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Review Article

Suicide: An Indian perspective

Rajiv Radhakrishnan, Chittaranjan Andrade1
Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA, 1Department of
Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

Abstract

Suicide is the third leading cause of death among young adults worldwide. There is a growing recognition that
prevention strategies need to be tailored to the region‑specific demographics of a country and to be implemented in a
culturally‑sensitive manner. This review explores the historical, epidemiological and demographic factors of suicide in
India and examines the strategies aimed at the prevention of suicide. There has been an increase in the rates of suicide
in India over the years, although trends of both increases and decline in suicide rates have been present. Distinct from
global demographic risk factors, In India, marital status is not necessarily protective and the female: male ratio in
the rate of suicide is higher. The motives and modes of suicide are also distinct from western countries. Preventive
strategies implemented at a community level and identifying vulnerable individuals maybe more effective than global
strategies.

Key words: Suicide, India, epidemiology, prevention

Introduction The rates of suicide have greatly increased among youth,

1
Suicide ‡ is among the top three causes of death among youth
worldwide. According to the WHO, every year, almost one
million people die from suicide and 20 times more people
attempt suicide; a global mortality rate of 16 per 100,000,
or one death every 40 seconds and one attempt every
3 seconds, on average. Suicide worldwide was estimated to
represent 1.8% of the total global burden of disease in 1998;
in 2020, this figure is projected to be 2.4% in countries with
market and former socialist economies. According to the
most recent World Health Organization (WHO) data that
was available as of 2011,[1] the rates of suicide range from
0.7/100,000 in the Maldives to 63.3/100,000 in Belarus. India
ranks 43rd in descending order of rates of suicide with a rate
of 10.6/100,000 reported in 2009 (WHO suicide rates).[1]
‡
The word “suicide” was first used by the English author, Sir
Thomas Browne in 1642 in his treatise “Religio Medici”. The word
originated from SUI (of oneself) and CAEDES (murder).
Address for correspondence: Dr. Rajiv Radhakrishnan,
Postdoctoral Associate, Department of Psychiatry, Yale
University School of Medicine, New Haven, Connecticut, USA.
E‑mail: rajivr79@yahoo.com
and youth are now the group at highest risk in one‑third
of the developed and developing countries. The emerging
phenomenon of “cyber‑suicide” in the internet era is a
further cause for concern;[2,3] also because the use of new
methods of suicide are associated with epidemic increases
in overall suicide rates.[4] Suicide is nevertheless a private
and personal act and a wide disparity exists in the rates of
suicide across different countries. A greater understanding
of region‑specific factors related to suicide would enable
prevention strategies to be more culturally sensitive. This
focus is also highlighted in the September 10, 2012 World
Suicide Prevention Day theme “Suicide Prevention across
the Globe: Strengthening Protective Factors and Instilling
Hope”.[5] This qualitative review explores the historical and
epidemiological aspects of suicide in with a special focus on
India. We hope that exposure of the problem will facilitate
primary prevention planning.
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How to cite this article: Radhakrishnan R, Andrade C. Suicide: DOI:

An Indian perspective. Indian J Psychiatry 2012;54:304-19. 10.4103/0019-5545.104793

304 Indian Journal of Psychiatry 54(4), Oct-Dec 2012

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Radhakrishnan and Andrade: Suicide in India
Historical Perspective
The story of suicide is probably as old as that of man himself.
Through the ages, suicide has variously been glorified,
romanticized, bemoaned, and even condemned. Be it the
tragic Greek heroes Aegeus, Lycurgus, Cato, Socrates, Zeno,
Domesthenes or Seneca; or the Roman figures Brutus,
Cassius, Mark Anthony or the Egyptian princess, Cleopatra;
or Samson, Saul, Abimelech and Achitophel of the Old
Testament; or the suicide bombers in the present world,
the universality of suicide transcends religion and culture.[6]
An understanding of suicide in the Indian context calls for
an appreciation of the literary, religious, and cultural ethos
of the subcontinent because tradition has rarely permeated
the lives of people for as long as it has in India. Ancient
Indian texts contain stories of valor in which suicide as a
means to avoid shame and disgrace was glorified. Suicide
has been mentioned in the great epics of Ramayana and
Mahabharata. When Lord Sri Ram died, there was an
epidemic of suicide in his kingdom, Ayodhya. The sage
Dadhichi sacrificed his life so that the Gods may use his
bones in the war against the demons. The Bhagavad Gita
condemns suicide for selfish reasons and posits that such
a death cannot have “shraddha’, the all‑important last
rites. Brahmanical view had held that those who attempt
suicide should fast for a stipulated period. Upanishads, the
Holy Scriptures, condemn suicide and state that ‘he who
takes his own life will enter the sunless areas covered by
impenetrable darkness after death’.
However, the Vedas permit suicide for religious reasons and
consider that the best sacrifice was that of one’s own life.
Suicide by starvation, also known as ‘sallekhana’, was linked
to the attainment of ‘moksha’ (liberation from the cycle of
life and death), and is still practiced to this day.[7] Sati, where
a woman immolated herself on the pyre of her husband
rather than live the life of a widow and Jahuar (Johar), in
which Rajput women killed themselves to avoid humiliation
at the hands of the invading Muslim armies, were practiced
until as recently as the early half of the 20th century; stray
cases continue to be reported*.[8,9]
2
Epidemiology
Suicide around the world
According to the World Health Organization (WHO), suicide
in 2004 was the 8th leading cause of potential years of life
lost worldwide among persons aged 15‑44 years.[10] Suicide
is the third leading cause of death among those aged
15‑44 years, and the second leading cause of death in the
10‑24 years age group in some countries; these figures do
not include suicide attempts which may be up to 20 times
*Vijayakumar, 2004[8] refer to Sati and Jahuar as “altruistic
suicides” while they may be classified more accurately as “fatalistic
suicides”.
Indian Journal of Psychiatry 54(4), Oct-Dec 2012
more frequent than completed suicide. The rate of suicide
is highest in Eastern European countries such as Belarus,
Estonia, Lithuania, and the Russian Federation. High rates
of suicide have also been reported in Sri Lanka, based on
data from the WHO Regional Office for South‑East Asia.[11]
There is an interesting speculation that latitude and the
daily amount of sunlight has an effect on rates of suicide.[12]
Rates of suicide are higher in northern parts of Japan and
in northern countries of Europe compared to the southern
countries. However, countries at about the same latitude,
such as the UK and Hungary, have substantially different
rates of suicide (21.6/100,000 and 6.9/100,000, respectively,
in 2009).[13] Low rates are found mainly in Latin America
(notably Colombia and Paraguay) and some countries in
Asia (eg., the Philippines and Thailand). Haiti reported no
suicides in 2003. Countries in other parts of Europe, North
America, and parts of Asia and the Pacific tend to fall in
between these extremes. Eighty‑six percent of all suicides
occurred in the low and middle‑income countries.[14]
A frequently cited cause for concern during recent decades is
the global trend for increasing rates of suicide.[15] According
to the WHO, suicide rates increased by 60% worldwide from
1950 to 1995.[16] The average rate of suicide increased from
10.1 per 100,000 in 1950 to 16 per 100,000 in 1995.[17] The
global male suicide rates and total suicide rates in 1995
were the highest rates recorded in the 1950‑1995 period
(24.7 and 16 per 100,000, respectively). Interestingly, the
global female suicide rate per 100,000 decreased from 8 in
1975‑1980 to 6.9 in 1995.[17] However, the increase in global
suicide rates must be interpreted with caution. The period
from 1950 to 1995 witnessed changes in world politics and
in reporting patterns which may have inflated the rates. For
instance, the period witnessed the end of the USSR (which
had an overall rate that was below the average) and its
former republics (some of whom have the highest rates in
the world) started to report individually, thus inflating the
global rate. Secondly, the figures for 1950 were based on
11 countries only while the estimates in 1995 were based
on 62 countries. It is likely that these 62 countries have
higher rates and are countries where suicide is a major
public health problem and were hence more likely to report
on suicide mortality.[18]
Suicide in India
The suicide rate in India is comparable to that of Australia
and the USA; and the increasing rates during recent decades
is consistent with the global trend. Data on suicide in India
are available from the National Crime Records Bureau (NCRB;
Ministry of Home Affairs). The suicide rates in India rose
from 6.3 per 100,000 in 1978 to 8.9 per 100,000 in 1990, an
increase of 41.3% during the decade from 1980 to 1990, and
a compound growth rate of 4.1% per year.[19] More recent
data, however, reveal a different picture. The rate of suicide
showed a declining trend from1999 to 2002 and a mixed
trend during 2003‑2006, followed by an increasing trend
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Radhakrishnan and Andrade: Suicide in India
from 2006 to 2010.[20] During 2009, the rate was 10.9 per
100,000 population.[21] This represented a 1.7% increase
in suicides since 2008.[22] In the most recent NCRB report
the rate in 2010 rose to 11.4 per 100,000 population; an
increase of 5.9% in the number of suicides.[20]
The NCRB data are based on police records. Sociocultural
factors undermine the veracity of these records. Suicide
attempt is a punishable offence under the Indian Penal Code
(IPC Section 309); this results in under‑reporting. Deaths in
rural areas are certified by village headmen (“panchyatdars”)
though all cases are investigated by the police. The process
of registering a death is particularly inefficient in rural
areas.[23] Eventually, only about 25% of deaths are registered
and only about 10% are medically certified.[24,25] Death by
suicide is frequently reported as due to illness or accident
to avoid police investigation. The families of suicide victims
usually do not want postmortems because of the fear of
mutilation of the body, the time‑consuming nature of the
process, and the stigma involved. Statistics derived from
police records hence under‑report suicides.
The suicide rates vary widely across the different states of
India, ranging from 0.5/100,000 in Nagaland to 45.9/100,000
in Sikkim against the national average of 11.4/100,000 in
2010.[20] Some studies have estimated the annual suicide
rate based on data from smaller samples and using different
methods, such as hospital‑based samples, longitudinal
cohort,[26] emergency service[27] and verbal autopsy[28‑32]
[Table 1]. Studies using verbal autopsies report that suicide
rates are 2‑3 times higher than those reported in other
studies.[28,31] The average annual suicide rate reported in these
studies range from 62 per 100,000[31] to about 95 per 100,000
for the general population[28] with age‑specific suicide rates
as high as 148/100,000 and 58/ 100,000 for young women
and men, respectively,[29] and 234/ 100,000 and 147/100,000
in elderly men and women, respectively.[30] This rate is about
9‑10 times the rate reported by NCRB. It is important to
remember that extrapolation of numbers based on small
samples are likely to overestimate the true rate because it
doesn’t factor in regional and age‑, gender‑specific variability
which is likely to be present and is also reflected in the NRCB
report. The true estimate is therefore likely to lie between
the NCRB estimate and that reported in these studies.
Demographics of suicide in India
Traditionally, in western literature risk factors associated
with suicide, including suicidal attempts ‑ include young age
(15‑24 years), female gender, low educational attainment,
unemployment, living alone, and history of socioeconomic
deprivation.[48] In this section, we examine the demographics
of suicide in India.
Age
Although suicide rates were commonly highest among
older adult males, rates among young people have been
306
increasing. Young adults are a particularly vulnerable group
and currently show the highest rates of suicide the world
over. Suicide is responsible for 6% of all deaths among
young people.[49] Developed countries show a second peak
of increased suicide rate in the elderly (above 60 years).
An Indian study showed that the suicide rate was highest in the
15‑29 years age group (38 per 100,000 population) followed
by the 30‑44 years group (34 per 100,000 population).
The rates of suicide was 18 per 100,000 in those aged
45‑59 years and 7 per 100,000 in those aged >60 years.[50]
Since these figures are calculated for the general population
and not the age‑specific “population of interest”, the higher
risk in youth may reflect a higher representation of youth
in the population.
The National Crime Records Bureau report of 2009 shows
a similar pattern.[21] Youth in the age group 15‑29 years
accounted for the largest proportion (34.5%) of suicides
followed by those in the age group 30‑44 years (34.2%).
Other studies in India also indicate that young adults are at
increased risk, with ages 20‑24 years followed by 25‑29 years
showing the highest rates of suicide in a psychological
autopsy study,[35] and the15‑39 age group identified as the
most vulnerable in another study.[51] Two‑thirds of women
who completed suicide were <25 years.[52,53]
This trend is also seen in attempted suicides. In one study,
the mean age of attempters was 25.3 years.[46] Suicidal
ideation was also more common in the 16‑45 years age
group in a study of suicidal ideators in a general hospital
setting.[54]
Adolescents and young adults
Youth is a period of heightened risk of suicide[55] and suicide
is a leading cause of death among young people in India.[29]
In a study which evaluated the cause of death among those
aged 10‑19 years, in a rural population of 108,000 in south
India, suicide accounted for about a quarter of all deaths
in males and between 50% and 75% of all deaths in females
aged 10‑19 years. The average suicide rate for girls was
148 per 100,000, and for boys, 58 per 100,000[29]
Among young people, suicidal behavior was found to be
associated with female gender, not attending school or
college, independent decision making, premarital sex,
physical abuse at home, lifetime experience of sexual
abuse, and probable common mental disorders.[56] Violence
and psychological distress were independently associated
with suicidal behavior. Factors associated with gender
disadvantage increased vulnerability, particularly in rural
women.[56]
Elderly
There is a global trend toward increased suicide in late
life, again mainly in men.[57,58] However, in a 5 year study
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Radhakrishnan and Andrade: Suicide in India

Table 1: Summary of selected studies on suicide and attempted suicide in India

Author and place Method Sample size Male: Female Age range (peak), Prevalence of axis I Suicide rates and
ratio marital status and other psychiatric illness commonest method
demographic factors
Rao VA. 1965 Hospital- 114 individuals 65:49 Age range of peak – Incidence of suicide in
Madurai, Tamil Nadu based study admitted with incidence- 10-40 years. Madurai- estimated at
using patient “attempted” suicide Single males> single 43/100,000 (from data
and family females among “attempters”).
interviews Commonest method:
Poisoning
Gajalakshmi et al., Population- Rural survey of 1.39:1 Peak incidence = – Average annual overall
2007[31] based, verbal 41,000 families; 15‑44yrs suicide rate = 62/100000
Rural Villupuram autopsy study verbal autopsy of population.(Men =
district, Tamil Nadu 38,836 deaths in 71/100000; Women =
1997-98 53/100000)
Commonest method:
Poisoning> hanging>
self-immolation
Saddichha et al., Emergency 1007 cases – – – Estimates of attempted
2010[33] service-based; of attempted suicides for 2008 =
Andhra Pradesh using Patient suicide between 6.4-7.6/1000 population
Care Record Jan‑Dec 2007 (Men = 3.2-3.8/1000
(PCR) population; women =
3.3-3.7/1000 population)
Commonest method:
Hanging and insecticide
poisoning (72%) (Men =
hanging and insecticide
poisoning; Women =
self-immolation and
hanging)
Chavan et al., 2008[34] Psychological 130 suicide 57.4% :42.6% Age range = 20-39 years 33.6% ( 48.5% –
Chandigarh autopsy. cases. Method of (1.35:1) (peak = 20-29 years). of whom sought
Community data collection: Majority of victims: treatment prior to act) Commonest method:
based Newspaper reports, high school educated Hanging (72.2%)>
police department, (32.6%), unemployed poisoning (15.8%)>
Office of the (55.4%), single (57.4%), self-immolation (5.9%)
Registrar of Births from urban background
and Deaths (70.2%)
Khan et al., 2005[35] Psychological 50 suicide cases. 58%:42% Age range = 15-35 years 24% sought –
Secunderabad, autopsy. Interview of relatives. (1.38:1) (peak 20-24 years). psychiatric treatment
Andhra Pradesh Hospital- Retrospective 52% unmarried, 72% prior to act Commonest method:
based diagnosis from urban Men: Hanging; Women:
medical records self-immolation.
Soman et al., 2009[32] Verbal 284 suicides among 1.7:1 (ranging Age range- <14->75 – 44.7/100,000 for males
Thiruvanathapuram, autopsy 4720 deaths from from 0.4:1 years; bimodal peaks at and 26.8/100,000 for
Kerala reported 1 July 2002 to in <14 yrs 15-35 yrs and 55-74 yrs females
by health 30 June 2007. age group to Commonest
workers. 4.5:1 in the method: Hanging>
Community 45-54 year age poisoing>drowning>self-
sample group) immolation = jumping in
front of a train
Kar, 2010[36] Hospital 149 Suicide 1: 1.1 in Age range: <19->60 yrs Psychiatric diagnosis –
Cuttack, Orissa based study attempters vs adults, 1: 3.4 (peak 20-40 years). in 80.6%
psychiatric ill in adolescents Married (59.1%), middle
(n = 40) and healthy socioeconomic status,
controls (n = 45) unemployed, rural
background (72.4%)
Sarkar et al., 2006[37] Hospital- 78 suicide attempters. 45:33 (1.36:1) Age range- 15-50 yrs; 56.4% –
Pune, Maharashtra based study Attempted to peak 21-30 years. Commonest method:
dichotomize Married>single in the Poisoning/drug
suicide attempters “failed suicide” group; overdose > self-inflicted
into categories of single> married in the wounds
“failed suicide” and “deliberate self-harm
“deliberate self-harm” group”
(Contd)

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Radhakrishnan and Andrade: Suicide in India

(Contd...)
Author and place Method Sample size Male: Female Age range (peak), Prevalence of axis I Suicide rates and
ratio marital status and other psychiatric illness commonest method
demographic factors
Behere et al., 2008[38] Psychological Farmers who – – – –
Wardha district, autopsy. Focus committed suicide
Maharashtra on farmer between January
suicides 2005 to March 2006
Das et al., 2008[39] Hospital- 166 cases of self- 53%:47% Age range: 12-76 yrs 52% (21.7% had -
Chandigarh based study. harm among 3092 (1.13:1) (peak 20-30 years). sought treatment prior
Psychiatry referral from 2000- Married (61%), middle to act)
referrals of 2005 SES (85%), Urban
“intentional background (53%)
self-harm”
Elangbam et al., Hospital- 200 cases of suicidal – Age range: 10->60yrs – –
2009[40] based study acts among 3953 (peak 20-35 yrs)
Imphal, Manipur emergency room
visits
Suresh Kumar, Hospital- 477 suicide Suicide Mean age of male – –
2004[41] based study attempters and attempters= attempters (44±16yrs)>
Kozhikode, Kerala 689 suicide victims 0.8:1 women (36±17.7yrs)
between Jan 2001- Suicide Mean age of male Among attempter:
Dec 2001 victims= 1.6:1 victims (41±17.1yrs) > Poisoning
women (29.76±12.05yrs). Commonest method:
In both groups majority Among victims:
were married, from rural Hanging
background, Hindu by
religion and educated
upto 10th std
Bhatia, 2000[42] Hospital- 260 suicidal ideators, Ideators = Age range of peak Among ideators: –
Delhi based study 58 attempters and 1.13:1 incidence for all 3 groups 44.1% had a
55 completers = 26-35 years. Majority in depressive disorder;
all 3 groups were married, 6.9% had a previous
had attained high-school attempt
education, and
Attempters = were employed/ Among ideators: Commonest method:
0.61:1 housewife 55.3% had Among attempter:
a depressive Poisoning>
disorder; 24.1%
had a previous attempt.
Completers = Among completers: Among completers:
1.12:1 18.2% had a previous Hanging> self-
attempt immolation
Jena et al., 2004[43] Review. 1205 adolescents Attempters: Majority: Hindu Risk factors for Life-time prevalence
Delhi Refers to aged 12-18 yrs Females> ideation/attempt: rates: Suicidal ideation =
Sidharata males Physical abuse by 21.7%, DSH = 18%,
et al., 2002 parent, suicide by Suicide attempt = 8%.
(unpublished friend, running away 1 year prevalence rates:
thesis data)- from home, feeling Suicidal ideation =
School based neglected 11.7%, DSH = 6.1%,
study Suicide attempt = 3.5%.
Narang et al., 2000[44] Hospital- 100 suicide 1.3:1 20-29yrs (41%)> <20yrs 57% had a psychiatric –
Ludhiana, Punjab based study attempters (32%). Urban, student/ disorder (majority: Commonest method:
housewife, low SES, mood disorder (35%) Poisoning
single males/ married
females
Sauvaget et al., Population- 132 000 participants – 40-60 yrs in those – Overall suicide rate =
2009[26] based 10 yr (≥35 yrs); 385 ≥35 yrs. Male, Hindu 39.3/100 000 person-
Thiruvananthapuram, longitudinal “registered” suicides by religion, alcohol use, years among adults 35-
Kerala study of a education level ≤ 7 yrs 90 years of age (men:
cohort 78/ 100000; women:
16.5/100000).
Commonest method:
Hanging>poisoning>
drowning
(Contd)

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Radhakrishnan and Andrade: Suicide in India

(Contd...)
Author and place Method Sample size Male: Female Age range (peak), Prevalence of axis I Suicide rates and
ratio marital status and other psychiatric illness commonest method
demographic factors
Sharma, 1998[45] Hospital- 75 cases of attempted 0.87:1 15-25 yrs (53.4%). Rural, 46.7% had a –
Shimla, based study suicide between unmarried, housewife/ psychiatric Commonest method:
Himachal Pradesh Jan 1996-June 1997 student diagnosis (most Poisoning
common- affective
disorder(21.4%))
Srivastava et al., Hospital- 137 consecutive 0.9:1 14-29 yrs (80%) 11.6% had a –
2004[46] based study cases of attempted Married, nuclear family, psychiatric disorder
Pondicherry suicide between uneducated, unemployed (most common: Commonest method:
July 1999- Oct 1999 alcohol dependence) Poisoning> hanging
Joseph et al., 2003[28] Population- 85 villages; 1:0.84 Peak age-specific suicide – Mean suicide rate for
Kaniyambadi, based, verbal population of rate in men and women: the 6 year period (1994-
Tamil Nadu autopsy study 108 873. Estimated 15-24 yrs and >65 yrs 1999) = 95.2/100 000
in 1999 suicide rates for the (range 83.7-106.3/100
period 1994-9 000)
Commonest method:
Poisoning (45%)>
hanging (41%)
Women: Drowning/ self-
immolation
Men: Poisoning/Hanging
Aaron et al., 2004[29] Population- Rural population of – Peak: 15-19 yrs for girls – Average age-specific
Kanyambadi, Vellore, based, verbal 108,000 in the age and boys suicide rate: Girls =
Tamil Nadu autopsy study group 10-19 yrs 148/100 000, Boys =
of suicides 58/100 000
from 1992- Commonest method:
2001 Hanging (44%)>
Poisoning (40%) > self-
immolation (9%)
Abraham et al., Population- Rural population of 1.52:1 Peak: 65-74 yrs – Average annual suicide
2005[30] based, verbal 108,873 in the age rate = 189/100 000
Kanyambadi, Vellore, autopsy study group >55 yrs Age-specific suicide
Tamil Nadu of suicides rate: Men = 234/ 100
from 1992- 000; Women = 147/100
2001 000)
Commonest method:
Hanging (52%)>
poisoning (39%)
Latha et al., 1996[47] Hospital- 73 consecutive 1.63:1 Peak: < 16-24 yrs (54%). 93% had a probable –
Manipal, Karnataka based study suicide attempters Unmarried, uneducated, psychiatric disagnosis Commonest method:
employed, from nuclear (most common: mood Poisoning
families disorder (64%)).
Previous attempt in
17%. Prior psychiatric
consultation in 10%

of 6312 suicide attempters, only 47 were above the age of
60 years.[59] The low prevalence of suicide among the elderly
in India may be because the aged are well‑integrated and
respected in the family; children take responsibility for their
care. Also, life expectancy in the elderly is lower in India
than elsewhere, contributing to the comparatively lower
suicide rate.[60]
The ratio of completed suicide to attempted suicide in
India is about 1:7 in the elderly, which is double the ratio
of 1:15 in lower age groups.[59] This may reflect a poorer
ability of the elderly to recover from the bodily insult of a
suicide attempt. Although studies from the west implicate
social isolation, as defined by ‘living along’ as a risk factor
for suicide among the elderly, an early study speculated
that for elderly in India ‘family and social integration’ were
the real determinants of risk, even if they were living by
themselves.[61] More recent studies from the west appear to
support this position.[62]
Gender
Globally, attempted suicide is commoner in women and
completed suicide is commoner in men.[63] In Chinese
women, however, the suicide rate is approximately twice
that of women elsewhere.[1,63] Men commonly use more
lethal modes and plan the act more meticulously to avoid

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Radhakrishnan and Andrade: Suicide in India
detection. In contrast, women commonly use less lethal
modes, and are more impulsive, less well planned, and
more likely to be found and rescued. The male:female
suicide ratio is 3.8, 3.9, 4.1, and 3.4 in Australia, Canada,
the United States, and the UK, respectively[64] and it is lower
in Asian countries.[65]
What are the data for India? Although some Indian studies
have found a higher incidence of suicide in men than in
women,[50] others have found the contrary.[52] The male:female
suicide ratio was 1.78 in India in 2008 and 2009. In children
up to age 14 years, the ratio was 1.04; that is, almost equal
between the sexes.[21] In young men and women in 1991‑1997,
the ratio was 1.3, contrasting with the male preponderance
in developed countries.[66] The reasons for greater female
suicide completion in India may be sociocultural. The
common practice of arranged marriages in India result in
social and family pressure for the woman to stay married
even in an abusive relationship; this may increase the risk of
suicide in women.[67] Also, stresses related to dowry demands
may drive young brides to suicide.[68]
And what of suicide attempters in India? Although
attempted suicide was as high as 1.2 times higher in women
relative to men in some studies[41] others studies showed
a male predominance, male: female ratio ranging from
1.13:1[39] to 1.63:1.[47] These differences may be reconciled
by an appreciation of social changes in India, with a shift
toward nuclear families and the cultural emphasis on the
male stereotype which the individual tries to fulfill in vain.
Marital status
In the West, marriage is generally protective against suicide;
this empirical regularity is referred to as the “coefficient
of preservation” based on Durkheim’s 1897 seminal
monograph Le Suicide.[69] Divorced, separated, widowed,
and single people are more likely to commit suicide than
married people. Persons living alone are at particular risk.[48]
This protective effect of marriage was seen more for men
than for women and rates of suicide decreased in order
from widowers to divorced, single, and married men. Young
widowers were at highest risk. Lower rates of suicide among
married compared to unmarried women may be explained
by sociological theories based on marital status integration
and social integration.[70]
Marriage is not a strong protective factor for suicide attempts
in developing countries.[71] In 2009, 70.4% of all suicide
victims in India were married and 21.9% were unmarried.
Divorcees and individuals who were separated accounted
for about 3.4%, while widows and widowers comprised
4.3% of the total suicide victims.[21] In individual studies,
some show higher attempted suicides among unmarried
persons[37,44,45,72] while others show a higher rate among
those who are married.[46,47] Among attempters, men were
more likely to be single and women, married.[73] In a general
310
hospital study, no suicide attempter was separated or living
alone. Those who were unmarried were living with their
extended families.[47] Widowed, separated and divorced
individuals were commoner among cases of completed
suicide relative to controls in a study of 100 suicide cases.[51]
The quality of marital relationship, emotional warmth,
extended family support, and ability to handle stresses
related to marriage and child rearing are more important
than marital status, per se, but these qualifiers of marital
status are difficult to study.
Education
Low intelligence results in a 2‑3‑fold increased risk of
suicide. Possible explanations are that persons with low
intelligence are less able to compete for jobs and therefore
acquire lower income and social status. They may also be less
efficient in coping with stress. Finally, neurodevelopmental
vulnerabilities may increase their risk of a psychiatric
disorder.[74]
Level of educational attainment is a surrogate marker of
intelligence, though drawing conclusions on this premise
is problematic when education is not universally available.
The NCRB data reveal that 25.3% of suicide victims were
educated up to primary level, 23.7% had a middle‑school
education, 21.4% were illiterate, and 3.1% were graduates
or postgraduates.[21] These percentages, however, may
reflect the proportion of persons with different educational
attainment in India.
In one study of attempted suicide in India, 55.5% were
uneducated.[46] In another study, 54% of suicide attempters
had received high school education or higher.[47] Women
attempting suicide tended to have a lower educational
status compared to men.[72] Again, it is hard to interpret
these percentages in the absence of information about the
educational attainment of the population from which the
samples originated.
Family structure
The sociological theory of suicide emphasizes social
integration, a theme reflected in John Donne’s “No Man is an
Island”. People who are well integrated with their families
and community have a good support system during crises,
protecting them against suicide. Risk factors related to the
family include parenting style, family history of mental illness
and suicide, and physical and sexual abuse in childhood.
“Affectionless control”, a parenting style characterized by
a combination of low levels of emotional warmth and high
levels of parental control or overprotection, is associated
with a three‑fold increase in the risk of suicidal behavior.[75]
Suicide attempters with a history of sexual or physical abuse
in childhood show more suicidal behavior and are at a
higher risk for mental disturbances in adulthood even after
controlling for other contributory factors.[76]
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Radhakrishnan and Andrade: Suicide in India
India has witnessed a change in family structure during
recent decades, with more people moving out of joint
and extended families into nuclear family structures.
The effect of this change on suicide rate has not been
systematically studied. Varying results in research may tap
a secular trend. The majority of suicide attempters were
from nuclear families,[46,47] possibly reflecting the role of
social integration, though an earlier study shows that more
suicide attempters come from joint families.[77] A study on
burns victims found that being in a joint family was a risk
factor for dowry deaths.[78] Another study found that family
and marital conflict was a major reason for suicide.[36]
Urban vs. rural residence
The suicide rate is generally reported to be higher in urban
areas because of a variety of stressors related to living and
working in cities, including overcrowding and social isolation.
In India, during the year 2000, though the suicide rate for the
country was 10.8, the rate in urban areas was slightly lower
at 9.94.[79] There has since been an increase in urban suicide
rates to 11.4% in 2005, around 13% in 2006 and 2007, and
12.1% to 12.5% in 2008 and 2009.[21] Studies in recent years
are consistent in this regard: suicide[35] and attempted suicide
were more common in persons living in urban areas.
Occupation
There is a fairly strong association between unemployment
rates and suicide, but the nature of this association is complex.
Unemployment may drive up the suicide risk through factors
such as poverty, social deprivation, domestic difficulties,
and hopelessness. Furthermore, persons with psychiatric
disorders are at higher risk of suicide and are also more likely
to be unemployed; this may be a double whammy. Adding
to the complexity is recent loss of employment vs long‑term
unemployment; the former is associated with greater risk.[80]
The association between unemployment and suicide may
also be more significant for young adults.[81] In India, in one
study of suicide attempters, 46% were unemployed.[46] In
another study, >50% of patients were employed, 12% were
unemployed and some were either students or housewives.[47]
The NCRB data shows that housewives account for 18.6% of
total persons committing suicides and for 52.8% of the total
female victims. Those involved in farming and agriculture
form the next largest group, comprising 11.9% of the total
victims followed by those working in the private sector
(7.8%) and unemployed (7.5%). and public sector (7.8% and
2.2%, respectively). Students accounted for 5.5% of total
suicides while unemployed persons accounted for 5.5% and
7.5%, respectively. Those employed in the public sector
(2.2% of total suicides) and government servants (1.3% of
total suicides) were the least represented group.[20]
Precipitating event
The relationship of suicide to negative life events,
stress, object loss, and negative interaction needs to be
Indian Journal of Psychiatry 54(4), Oct-Dec 2012
understood in the framework of a model of vulnerability,
support, coping, and problem‑solving. Rich and Bonner[82]
found in a stress‑vulnerability model that negative life
events and stress accounted for 30% of the variance in
suicidal ideation. Indian society, being sociocentric, lays
importance on interpersonal relationships. It is therefore
unsurprising that marital conflict is the commonest cause
of suicide among women, while interpersonal conflict is the
commonest cause among men.[20,52]
Other suicide triggers include physical illness, bankruptcy,
illicit relationships, and drug intoxication. An interesting
finding, rarely seen in the West, is the high rate of suicide
associated with sexual abuse and illegitimate pregnancy.[20]
This may be a reflection of cultural taboos related to sexuality
in India.
A similar trend is seen for attempted suicide with
interpersonal conflict, financial stressors, and educational
burden being the most common triggers.[35,45,46,83] Chronic
pain and illness is featured as a common reason in some
studies.[46]
Studies which measured stressful life events found that
approximately 90% of suicide attempters reported negative
life events[47] and about 35% experienced stressful life events
in the previous 6 months.[46] However, in the absence of a
control group, it is hard to interpret the significance of
life events. After all, everybody experiences stressful or
negative life events.
Mode of suicide
The difference between countries in methods employed for
suicide may reflect differences in socioeconomic factors,
availability of lethal means, and firearms legislation, rather
than differences in the nature of the behavior, per se.
Common methods used in developed countries include
firearms, car exhaust asphyxiation, and poisoning whereas
in developing countries, pesticide poisoning, hanging, and
self‑immolation lead the list.
In India, during 2009 consumption of a poison (33.6%),
hanging (31.5%), self immolation (9.2%), and drowning (6.1%)
were the commonest modes of suicide.[21] Jumping from
buildings accounted for 1.5%. This pattern is recapitulated
in the NCRB 2010 report.[20]
Studies show that consumption of pesticides, such as the
readily available agricultural pesticides in rural areas, is
the commonest means of suicide and attempted suicide in
India[45,46,52] and in rural areas of low income countries.[84]
Agricultural chemical poisoning has also been reported
in Japan,[85] Thailand,[86] Sri Lanka,[87] Bangladesh,[88] and
the USA.[89] Men are more likely to use organophosphate
poisons and women are more likely to use plant poisons.[72]
The use of plant poisons as a means of suicide/attempted
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Radhakrishnan and Andrade: Suicide in India
suicide is more common in India and south‑east Asia.[90] It is
however, interesting to note that the increased accessibility
to plant poisons over the internet has led to reports of
their use in other parts of the world as well.[91,92] The use
of aluminium phosphide, a fumigant used to protect grain
stores, is associated with a case fatality of >70% and is a
particular feature of self‑poisoning in northern India.[93]
Suicide by hanging is the next most frequent method in
India.[22,35,94] The profile of victims comprises married females
or unmarried males in the age group of 21‑30 years, faced
with stressors in the form of unemployment, harassment for
dowry, prolonged illness, failure in examinations, financial
duress, or interpersonal problems.[95] Drug overdose using
medically prescribed and non‑prescribed drugs is another
common though less frequent method.[96] Violent methods
such as drowning, jumping from a height, and strangulation
are less common.[47]
Self‑immolation accounts for <1% of suicides in western
studies[97] but has strong sociocultural motivations in
Indian culture, and accounts for a substantial proportion
of suicides. With the practice of Sati and Jauhar, in ancient
India, self‑immolation was seen as an escape from hardship
and humiliation. More recently, self‑immolation has been
employed in India as a means of protest against government
policy,[98] as by Buddhist monks in South Vietnam and
Sri Lanka. Indian women may be over‑represented in the
population of self‑immolators with domestic issues as a
trigger.[72,99]
Motives for Suicide
A truism in suicide literature is that “not all persons who
commit suicide want to die and not all persons who want
to die commit suicide”. The intentionality and lethality of
suicide are important dimensions which describe the motive
behind the act. Lethality is a function of the mode of suicide
and has already been examined in an earlier section. Motives
may go beyond Freud’s concept of the ‘wish to kill’, the ‘wish
to die’ and the ‘wish to be killed’, and beyond Durkhiem’s
sociological typology; and may be more complex than just
a cry for help. The motive for suicide may be as diverse as
a need for identification as in the case of ‘copy‑cat’ suicides
(also called the Werther effect) to delusional beliefs as in
the case of Klingsor syndrome (genital self‑mutilation based
on religious delusions).[100]
An Indian study of suicide attempters classified motivation
into ‘the wish for change’ and ‘the wish to die’ groups and
found that the former had low lethality, lack of planning
for their attempt, more likelihood of rescue and were
not intoxicated during the attempt. The latter group
utilized more drastic measures, such as hanging and was
more likely to have a psychiatric disorder with comorbid
alcoholism.[101]
312
In India, the top 10 causes or correlates of suicide in 2009
were family problems (23.7%), illness (21%) [including insanity/
mental illness (6.7%)], unemployment (1.9%), love affairs
(2.9%), drug abuse/addiction (2.3%), failure in examination
(1.6%), bankruptcy or sudden change in economic status
(2.5%), poverty (2.3%), and dowry dispute (2.3%).[21] The high
rates of suicide among persons with mental illness and
drug abuse/addiction, though not a measure of intent, are
of much concern. Many of the remaining causes [namely,
suspected/illicit relation, cancellation/nonsettlement of
marriage, not having children (barrenness/impotency),
death of a dear one, dowry dispute, divorce, ideological
causes/hero worship, illegitimate pregnancy, physical abuse
(rape, incest, etc.), poverty, professional/career problem][21]
reflect the unique social structure of our society and the
social pressures that individuals face.
Studies on suicide notes report that a last wish was
mentioned in 30%.[94] Mass suicides are seen as suicide
pacts in couples or families[20] rather than as part of
religious cults as in western societies. Suicide pacts are
rare, accounting for <1% of all suicides, and there is a
trend in western literature showing a decrease in rates
over the years.[102] Suicide pacts almost always involve
people well known to each other, mostly spouses, most
of them childless.[103] However, there is an emerging trend
for cyber‑based internet‑facilitated suicide pacts which
increasingly involve two or more strangers who meet on
the internet and share similar world views.[2] Such cases
have been reported in the press, but have not been studied
in a scientific manner.
Psychiatric diagnosis
Mental disorders (particularly depression and alcohol use
disorders) are a major risk factor for suicide in Europe and
North America; however, in Asian countries impulsiveness
plays an important role. It is often reported that rates of
psychiatric disorders are higher among suicide completers
in developed countries relative to developing countries,
though under‑diagnosis in developing countries is a
possible explanation.
Studies in India show varying results with rates of
psychiatric disorders ranging from 9.5 to 24.9%.[104,105] In
one psychological autopsy study, 24% of suicides had a
psychiatric diagnosis, namely major depressive disorder,
bipolar affective disorder, or schizophrenia; substance
abuse was prevalent in 18%.[35] In a study of attempted
suicide, 11.6% had a psychiatric diagnosis with alcohol
dependence followed by depression being the commonest
diagnoses; schizophrenia, conduct disorder, and personality
disorder comprised the rest.[46] In a psychological autopsy
of 100 consecutive suicides in a rural population, 37% had
a DSM‑III‑R psychiatric diagnosis; alcohol dependence
(16%) and adjustment disorders (15%) were the commonest
diagnoses, and schizophrenia, major depressive episode,
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Radhakrishnan and Andrade: Suicide in India
and dysthymia constituted a smaller proportion (2%
each).[106]
Rates of psychiatric diagnosis as high as 46.7%,[45] 59.7%,[54]
57%[107] and even 93%[47] have been described among suicide
attempters. Mood disorders, particularly depressive
disorders, were the most common diagnosis followed
by alcohol abuse.[47,107] Neurotic, stress‑related, and
somatoform disorders were diagnosed in 14.5%[108]
In a study of patients with major depressive disorder with
suicidal ideation, incidence of suicidal attempt was 16.6%,
all attempters were <30 years old.[73] Suicidal attempt has
also been found to be positively correlated with severity of
depression.[109]
Dysthymia underlying suicidal behavior is commoner in India
than in the West.[47,108] In a general hospital study on suicidal
ideation, psychiatrically ill patients were overrepresented:
59.74% had depression followed by substance abuse and
psychosis in 9.74% each. 9.09% were diagnosed with bipolar
disorder and 7.14% constituted a group with neurotic
disorders.[54]
In a study of 1560 patients with schizophrenia, the rate of
attempted suicide was 4.7%. These patients did not differ
in illness duration from patients with depression who had
attempted suicide.[110]
Personality disorders
Multiple suicide attempts of low intentionality and lethality
are typically associated with maladaptive coping and
impulsivity in personality disorders. The rate of personality
disorders among those who attempt suicide in India ranges
from 7 to 50% in various studies.[47,108,110] The most common
diagnoses were schizoid, borderline, and antisocial
personality disorders.[110] In a study of personality disorder
among first attempters, the most common diagnoses were
anankastic and histrionic personality disorder.[108] In a 16‑PF
study of personality, self‑immolators were found to lack
ego strength, lack frustration tolerance, be emotionally less
stable, and be impulsive.[111] The association of impulsivity
and marital discord among self‑immolators has been
frequently reported in Indian[99] and other Asian studies.[112]
Physical illness
Chronic physical illness, abnormal vaginal discharge, and
tobacco use are risk factors for common mental disorders
among women in India.[113] A similar pattern is seen among
suicide attempters. About one‑fifth were found to have a
physical illness in one study with dysmenorrhoea being
the commonest ailment, followed by peptic ulcer disease;
hypertension, bronchial asthma and arthritis comprised the
remaining.[46] Pain in the abdominal and pelvic regions has
been reported more frequently among attempters.[46,114] This
finding was also reported in Hispanics[115] and Americans.[116]
Indian Journal of Psychiatry 54(4), Oct-Dec 2012
Other Risk Factors
In one study, depression and suicidal tendency were
associated with early parental deprivation, recent
bereavement, and family history of suicidal behavior.[117] In
another study, suicidal attempt was positively correlated
with severity of depression, male sex, being married,
employed, and <35 years of age.[109]
Alcoholism is another risk factor with both high rates
of suicide among alcoholics and high proportion of
alcoholics among suicide attempters (Agarwal et al.1996).
The risk of suicide is higher with early onset of alcohol
use, dependence pattern of use, family history of alcohol
dependence and depression, and comorbid antisocial
personality disorder.[118] Spouses of alcoholics are also at
increased risk of attempted suicide.[105,119] Determinants of
suicidal attempts in this subpopulation include financial
difficulties, marital discord, delusional jealousy, and suicidal
ideation expressed by the alcohol abuser. Of significance is
the emotional reaction of women in response to suspicion
of their fidelity, reflecting the value Indian culture imposes
on chastity.[120]
Predicting suicide
In a 10‑year prospective study of patients admitted
with suicidal ideation, Beck et al. found that only the
Hopelessness Scale and pessimism items on the Beck
Depressive Inventory predicted suicides. A score of 10
or more on the Hopelessness Scale correctly identified
91% of eventual suicides.[121] Hopelessness has been
found to have a positive correlation with degree of
suicidal intent.[122] 85% of children and adolescents in the
12‑19 years age group had expressed suicidal ideation
prior to the event.[123]
Scales used to identify suicidal risk include SAD PERSONS
scale, Beck Suicidal Intent Scale and the Suicidal Intent
Questionnaire (SIQ) validated in the Indian setting.[124] The
SIQ consists of a 10‑item questionnaire which is scored as
0, 1 or 2. The scale was initially piloted in 40 patients with
suicidal ideas and 40 controls, and subsequently tested
in a clinical sample (n=278) consisting of patients with
schizophrenia, bipolar disorder and “neurosis”. The scale
identified suicidal ideation in about 35% of this sample. In
a more recent study of communication of suicidal intent
among suicide attempters, Srivastava et al.[109] reported
that the majority of the sample (73.3%) communicated
suicidal intent using the SIQ. The scores on the SIQ showed
a low positive correlation with the Hamilton Depression
scale.[109]
Attempted suicide is of particular interest as it has been
found to be one of the predictors of future suicide.[125] This
fact is reiterated in studies which show that about 18% of
suicide victims had a previous suicide attempt.[42]
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Attempters vs. completers
Are persons who attempt suicide different from those who
succeed? An Indian study which compared these two groups
found more similarities than differences. Both groups
consisted of predominantly middle aged, unemployed,
married males and housewives, with high school education
and from rural background. The study concluded that
attempters with high intent/lethality and completers were
overlapping populations.[41] These findings are unlike the
younger age for attempters and higher age for completers
reported in western studies.[126]
The significant risk factors for fatal suicide includes presence
of previous suicidal attempt, interpersonal conflicts and
marital disharmony, alcoholism, presence of a mental
illness, sudden economic bankruptcy, domestic violence,
and unemployment.[67] Individuals completing suicides did
not have a positive outlook toward life, problem‑solving
approaches, and coping skills.
In an analysis of suicide attempters which distinguished
between those who had intended to die but accidentally
survived (failed suicide group) and those who had not
intended to die (deliberate self‑harm group), Sarkar et al.
found that, in the former, the attempts were planned,
intentionality and lethality were high, and most attempted
to conceal the act. The latter comprised adolescents and
young adults who were unmarried and had emotionally
unstable and/or histrionic personality traits. The attempts
in this group were impulsive, of low intentionality and
lethality, and most sought help after the attempt.[37]
Locations of suicide
The location of suicide offer clues to the individual’s
psychological state and to the intentionality of suicide.
Few studies reported this detail. In one study, home
was the most common place for committing suicide.[94]
Approximately a third of males preferred sites outside their
homes, especially hotel rooms, river beds, and the work
place. Most males who consumed an insecticide or resorted
to self‑immolation did so at home.[127] In another study,
indoor incidence was almost double the outdoor incidence,
mostly in rainy season, and almost equally during day and
night.[83] A negligible proportion of women chose a site
outside their homes, possibly reflecting the sociocultural
traditions that restrict the movement of women outside the
household.[127‑129]
Special populations
Cancer
Cancer was found to be related to 0.6% of all suicides in
2010.[20] In a study of terminally ill cancer patients, 18.5%
expressed suicidal ideation.[130] The rates of depression
among patients with cancer range from 16.7[130] to 34.4%.[131]
Depression, hopelessness and poorly controlled pain are
significant predictors of suicide[132] whereas spiritual coping
314
is associated with a better quality of life.[133] The particular
challenges in reducing the risk of suicide among patients
with cancer relate to the stigma of cancer and suicide, the
fear of criticism at harboring suicidal thoughts, the lack
of awareness of the diagnosis of cancer or what it means,
cultural taboos and degree of family support.
Epilepsy
Psychiatric morbidity is known to be higher among patients
with epilepsy relative to the general population, with rates
of suicide being five times higher.[134] In a hospital‑based
study, the rate of attempted suicide was 16% among
epileptics with 88% of patients having overdosed themselves
with antiepileptic drugs.[135]
Farmer suicides
Farmer suicides are a particular concern in the India,
although this phenomenon has been reported in England
and Wales as well.[136] In India, 182,936 farmers were
recorded to have committed suicide between 1997 and
2007.[137] The actual numbers may be larger, partly because
the NCRB defines ‘farmers’ as men (but not women) who
work in agriculture. About two‑thirds of these suicides were
in 5 of the 28 states and 7 union territories: Maharashtra,
Karnataka, Andhra Pradesh, Madhya Pradesh and Chattisgarh
account for about a third of the country’s population but
two‑thirds of farmer suicides. Factors contributing to the
high rate of suicide in this vulnerable population include
economic adversity, exclusive dependence on rainfall for
agriculture, and possibly monetary compensation to the
family following suicide.[38]
Neurobiology
Studies on the neurobiology of suicide have implicated
dysfunction of serotonin, dopamine, acetylcholine,
adrenaline, noradrenaline, opioid, GABA, and glutamate
systems. Abnormalities have been reported in the
hypothalamic‑pituitary‑adrenal axis, lipid metabolism,
polyamines, growth factors, and astrocytes and other
glial cell.[138] An Indian study reported low levels of CSF
5-HIAA in a subgroup of patients with depression.[139] This
finding was also obtained in patients with schizophrenia
and nondepressed, nonpsychotic persons who attempted
suicide.[140] The low CSF 5‑HIAA levels may be a marker
of violent suicide attempts.[141] In another study, very
low levels of melatonin were found to correlate with
hopelessness and could hence constitute a predictor of
suicide.[142]
There is some literature that lipid‑lowering agents may
increase deaths due to suicide or violence, presumably via
increased insulin secretion and low serotonin turnover.[143,144]
Suicide attempters were found to have lower total serum
cholesterol levels compared to controls in one Indian
study.[144]
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Role of the media
The role of the media is becoming increasingly relevant. The
media and internet have been identified as playing a crucial
role in the dispersion of information about novel suicide
methods.[145] A case in point is the trend of suicide epidemics
in South‑East Asia, namely the epidemics of charcoal burning
in Hong Kong (1998‑2002) and self‑poisoning with seeds
of the yellow oleander tree in Northern Sri Lanka (1980s
to mid 1990s).[84,145‑147] These two methods were initially
rarely observed within national suicide statistics. However,
extensive media reporting of a few cases was blamed for
the subsequent increase in popularity of these methods.
In Vienna, media guidelines for the responsible
reporting of suicides were introduced in 1987, banning
newspapers from reporting the method of suicides.[148]
It was hypothesized that the 80% reduction in the rates
of subway suicides observed in the subsequent 6 months
was due to the introduction of these guidelines. A more
recent study using interrupted time series analysis has
confirmed these findings and the authors believed that
the effects were due to changes in the quality and quantity
of reporting.[149]
The media can also have a positive influence. The ‘Papageno’
protective effect of media reporting describes how articles
on individuals who adopted coping strategies other than
suicidal behavior in adverse circumstances, were negatively
associated with suicide.[150] The media can also be a source
of information about where to seek help and advice.
In an interesting study, Ramdas et al.,[151] evaluated the
effectiveness of a one‑day workshop wherein journalists
and mental health professionals devised a guideline aimed
at responsible reporting of suicide by the media, paying
specific attention to avoid normalizing, idealizing, or
sensationalizing suicide, and encouraging readers to seek
help themselves or refer those in need. The quality of media
reports that appeared in a leading newspaper were assessed
at 1 year, 2 years and 6 years after the workshop. Although
the study found a non‑significant improvement in reporting
standards, newspaper reports continued to normalize/glorify
suicides and report suicide as the only method of coping.
Prevention
Suicide is an important, largely preventable public health
problem. The problem is however a difficult one; as aptly
expressed by Gajalakshmi et al as “a complex array of factors
such as poverty, low literacy level, unemployment, family
violence, breakdown of the joint family system, unfulfilled
romantic ideals, inter‑generational conflicts, loss of job or
loved one, failure of crops, growing costs of cultivation,
huge debt burden, unhappy marriages, harassment by
in‑laws and husbands, dowry disputes, depression, chronic
physical illness, alcoholism/drug addiction, and easy access
to means of suicide.”[31]
Indian Journal of Psychiatry 54(4), Oct-Dec 2012
In 2000, the WHO launched the multisite intervention
study on suicidal behaviors (SUPRE‑MISS) which aimed to
increase knowledge about suicidal behaviors and about
the effectiveness of interventions for suicide attempters in
culturally diverse places around the world.
Early detection and adequate treatment of a primary
psychiatric disorder is of paramount importance.
In psychiatrically ill subjects, lithium,[152‑154]
clozapine. [155‑157]
olanzapine,[158]
antidepressants,[159] and
behavioral interventions such as dialectical behavior therapy,
DBT[160] have been shown to have antisuicidal effects.
Since the greatest predictor of completed suicide is the
presence of a previous suicide attempt, interventions aimed
at suicide attempters may be the most effective in reducing
suicide rates. Vijayakumar et al., 2011[161] examined the
efficacy of brief intervention and regular contact in a
randomized controlled trial in suicide attempters and
found that it did reduce rates of completed suicide over an
18‑month period. Importantly however, the care received
by the treatment‑as‑usual arm in this study was below
desirable standards because it was limited to the acute
management of the somatic sequelae of the suicide attempt
and did not include psychiatric or psychological assessment
or treatment.
In a psychological autopsy, 24% of suicide completers had
consulted a psychiatrist/ physician before the event and
family of the victim were aware of their suicidal intent
in 68% of cases.[35] This finding is similar to data from the
west, where two‑third visited their general practitioners in
the month prior to death and 40% in the week before.[162]
This calls for adequate training of general practitioners in
detection and referral of patients with common mental
disorders, which may result in a significant decline in suicide
rates.[163] This may also have to be culturally sensitive; the
higher rate of somatic symptoms, rather than cognitive
symptoms, among depressed patients in the Indian setting,
is a case in point.[164]
The early identification and treatment of vulnerable
populations with risk factors for suicide across the life-
span is another strategy. Given the strong link between
negative life-events early in childhood and suicide risk, it is
important to identify populations that have been exposed
to traumatic childhood experiences, such as sexual/physical
abuse and parental domestic violence. The identification of
such individuals requires a multidisciplinary approach with
active participation from teachers and school authorities,
health professionals and the legal system. Primary
prevention strategies include promoting positive health
and instilling adaptive coping stategies among children;
improving awareness among parents, teachers and
healthcare professionals regarding child-rearing practices
and early intervention for maldaptive coping styles. At the
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Radhakrishnan and Andrade: Suicide in India
community level, the establishment of social programs such
as child and family support programs and programs aimed
at achieving gender and socio-economic equality maybe
prove useful.[165]
The need for a strategy which will raise awareness and
help make suicide prevention a national priority has long
been recognized.[166] Such a national strategy will need a
comprehensive approach that encompasses the promotion,
coordination, and support of activities to be implemented
across the country at national, regional, and local levels.
The program would need to be tailored for populations at
risk. For example, prevention programs aimed at children
and young adults would have to address issues related
to gender inequality, physical/sexual abuse, violence
and mental illness.[56] Strategies with empirical evidence
in western literature such as the Universal, Selective,
Indicated (USI) model,[167] ‘gatekeeper training’[168] and
outpatient follow‑up and emergency outreach[169] may also
be relevant to India. The USI model outlines ‘universal’
preventive strategies for the population as a whole (eg.,
restricted access to lethal means), ‘selective’ strategies
targeting at‑risk individuals (eg. psychiatrically ill, homeless,
socially‑excluded groups) and ‘indicated prevention’
strategies targeting suicide attempters (eg. outpatient
contact and emergency outreach). Gatekeeper training
focuses on skill development to enable community members
such as teachers, coaches and others in the community to
identify signs of depression and suicide‑related behaviors
among youth. It encourages individuals to maintain a high
index of suspicion and to inquire directly about distress,
persuade suicidal individuals to accept help, and serve as a
link for local referrals. Such approaches would also require
a multidisciplinary team approach involving psychiatrists,
general physicians, psychiatric nurses, psychiatric social
workers, and non‑governmental organizations (NGOs).
The role of the media is becoming increasingly relevant.
A delicate balance needs to be maintained between press
freedom and responsibility of the press to minimize the
harm to vulnerable individuals. The role of advocacy and
legislature cannot be over‑emphasized. Laws restricting
availability of lethal agents such as firearms have been
advocated by the WHO. NGOs can play an important role
in advocacy as exemplified by the proactive stance taken
by the NGO Sneha which found that the suicide rate was
highest among students who had failed in one subject.
Subsequently, the government introduced a new scheme in
2002 wherein students who fail in one subject can rewrite
their examination within a month and can pursue their
further studies without losing an academic year.[170]
The task of suicide prevention is daunting. Although suicide
attempters are at increased risk of completed suicide, about
10% of attempters persistently deny suicidal intent. This group
may continue to be vulnerable. Though restricting availability
316
of lethal means appears to be a possible solution,[171] an
early study in India in West Bengal, where legislation was
introduced to restrict sale of a pesticide, found no reduction
in the overall suicide rate, but merely a change in the modes
of suicide.[53] The solutions to suicide prevention may prove
to be more complex than the problem of suicide itself.
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Source of Support: Nil, Conflict of Interest: None declared

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