Special Feature: Suicide in India, a Social Evil, Let’s Pledge for its Prevention

Never let a stumble in your road be the end of your journey”

According to the World Health Organization (WHO) data in 2017, India accounts for 17 percent of the total deaths due to suicide occurring across the world, even though India makes up a mere 18 percent of the world population. Because of such a high propensity of suicide in India, it isn’t a surprise why India is also infamous as the ‘suicide capital’ of the Asian subcontinent.

Among these deaths, a staggering 35 percentage of suicides are committed by adolescents and young adults. In 2016 the total number of suicides in India had increased to 230,314. Suicide was the most common cause of death in both the age groups of 15–29 years and 15–39 years, the most productive of the population. The adolescent population has fallen prey to this ‘social evil’, primarily in the industrial and urbanized cities of south India (like Bengaluru, Chennai, Cochin) and the agriculture-oriented states in the east (like Tripura, West Bengal, Assam). Suicide among women is substantially higher in the north-eastern states and the northern states of Kashmir and Haryana.

Though, suicide is a deeply personal and individual act, however, it is incensed by innumerable social factors as well. It is best understood as a multidimensional malaise which is considered as a social problem in our country which can have its roots in societal and environmental situations like family conflicts, social maladjustment, discrimination, physical or psychological abuse etc.

Suicide is never a decision taken in the spur of a moment. It is a result of a pervasive battle fought with the unfavorable circumstances in one’s life. Often urges or desire to end one’s life manifests themselves as talking about wanting to die, showing a sense of hopelessness, drafting a plan or looking for ways to end their lives, seemingly complaining about having emotional and physical pain, dramatic changes in mood, bidding adieu to friends and family. Identifying these indicators is the stepping-stone for helping someone with suicidal tendencies. While this may seem like a basic step, this is where one needs to devote more effort and time as some people might not be so overt about their plans to end their lives. In such cases one may give subtle hints and cues like withdrawal from friends, minimal social interaction and lack of interest in once pleasurable activities or increased proclivity to engage in risky behaviors.

Perspectives from India

The Mental Health Care Bill (MHCB) passed in 2017 has taken a commendable decision of decriminalizing suicide, hence making it safer to seek help in such predicaments. However, India still has miles to go in terms of tackling this grave issue. It lacks the proper resources and has a paucity of trained medical staff to fight suicidality and also the suicide-survivors. Legislation often stays confined to paper and the implementation is the real challenge. Immense guilt, shame and embarrassment often follows with a failed suicide attempt, further increasing the risk, which needs to be dealt sensitively. Isolation, loneliness, drug abuse, mental illness and stigma are all perpetuating factors for this social evil.

Majority of studies note that around 90% of those who commits suicide have a mental disorder. Suicidal behaviors are interwoven in various social and psychological factors. It is seen that a major chunk of completed suicides were found to be due to depression, anxiety and stress. In one study in 2017, Vijaykumar noted that a majority of cases committed suicide during their very first episode of depression and more than 60 percent of the depressive suicides had only mild to moderate depression. The ironic part is that it is often under-detected due to lack of awareness or diagnostic overlooking. Vijaykumar has also drawn a connection between alcoholism and suicides. Although social drinking is not a way of regular life in India, alcoholism plays a significant role in suicide in India. Alcohol dependence and abuse were found in 35 percent of suicides in the National Mental Health Survey (NMHS). Around two-thirds of male suicides was under the influence of alcohol or other drugs at the time of the act and many wives have been driven to desperate decisions by substance abuse in the families. Not only are there a large number of suicides due to drug-intoxication but also genetic influence of alcohol abuse in the family influences the early consumption of alcohol with severe dependence and abuse, which is again an important factor for suicidal risk.

These facts and figures make it extremely important to understand suicide through the social purview and as a public health concern rather than just looking at it as an individual choice. The individual can be seen as an important factor in the various nexuses we form as a community. The life of every individual is of utmost importance and worth living. The moralistic and existential angle here is the individual autonomy to end one’s life, but it is important to understand here is that most decisions to do so are desperate, marked by obligation and lack of support, even while asking for the same.

Prevention is the ONLY way

Talking about prevention, suicide is among the top five preventable causes of death globally, according to the World Health Organization. WHO’s suicide prevention multisite intervention study on suicidal behaviors (SUPRE-MISS), has revealed that it is possible to reduce suicide mortality through brief, low-cost intervention in developing countries. In fact, in the World Mental Health Day, 10th October last year, the WHO had set the theme to “Working Together to Prevent Suicide”, which is indeed an excellent step to take this fight forward. The same theme is resonated even on this World Suicide Prevention Day (10th September). Awareness, sensitization at the grass-root levels and eradicating stigma are the need of the hour.

It is vital we recognize that suicide is not a problem with defined cures and remedies. There is a wide array of techniques that can be explored with while dealing with this silent ‘social evil.’ One such technique that has been gaining grounds lately is the Gatekeepers training which is a ‘suicide prevention strategy’ recommended by the WHO. The aim of this training is to equip individuals with the necessary skills to be a first responder for someone who is going through emotional distress and is potentially suicidal. In a nation, where thousands of youth are lost due to this cause annually, there is a pressing need for a large-scale mental health interventions that address mental health issues amongst students. To tackle this, various non-government organizations are following a three-pronged approach of “Advocacy”, “Action” and “Research” in their work with suicide prevention and suicide-survivors. The QPR model (Question-Persuade, Refer) for gatekeeper training is followed to train youngsters to effectively carry out their roles of primary care givers. Every single person can be a potential caregiver to save lives, irrespective of their qualifications, attributes and professional positions.

Vitally, every attempt of suicide need not be due to a mental disorder but various other personal, social, occupational or environmental factors.

The youth serves as the flag bearers in the mental health movement of India. Organizing mental health trainings at educational institutes have been only half as challenging, as students lobby and colonize to have greater institutional support for mental health awareness. They often make networks across various platforms to arrange for trainings. As the Millennials give way to the Gen-Z over time, technology has been a way of life for most. Besides the innumerable health hazards brought about by the unhealthy use of technology, there are millions of ways in which online forums can be bring about awareness and spread the word to the masses to fight stigma. Various online helplines like Takehelp.in, yourdost.com, etc. can be accessed all through for reaching out in need of help, as and when needed. Even if not direct suicide intervention, these helplines help in listening to the distress and providing the right guidance to the individual seeking help. Besides, there are also national and state level suicide helplines, which are operative twenty-four hours.

Various NGOs are doing exemplary work and carrying out interventions along the lines of suicide prevention like organizing various activities that provide insights and cognizance into this issue, thus equipping people with the necessary skills and knowledge needed for suicide prevention. More public-private collaboration is needed in this field. The policymakers with all their good intentions are keener to work in the lines of suicide-prevention. We need to give them proper insights and research data to supplement the cause.

Way Forward

With the pandemic scare on the rise for the last eight months and an unprecedented toll on all our lives, psychological burden is anticipated as much as the public health consequences. Besides fear, uncertainty, loneliness and panic, various mental disorders like depression, anxiety, insomnia and post-traumatic stress are also rising based on research all around the world. Added to that is the burden of misinformation by the excessive social media use during the months of lockdown. Though systematic data on the effect of COVID-19 situation on suicide is yet to be published, theoretically the risk is higher, especially in the post-pandemic aftermath when the socio-economic and emotional burden will rise further. For every death due to suicide, 8-10 more people might have unsuccessfully attempted it, which leads to further social hassles, guilt, shame and difficulty in reintegrating into the usual life.

Suicide awareness and prevention need to be facilitated, but not romanticized or idealized as often done in popular media. Reporting of suicides, whether that of farmers or celebrities, need to be sensitive and humane. A ‘blood-hunt’ for publicity made retrospectively into the lives of anyone who ended it prematurely following an event, will do nothing to bring it back. It needs to be looked at through a broader social perspective, rather than just shunned away as a malady residing within an individual. Suicide survivors need acceptance and help instead of criticism and shame. The resources, both social and monetary need to be mobilized and community support needs to be garnered by making them aware of the implications of suicide on the entire society and not just the individual. It is our collective responsibility, as a human society, to fight it. Suicide can BE PREVENTED with timely action and awareness by all of us, and that’s the BOTTOM LINE.

Even if we save one life at a time, IT’S WORTH IT!

Author Dr. Debanjan Banerjee M.D. Psychiatry (NIMHANS)
FIPS, FIASP, FIAGMH,Life Fellow, World Association of Mental Health.

He is associated with National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore as D.M. Geriatric Psychiatry Senior Resident,