A suicide among our loved ones shocks us to the core and we begin to ask why. A suicide among the ‘rest’ we consider a mere statistic. We need to change. Each life is precious and we must all do our best to save lives says Dr. Lavina M. Noronha, Director Ave Maria Palliative Care centre Mangalore, and Member Core Committee, Suicide LifeLine, Mangalore (A unit of Susheg Charitable Trust) in this eye opening article that delves deep into this intensifying public health crisis.
According to World Health Organization (WHO), suicide is the 8th leading cause of death worldwide among persons 15-44 years and the 2nd leading cause of death next to accidents in the 10-24 age group. These figures do not include suicide attempts which are reported to be twenty times higher. In 2003, with a suicide rate of 10.6 per 1 lakh population, India ranked 43rd in the world (WHO, 2004) and, in the year 2008, of the 4 lakh people who committed suicide all over the world, 40% were from Japan, China and India.
Suicide rates have literally reached pandemic proportions which has been a source of concern for mental health professionals all over the country. There has been a three-fold increase in suicides from 40,000 deaths in 1980 to 1,22,000 in 2009 and the state of Karnataka has earned the notorious status of being among the top five states. The five states- West Bengal, Andhra Pradesh, Tamil Nadu, Karnataka and Maharashtra account for more than 50% of the suicidal deaths in the country. The States with low suicide rates are Manipur, Bihar and Nagaland (Injury and Violence in India: Facts and Figures, Dept. Of Epidemiology, NIMHANS/WHO). According to National Crime Records Bureau (NCRB) in the year 2012 Kerala and Tamil Nadu accounted for 12.5% of all suicides in India while Bihar had the lowest suicide rate of 0.8%.
Bengaluru has been known as the suicide capital of Karnataka with a suicide rate of 39 per one lakh population. In the year 2012 there were 19,120 suicides in India’s 53 largest cities. Chennai reported the highest number of suicides at 2,183 followed by Bengaluru at 1,989(NCRB). In fact, the alarming rise in people committing suicide has been observed not just in major cities, but also in smaller cities and rural areas. For example, Tiruppur district in Tamil Nadu which has a population of 1.2 million recorded a suicide rate of 32 per one lakh.
NCRB report of 2009 indicated that youth in the age group 15-29 years accounted for 34.5% of suicides followed by 34.2% suicides in 30-44 year olds. Many studies reiterate this trend of young adults being at the highest risk for suicides. NCRB also reported that two-thirds of the completed suicides were women.
Suicide and Women
India has historically glorified suicide by considering ‘Sati’,( where a woman sacrificed her life by jumping into the funeral pyre of her deceased husband) and ‘Jahuar’ (in which Rajput women of royalty killed themselves to avoid humiliation at the hands of Muslim invaders) as noble gestures. Even in recent years, the highest number of fire-related deaths was among women. Due to the stigma attached to suicidal deaths, many self-immolation or drowning cases are registered as accidents and not as suicides. According o NCRB (2008), 52.8% of those who killed themselves were women of which 18.6% were home makers. In 2012, two-thirds of those who completed suicides were women. Globally, women outnumber men in suicide attempts but completed suicides higher among men. Studies have found that young women who had a history of physical abuse or sexual abuse were at a higher risk for mental disorders and for suicide.
In the west, marriage has been considered to be a buffer against suicide. Studies have concluded that divorced, separated, widowed and single people are more likely to commit suicide compared to married people. However, it does not seem that marriage is a protective factor in developing countries like India. For example, in 2009, 70.4% of those who killed themselves were married and only 21.9% were unmarried which proves that the quality of marital relationship, emotional warmth, support from extended family and the ability to cope with stress were more important that marital status.
In the younger age groups, for every completed suicide there are 15 attempters. However this ratio is 1:7 in the elderly populations. Suicide attempt by far has been the best predictor of future suicide. Many studies show that 18% of those who committed suicide had a previous suicide attempt. Availability of lethal means of suicide and lack of emergency medical care has been cited as two reason for increased suicide mortality in India.
Mode of Suicide:
In developing countries firearms, car exhaust asphyxiation and poisoning are the top three methods used to commit suicide. In India, pesticide poisoning, hanging and self immolation seem to top the list. Jumping from buildings, consumption of pesticides, especially agricultural pesticides were the other means used for suicides and suicide attempts. In recent years, drug overdose especially of prescription medication use is also seen.
Suicide and the law
Until 2014, suicide was illegal in India and the survivor faced a jail term of up to one year and fine under section 309 of the Indian Penal Code. This had resulted in underreporting of suicides and also terming them as accidents which consequently deprived them of mental health attention. Suicide was decriminalized in 2016 and based on the recommendation of the Law Commission, the Govt of India introduced the mental health Care Bill.
What generally drives them to this fatal step?
In India, the causes of suicides in 2009 were family problems (23.7%), illness (21%), unemployment(1.9%), love affairs (2.9%), drug/alcohol abuse (2.3%), failure in examination (1.6%), bankruptcy or sudden change in economic status (2.5%), poverty (2.3%), and dowry disputes (2.3%). In 2014, 28,602 suicides were due to family problems and illness claimed 23,746 lives. Marital conflict, extra marital affairs, conflicts with in-laws have been commonly cited as causes of suicide in India. Chronic physical illness, financial loss, drug abuse, out-of-wedlock pregnancy have also been implicated in a number of suicides.
Cancer diagnosis and suicide are related. In a 2010 study, 18.5% cancer patients had expressed suicidal ideation. When people are given a death sentence of a terminal diagnosis and every option in finding a cure is exhausted, feelings of hopelessness and despair sometimes overwhelm. In addition, there is excruciating pain that most end-stage cancer sufferers have to endure, death seems a viable option.
29-year old Jeevan, who was suffering from multiple myeloma, advanced bone cancer knew very well that his days had been numbered. Due to his brittle bones, every move spelled fracture and he had to lie in bed. “Can you please give me a week’s supply of Morphine, sister? I am going to die you know it and I know it; why endure more pain? I just want to end it.” After adjustment of the dosage of pain medications and a little counselling, Jeevan was comfortable and the thought of putting an end to his life surfaced.
Presence of a psychiatric diagnosis has been a risk factor for suicide in India as in western countries. Major depressive disorder, bipolar affective disorder, schizophrenia and substance abuse were implicated in more than 18% of suicidal deaths. Additionally, many studies have found that personality disorders like borderline, schizoid, and antisocial were common in 50% of the suicide attempters. Lack of frustration tolerance, impulsivity, and emotional instability found in those diagnosed with personality disorders also puts them at risk for suicidal behaviours. Neurobiologists conclude that imbalance in neurochemicals like serotonin, dopamine, acetylcholine, GABA systems have been found in the brains of those who had committed suicide in autopsy studies.
NCRB reported that of all the suicides that took place in the farming communities two thirds were from Maharashtra, Karnataka, Andhra Pradesh, Madhya Pradesh and Chhattisgarh. Financial hardships, debt, weather anomalies and monetary compensation to the family following suicide have been listed as the reasons for high suicide rates.
The police personnel are not immune to suicide either. According to National Crime Records Bureau between 2003 and 2013, 122 cops had committed suicide. The most vulnerable age group is between 35 and 45 years. Insufficient salaries, long working hours, political pressure and harassment from senior officials were listed as the top four causes of suicides among the cops (NCRB). It is possible that easy access to weapons and skill is using the same is what makes cop suicides fool proof.
In this internet era, “cyber suicide” and suicide challenges are also a source of growing concern. There have been reports of youngsters falling prey to the so called ‘blue whale’ challenge in the last few months in India.
Gajalakshmi V and Peto, R implicate a complex array of factors in predisposing someone to suicide which range from poverty, low literacy level, unemployment, family violence, breakdown of the joint family system, unfulfilled romantic ideals, intergenerational 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.
What are some solutions?
• Timely professional support and intervention with those with suicidal tendencies will go a long way in deterring people from ending their lives prematurely. Early detection and adequate treatment of psychiatric problems like depression, anxiety, mood disorders, alcohol issues and drug abuse is of paramount importance.
• Since the greatest predictor of suicide is the presence of previous suicide attempt, every person who attempts suicide must receive mental health intervention and counselling. Most often, those who have failed in their attempts receive only medical attention in emergency, poison control or burn units purely geared towards somatic complications related to the suicide attempt.
• Training in Life skills could be a protective factor against suicide. Life skills education must be incorporated into the middle school and high school curriculum in order the strengthen the young minds psychologically.
• Setting up crisis help-lines/hotlines that operate 24X7 in every city will go a long way in assisting those in psychological distress.
• Restricting the availability of lethal means of suicide is one of the ways of reducing the rates of suicide. For example, in the United States of America, the States which have strict gun control laws have lower incidence of suicides. In a country like India, restriction of pesticides and over the counter medications may be helpful.
• Voluntary organizations, Non-Governmental Organizations can play an important role in influencing the govt for a policy change. The NGO Sneha found that suicide rates were highest in students who had failed in one subject. The Government introduced a new scheme wherein students were allowed to rewrite their examination within a month so that they could pursue higher studies without losing an academic year.
• Instead of waiting to fix what is broken, there is a need to be proactive in terms of promotion of mental health. Early identification of vulnerable or “at-risk” populations and timely interventions would definitely help prevent suicides. Using a multidisciplinary team- involving psychiatrists, general physicians, psychiatric nurses, psychiatric social workers, and non-governmental organizations (NGOs) it is possible to address the concerns and issues of persons at risk.
• Suicide awareness programmes starting at the middle school level aimed at sensitizing students, teachers, and parents will help detect children at risk. Early identification and intervention are possible when school personnel and parents are trained in picking up cues and warning signs.
• It is unfortunate that policy makers do not consider suicide as a public health issue. Putting in place a national policy on suicide prevention and implementing programmes and mental health interventions to this effect is the need of the hour. Due to the complexity of India’s demographics, culturally sensitive measures geared towards education, intervention and prevention are warranted.
About 800000 people commit suicide worldwide every year. That the suicide rate in Dakshina Kannada too is of great concern was confirmed by a survey on mental health and well-being of 1016 students between the ages of 14-25 years of Mangaluru by Mr. Roshan Monteiro, Sr. Marie Evelyn A.C., & Dr. Lavina Noronha conducted in March 2017 as a precursor to the setting up of the suicide Lifeline. Preliminary analysis of the results indicated that 4.52 percent of students surveyed have a history of past suicide attempt and a significant number (6.79%) of students have suicidal ideation.
Susheg Charitable Trust, in collaboration with St. Agnes College, St. Aloysius College, Roshini Nilaya and a number of concerned citizens have set out to do just that. Months of preparation culminated in the launch of this 24x7 emotional support service on October 1 2017 with the number 0824-2983444. The primary goal of the Suicide Lifeline is to prevent suicide and promote mental health and well-being.
Those in distress are encouraged to call the life line which will be available to distressed callers 24 hours a day 7 days a week. Professionally trained multilingual operators with excellent communication skills will be the frontline recipients of the distress calls. The call will immediately be transferred to a trained volunteer who will also be working in shifts 24X7 and who will then respond and assist the caller according to a protocol – Confidentiality and immediacy are the cornerstones of this protocol.
There will also be one back up clinician available for consultation and assistance to the volunteers. If lethality is assessed to be high, the volunteer will consult the back-up clinician, and the phone line coordinator who will make arrangements for immediate intervention, evacuation and/or emergency medical assistance. Police assistance will be sought by the clinical supervisor/operator if the situation demands.