India is facing a ‘suicide’ crisis. As per World Health Organization (WHO) data in 2017, India contributes to almost 17 per cent of the total deaths in the world due to suicide, though itself accounting for only 18 per cent of the world population. This is alarming, and aptly India has been termed as the ‘suicide-capital’ of Asia. What is most concerning amongst the figures is that 35 per cent of the total suicide burden is borne by the adolescents and young adults (15-35 years of age) and the number of deaths annually in this age-group is maximally due to suicide.
The adolescent population is more affected in the industrial cities of south India (like Bengaluru, Chennai, Cochin) and the agriculture-predominant states of the east (like Tripura, West Bengal, Assam). Suicide among women is much higher in the north-eastern states and the northern states of Kashmir and Haryana, where many premature deaths are not even accounted for officially due to personal or political interests. It is clear, thus, that with women and young adults being most affected by this ‘social-evil’, suicide is bound to affect the social and mental health standards of India.
There is extensive literature on the problems related to suicide, data from various research projects, and methods of suicide prevention. In fact, the Mental Health Care Bill (MHCB) passed in 2017 does an amazing job of de-criminalizing suicide. The most important question is, ‘how much can be prevented’? An excellent review of suicide-prevention strategies by Menon and his team in 2018 shows that up to 50 per cent of all suicides can be prevented, irrespective of the cause.
One in three of such persons visits at least one physician (of any specialty)/counsellor within the last two weeks of carrying out a suicide attempt. Also, data from the suicide prevention research done by the National Institute of Mental Health (NIMH) in 2015-16 shows that at least half of the people contemplating suicide or self-harm would try to divulge it directly or indirectly to someone soon before performing the act as a ‘last desperate method to protect their life’. The ironic part is that this early sign is often missed, leading to millions of preventable deaths around us.
The scope and nature of prevention
Suicide is among the top five preventable causes of death worldwide, according to the WHO. Also, around 40 per cent of attempt it survive the first attempt, and these survivors are often at a greater risk of attempting suicide again due to guilt, frustration, shame and persistence of the psychological distress. The predominant causes of suicide in India are domestic or political unrest, mental illness (most commonly depression, schizophrenia, borderline personality disorder), and ‘farmer’s suicide’ (which is a different phenomenon and is beyond the scope of this article).
The act of suicide does not happen one fine day; the human mind is complex and the age-old myth that the ‘weak’, the ‘cowardly and the ‘uneducated’ are the ones who commit suicide is redundant. In fact, Indian population data from 2012 shows that 80 per cent of those who attempted suicide had at least secondary-level education. These are the usual processes: Passive death wish (“It would be so good if I didn’t have to live”); active death wish (“What if I die today, and things will be so better to deal with!”); suicidal wish (the first idea of killing oneself, visualizing one’s death and the aftermath); suicidal intent (making active plans and scenarios to carry out the suicidal act); suicide attempt (the final act of trying to take one’s own life by any means).
What is interesting to note is that at every stage the human consciousness, with an inborn instinct to live, tries to protect the individual, and he/she might just find windows of right opportunities to share this distress/plan/dilemma that he/she is going through. At that stage, the first person to suspect the death wish or intent should react with supervision, informing the person’s primary care-givers and, most importantly, seeking medical/psychiatric help.
Research shows that the major barriers to seeking help even while debating suicide are stigma, dilemma, guilt and lack of audience. It is as simple as “You do not ask, and they shall not tell!” In this context, ‘gatekeeper training’ is an important concept used in the national suicide prevention strategies of our National Mental Health Policy (NMHP). It basically means that irrespective of the profession, if anyone suspects the intention of a person to cause any form of self-harm, it should be aggressively prevented and brought to the notice of his/her family and the health care system.
These are certain important risk factors/warning signs to be kept in mind: History of previous suicide-attempts, Isolation/divorced, male gener, any form of drug abuse, has a mental illness (example: depression, anxiety), history of domestic violence/sufferer of political or familial unrest, recent incident of any form of abuse/trauma/major loss to self-identity, respect or finances, access to dangerous means or opportunities (water bodies, ropes, empty and isolated spaces, firearms, pharmaceuticals like fertilizers or pesticides), and someone who has voiced the wish to end their life even once.
It is unfortunate that mental health professionals, even with their best intentions, are often not able to detect and save the lives of people who otherwise would have spoken about this latent wish. The WHO has an excellent standard of practices forming the suicide prevention strategies, but such a structured format needs to be implemented as a part of our health care policy at the earliest. There are various effective pharmacological, psychological and social methods of taking care of suicidal patients. Multiple suicide helplines exist around us and mental disorders leading to a risk of suicide can be treated. However, the first step for all these to be useful is the early screening and detection of such ‘at risk’ people and bringing them to the health care system.
It is high time we look at this problem through the ‘social lens’ and try to estimate what toll it has been taking on young lives. Even the suicide survivors continue suffering from post-traumatic stress disorder, anxiety, depression and significant guilt for most of their remaining lives. Suicide is not just an illness which has a simple cure. Advertising in media or posters of suicide helplines or celebrities talking about their own depression would not be of any avail if we are not aware of the stigma and conscious of the sufferings of people around us. All classes of people should consider it their collective responsibility to fight this most preventable cause of death, which is posing the greatest threat to our nation’s health.