeys: exploring the realities of suicide tourism

Mental health issues in international travellers have received limited attention in the travel medicine literature.1 Awareness of suicide and discussions in relation to putative preventative strategies to reduce the risk of suicide have attained greater attention in popular media in the recent years. One aspect of suicide that is ethically and morally debated is suicide tourism, a practice whereby an individual travels to a particular destination with the intention of ending one’s life. Indeed, suicide in international travellers was previously noted to be the fourth most common cause of traveller mortality.2 While suicide tourism may be perceived more commonly as assisted suicide (physician-assisted suicide or euthanasia), the principal focus of this article addresses the less discussed practice of unassisted suicide. In this perspective on suicide tourism, we examine the following: (1) factors associated with an individual travelling who ends his/her life by suicide or by planned or unplanned means; (2) methods that are utilized by suicide tourists to end their life; (3) factors associated with destinations being regarded as potential `suicide hotspots’ (specific, accessible and usually public sites frequently used as locations for suicide and gain reputations as such)3; and (4) possible preventative measures associated with both the individual traveller and the chosen suicide destination. Assisted suicide is undertaken in a clinical setting by means of lethal medication administration and can be classified as either physician-assisted suicide or euthanasia, whereby the patient administers a lethal dose of medication to themselves under physician guidance. Switzerland is the destination most commonly associated with assisted suicide, with a total of 611 individuals travelling to Switzerland for this purpose between 2008 and 2012.4 The ethical and moral issues underpinning assisted suicide have been extensively discussed elsewhere.4 In relation to unassisted suicide, several factors have been associated with individuals ending or attempting to end their lives as suicide tourists. Suicide tourists can be divided into those individuals who travel with the principal aim of ending their life by suicide and individuals who, when travelling for other purposes (e.g. recreation or business), develop thoughts and plans to end their life by suicide. It is arguable that the term `suicide tourists’ does not clearly apply to the latter cohort; however, several factors are associated with an increased suicide risk in this group, and potential strategies to reduce risk in these tourists are worth considering. Risk factors for suicide in international travellers are influenced by both mental health-related and travel destination-related factors. Individuals with a previous history of attempted suicide, particularly if this occurred when travelling, those experiencing an acute episode (e.g. psychotic, manic or severe depressive episodes) of a major mental disorder (e.g. schizophrenia, bipolar disorder, recurrent depressive disorder) and treatment non-adherence with prescribed psychotropic medications when travelling or prior to travelling can increase the risk of psychopathology leading to suicide. Factors associated with travel, particularly in individuals with a pre-existing diagnosed mental disorder or in individuals with a history of previous suicide attempts, include insomnia, traumatic events during the travel period (e.g. a serious accident or exposure to distressing events abroad such as extreme poverty or child illness to which the tourist would not normally be exposed), stress associated with engaging in travel itself including acclimatizing to unfamiliar environments and cultures and misuse of alcohol or psycho-active substances increasing disinhibition or exacerbating psychotic, depressive or manic symptoms.5 Individuals who travel with a pre-planned rationale to end their lives by suicide may choose a location with a personal, cultural or religious symbolic motif and frequently correspond with locations associated with high rates of suicide denoted as `suicide hotspots’. Table 1 presents 12 such `suicide hotspots’, with characteristics of their locations and preventative strategies employed at these sites. Many such settings are associated with overt risk due to significant height (Golden Gate Bridge in San Francisco, the Cliffs of Moher in the Republic of Ireland and Niagara Falls on the Canadian–US border) or fast-moving trains (London Underground, São Paula metro).6 However, there are recognized suicide hotspots, which may hold a symbolic significance to certain individuals such as Aokigahara, also known as the `Suicide Forest’ near Mount Fuji in Japan7, or places of worship such as the Grand Mosque in Mecca.8 Examples of suicide `hotspots’ Examples of suicide `hotspots’ Some travel destinations can increase suicide risk given their inherent characteristics, including in individuals without a history of mental illness. For example, high-altitude travel is tentatively associated with several risk factors for both mental illness and suicide attempts including isolation, risk of interpersonal conflicts in a highly stressful environment, unpleasant physical environments, anxiety associated with reaching mountain summits and hypoxia, which may have an impact on serotonin synthesis.9 Travel to some tropical locations is similarly associated with an increased risk of suicide, due to challenging physical environments, malaria chemoprophylactic medications with psychiatric adverse effects (e.g. mefloquine) and hotter temperatures.10 Whether the seasonality observed in domestic suicides, which peak in late spring/early summer11, is replicated in international travellers deserves further research. Prevention of suicide is difficult, and perhaps especially so in `suicide tourists’, where many individuals travel with minimal, if any, contact with their treating primary care or specialist physician (e.g. psychiatrist or travel physician). In circumstances where an individual attends their treating clinician prior to travel, certain pre-travel enquiries may help to elucidate the risk of suicide. Such enquiries include, but are not limited to, ascertaining a rationale for the travel destination (particularly if a known suicide hotspot), the purchase of a one-way ticket, the presence of a travelling companion(s) and the tourists’ contemplation of potential difficulties regarding the trip and support measures considered for these, particularly if the location is associated with risk (e.g. high altitude, extreme heat and risk of violence).12 For individuals attending local mental health services, planning travel may substantially reduce the risk of a recurrence of psychiatric pathology and risk of suicide. For example, organizing or agreeing appropriate medication regimes (e.g. attainment of support for clozapine monitoring in foreign locations, treatment with depot antipsychotic medications prior to travel) and having contact details for a member of their treating community mental health team when travelling may provide the necessary support should difficulties arise. Advice in relation to appropriate planning of travel, awareness of support structures available prior to travelling and caution regarding alcohol and psycho-active substance use should be provided to all travellers. As detailed in Table 1, several strategies have been utilized in recent years, with variable success at reducing suicide rates in these locations, including erecting suicide barriers at suspension bridges, limiting access to train platforms, positioning security patrols at certain cliff tops and providing supportive messages for support services at high-risk locations.13 However, many of these strategies have a significant economic cost. Future directions regarding suicide prevention may entail geo-located alerts being sent to patrol staff when individuals at `suicide hotspots’ are acting unusually or spending extended periods of time in these locations. Suicide tourism can include unassisted suicide and involve an individual travelling to certain locations including `suicide hotspots’ for their cultural, religious or personal significance to end one’s life. Additionally, some individuals travelling for other purposes develop thoughts of ending their life by suicide. A large array of risk factors due to either the individual or the travel location can increase suicide risk and preventative measures to reduce these factors are required, albeit not always possible due to either a lack of contact with the individual prior to travel or the inherent geography of the chosen suicide destination. The traumatic death of an international tourist is associated with significant distress for the individual’s family, with repatriation of the deceased’s remains often complex, distressing and associated with legal complications for the individual’s family.14 A greater awareness of potential preventative measures by all physicians (primary care, travel physicians and psychiatrists) is advised with additional research evaluating preventative strategies focusing on both individual and location-specific factors merited. Conflict of interest: None declared.