Suicide is an important issue in the Indian context. More than one lakh (one hundred
thousand) lives are lost every year to suicide in our country. In the last two decades,
the suicide rate has increased from 7.9 to 10.3 per 100,000. There is a wide variation
in the suicide rates within the country. The southern states of Kerala, Karnataka,
Andhra Pradesh and Tamil Nadu have a suicide rate of > 15 while in the Northern States
of Punjab, Uttar Pradesh, Bihar and Jammu and Kashmir, the suicide rate is < 3. This
variable pattern has been stable for the last twenty years. Higher literacy, a better
reporting system, lower external aggression, higher socioeconomic status and higher
expectations are the possible explanations for the higher suicide rates in the southern
states.
The majority of suicides (37.8%) in India are by those below the age of 30 years.
The fact that 71% of suicides in India[1] are by persons below the age of 44 years
imposes a huge social, emotional and economic burden on our society. The near-equal
suicide rates of young men and women[2] and the consistently narrow male: female ratio
of 1.4: 1 denotes that more Indian women die by suicide than their Western counterparts.
Poisoning (36.6%), hanging (32.1%) and self-immolation (7.9%) were the common methods
used to commit suicide.[1] Two large epidemiological verbal autopsy studies in rural
Tamil Nadu reveal that the annual suicide rate is six to nine times the official rate.[3
4] If these figures are extrapolated, it suggests that there are at least half a million
suicides in India every year. It is estimated that one in 60 persons in our country
are affected by suicide. It includes both, those who have attempted suicide and those
who have been affected by the suicide of a close family or friend. Thus, suicide is
a major public and mental health problem, which demands urgent action.
Although suicide is a deeply personal and an individual act, suicidal behaviour is
determined by a number of individual and social factors. Ever since Esquirol wrote
that “All those who committed suicide are insane” and Durkheim proposed that suicide
was an outcome of social / societal situations, the debate of individual vulnerability
vs social stressors in the causation of suicide has divided our thoughts on suicide.
Suicide is best understood as a multidimensional, multifactorial malaise. Suicide
is perceived as a social problem in our country and hence, mental disorder is given
equal conceptual status with family conflicts, social maladjustment etc.[5] According
to the official data, the reason for suicide is not known for about 43% of suicides
while illness and family problems contribute to about 44% of suicides.
Divorce, dowry, love affairs, cancellation or the inability to get married (according
to the system of arranged marriages in India), illegitimate pregnancy, extra-marital
affairs and such conflicts relating to the issue of marriage, play a crucial role,
particularly in the suicide of women in India. A distressing feature is the frequent
occurrence of suicide pacts and family suicides, which are more due to social reasons
and can be viewed as a protest against archaic societal norms and expectations. In
a population-based study on domestic violence, it was found that 64% had a significant
correlation between domestic violence of women and suicidal ideation.[6] Domestic
violence was also found to be a major risk factor for suicide in a study in Bangalore.[7]
The population-based study has been done in various cities in India, however the Bangalore
study is the only psychological autopsy study that focused on completed suicide and
domestic violence. Poverty, unemployment, debts and educational problems are also
associated with suicide. The recent spate of farmers' suicide in India has raised
societal and governmental concern to address this growing tragedy.
MENTAL DISORDERS AND SUICIDE
Mental disorders occupy a premier position in the matrix of causation of suicide.
Majority of studies note that around 90% of those who die by suicide have a mental
disorder.[9] The number of published reports specifically studying the psychiatric
diagnoses of people who die by suicide has been relatively small (n = 15629). The
majority (82.2%) of such reports come from Europe and North America with a mere 1.3%
from developing countries.[8] Two case control studies using psychological autopsy
technique have been conducted in Chennai[10] and Bangalore[7] in India. Among those
who died by suicide, 88% in Chennai and 43% in Bangalore had a diagnosable mental
disorder. However, diagnostic evaluations were not done in the Bangalore study.
Countless experts have found that affective disorders are the most important diagnosis
related to suicide. In Chennai, 25% of completed suicides were found to be due to
mood disorders. However, the suicide rate increased to 35% when suicide cases with
adjustment disorder with depressed mood were also counted. The crucial and causal
role of depression in suicide has limited validity in India. Even those who were depressed,
were depressed for a short duration and had only mild to moderate symptomatology.
The majority of cases committed suicide during their very first episode of depression
and more than 60% of the depressive suicides had only mild to moderate depression.[10]
Although social drinking is not a way of life in India, alcoholism plays a significant
role in suicide in India. Alcohol dependence and abuse were found in 35% of suicides.
Around 30-50% of male suicides were under the influence of alcohol at the time of
suicide and many wives have been driven to suicide by their alcoholic husbands. Not
only were there a large number of alcoholic suicides but also many had come from alcoholic
families and started consumption of alcohol early in life and were heavily dependent.
The odds ratio (OR) for alcoholism was 8.25 (confidence interval: CI 2.9-3.2) in Chennai[10]
and 4.49 (CI 2.0-6.8) in Bangalore.[7] About 8% of suicides in India are committed
by persons suffering from schizophrenia. Srinivasan and Thara found that the male
to female ratio for schizophrenic suicides is more or less equal.[11] Although diagnosable
mental disorders were found in 88% of suicides in the Chennai study, only 10% had
ever seen a mental health professional. According to a government report, only 4.74%
of suicides in the country are due to mental disorders.
Personality disorder was found in 20% of completed suicides. The OR was 9.5 (CI 2.29-84.11).
Cluster B personality disorder was found in 12% of suicides. Comorbid diagnosis was
found only in 30% of suicides.[10] A history of previous suicide attempt(s) increases
risk of subsequent suicide. The OR for previous suicide attempts was 5.2 (CI 1.96-17.34)
in Chennai and 42.62 (5.78-313.88) in Bangalore. In the Bangalore study, family history
of completed suicides showed a greater risk of suicide (OR 7.69 CI 2.13-32.99) as
compared to the suicidal risk indicated by the family history of attempted suicides.
In the Chennai study, 12% had a family history of suicide (OR 1.33; CI 0.6-3.09) in
first-degree relatives and 18% in second-degree relatives (Fisher Exact Probability
test (FET) P = 0.001).
Clusters of suicides
The media sometimes gives intense publicity to “suicide clusters” - a series of suicides
that occur mainly among young people in a small area within a short period of time.
These have a contagious effect especially when they have been glamorized, provoking
imitation or “copycat suicides”. This phenomenon has been observed in India on many
occasions, especially after the death of a celebrity, most often a movie star or a
politician. The wide exposure given to these suicides by the media has led to suicides
in a similar manner. Copying methods shown in movies are also not uncommon. This is
a serious problem especially in India where film stars enjoy an iconic status and
wield enormous influence especially over the young who often look up to them as role
models.
The implementation of the recommendation of the Mandal Commission to reserve 27% of
the positions for employment in Government created unrest in the student community
and a student committed self-immolation in front of a group of people protesting against
such a reservation. This was sensationalized and widely publicized by the media. There
was a spate of student self-immolation (n = 31) around the country. These copycat
suicides caused public outcry and was considered one of the reasons for the fall of
the government in power at that time.[12]
Social change
The effects of modernization, specifically in India, have led to sweeping changes
in the socioeconomic, sociophilosophical and cultural arenas of people's lives, which
have greatly added to the stress in life, leading to substantially higher rates of
suicide.[13] In India, the high rate of suicide among young adults can be associated
with greater socioeconomic stressors that have followed the liberalization of the
economy and privatization leading to the loss of job security, huge disparities in
incomes and the inability to meet role obligations in the new socially changed environment.
The breakdown of the joint family system that had previously provided emotional support
and stability is also seen as an important causal factor in suicides in India.[14]
Religiosity
Religion acts as a protective factor both at the individual and societal levels. The
often-debated question is whether the social network offered by religion is protective
or whether it is the individual's faith. A study in Chennai found that the OR for
lack of belief in God was 6.8 (CI 2.88-19.69).[15] Those who committed suicide had
less belief in God, changed their religious affiliation and rarely visited places
of worship. Eleven per cent had lost their faith in the three months prior to suicide.
Gururaj et al. also found that lack of religious belief was a risk factor (OR 19.18,
CI 4.17-10.37).[7]
Legal issues
In India, attempted suicide is a punishable offence. Section 309 of the Indian Penal
Code states that “whoever attempts to commit suicide and does any act towards the
commission of such an offense shall be punished with simple imprisonment for a term
which may extend to one year or with a fine or with both”.
However, the aim of the law to prevent suicide by legal methods has proved to be counter-productive.
Emergency care to those who have attempted suicide is denied as many hospitals and
practitioners hesitate to provide the needed treatment fearful of legal hassles. The
actual data on attempted suicides becomes difficult to ascertain as many attempts
are described to be accidental to avoid entanglement with police and courts.
SUICIDE PREVENTION
The view that suicide cannot be prevented is commonly held even among health professionals.
Many beliefs may explain this negative attitude. Chief among these is that suicide
is a personal matter that should be left for the individual to decide. Another belief
is that suicide cannot be prevented because its major determinants are social and
environmental factors such as unemployment over which an individual has relatively
little control. However, for the overwhelming majority who engage in suicidal behaviour,
there is a probably an appropriate alternative resolution of the precipitating problems.
Suicide is often a permanent solution to a temporary problem.
Mrazek and Haggerty's[16] framework classified suicide prevention intervention as
universal, selective or indicated on the basis of how their target groups are defined.
Universal interventions target whole populations with the aim of favorably shifting
proximal or distal risk factors across the entire population. Selective interventions
target subgroups whose members are not yet manifesting suicidal behaviour but exhibit
risk factors that predispose them to do so in the future. Indicated interventions
are designed for people already beginning to exhibit suicidal thoughts or behaviour.
NONGOVERNMENTAL ORGANIZATIONS (NGOS)
India grapples with infectious diseases, malnutrition, infant and maternal mortality
and other major health problems and hence, suicide is accorded low priority in the
competition for meager resources. The mental health services are inadequate for the
needs of the country. For a population of over a billion, there are only about 3,500
psychiatrists. Rapid urbanization, industrialization and emerging family systems are
resulting in social upheaval and distress. The diminishing traditional support systems
leave people vulnerable to suicidal behavior. Hence, there is an emerging need for
external emotional support. The enormity of the problem combined with the paucity
of mental health service has led to the emergence of NGOs in the field of suicide
prevention.
The primary aim of these NGOs is to provide support to suicidal individuals by befriending
them. Often these centers function as an entry point for those needing professional
services. Apart from befriending suicidal individuals, the NGOs have also undertaken
education of gatekeepers, raising awareness in the public and media and some intervention
programmes. However, there are certain limitations in the activities of the NGOs.
There is a wide variability in the expertise of their volunteers and in the services
they provide. Quality control measures are inadequate and the majority of their endeavors
are not evaluated.[17]
NATIONAL PLAN
The World Health Organization's (WHO's) suicide prevention multisite intervention
study on suicidal behaviors (SUPRE-MISS), an intervention study, has revealed that
it is possible to reduce suicide mortality through brief, low-cost intervention in
developing countries.
There is an urgent need to develop a national plan for suicide prevention in India.
The priority areas are reducing the availability of and access to pesticide, reducing
alcohol availability and consumption, promoting responsible media reporting of suicide
and related issues, promoting and supporting NGOs, improving the capacity of primary
care workers and specialist mental health services and providing support to those
bereaved by suicide and training gatekeepers like teachers, police officers and practitioners
of alternative system of medicine and faith healers. Above all, decriminalising attempted
suicide is an urgent need if any suicide prevention strategy is to succeed in the
prevailing system in India.
10th September - World Suicide Prevention Day: The World Suicide Prevention Day was
formally announced on 10th September, 2003. Each year the International Association
for Suicide Prevention (IASP) in collaboration with WHO uses this day to call attention
to suicide as a leading cause of premature and preventable death. The theme for the
year 2007 is “Suicide Prevention—Across the Life Span”. It calls attention to the
fact that suicide occurs at all ages and that suicide prevention and intervention
strategies may be adapted to meet the needs of different age groups. It is hoped that
the theme will focus on vulnerable, ignored and stigmatized groups and also draw together
researchers, clinicians, societies, politicians, policy makers, volunteers and survivors
in a concerted action.
CONCLUSION
Suicide is a multifaceted problem and hence suicide prevention programmes should also
be multidimensional. Collaboration, coordination, cooperation and commitment are needed
to develop and implement a national plan, which is cost-effective, appropriate and
relevant to the needs of the community. In India, suicide prevention is more of a
social and public health objective than a traditional exercise in the mental health
sector. The time is ripe for mental health professionals to adopt proactive and leadership
roles in suicide prevention and save the lives of thousands of young Indians.