“Sometimes we look for hope, even at the end of times. The search is desperate and the struggle is true.”
We may remember hearing something along these lines from someone close to us whom we lost to suicide years ago. And if this has got you wondering, let us clarify. This person may not have had a psychiatric illness, a term that is invariably and irrevocably linked to every suicide.
India has the highest suicide rate in the Southeast Asian region, according to the World Health Organization (WHO). For more perspective, suicide is responsible for more deaths than malaria, breast cancer, war or even homicide. It is, in fact, the most common cause of death in Indian adolescents/youth, with numerous lives lost prematurely to this social evil. Increasing conversations on mental health may be gradually advancing our understanding of the medical aspects of suicide, but there remains much to understand about it in the broader social realm.
Whenever there is news of suicide anywhere, we may be used to hearing phrases like “Oh, surely they were depressed” or “Zarur dimaag mein kuch chal raha tha”. Oftentimes, we assume or attempt to decipher the causation of suicide in these individuals while subconsciously distancing ourselves. And while it is true that mental illness is the fundamental driver of suicide at the individual level, the problem with viewing suicide as solely an individual problem or as having a unidirectional relationship with mental illness is that we may be minimising the impact of social issues on the individual. This has become the common theme of public conversation as well as media perception, which may be reductionistic and harmful in our effort towards prevention as a society.
Let us provide an example from our background. A medical student who had been obligated to take up the stream due to the wishes of his family faced tremendous difficulties with the academic rigour of subjects he never wanted. He may choose to end his life someday, being consistently pushed against the wall. To what would we attribute his crisis then: depression and stress, or his unheard voice and unrealistic family expectations?
Viewing suicide as an individual crisis, where a person snaps one fine day, undermines the immense preventive potential. In fact, most suicides can be avoided if timely action is taken.
Do we overlook the impact of poverty, loss of employment, loss or lack of housing, disabilities, domestic abuse, elder abuse, easy access to pesticides, alcohol abuse and migration when discussing the factors leading up to suicide? And is it really fair to assume that only genetic predispositions and clinical depression would lead to suicide?
Emile Durkheim examined the sociological aspects of suicide and proposed that the risk of suicide in a population increases when the social context fails to provide a healthy sense of purpose or belonging.
Some examples of social forces causing psychological distress may be the transition from one social role to another—moving away for college, becoming a parent, having your firstborn move out or retiring from office and the stress around common socio-cultural beliefs and practices such as inter-caste marriages, pregnancy, the beliefs around the gender of the baby and postpartum traditions.
In times of the pandemic, stress due to social isolation, loneliness, distance learning, loss of employment and lack of basic needs, especially among the underprivileged classes, is also becoming increasingly common. The risks of suicide have also thus increased, though we still lack systematic data from India.
Financial issues, examinations, disharmony at home and interpersonal conflicts are commonly known to lead to distress; however, the stress of not being able to live up to the expectations of self or others, the stress of uncertainty, sexual health concerns, bullying, criminal charges and feelings of shame and guilt may also play significant roles in suicide causation.
Then suicide can be a culmination of the loss of regulatory forces, a thwarted belonging of the self, interpersonal conflict and separation, or the loss of a role or belonging. Suicide can also be due to the availability of lethal means among people already at risk. In the age of the internet, the virtual world can sometimes be the medium through which information of such means are sought and at other times could be the reason itself, such as in the case of cyber-bullying, online fraudulent practices, suicide pacts and games or challenges aimed at self-harm. Additionally, there is increasing evidence that social media can influence suicide-related behaviour.
These risks are compounded by stigma, other barriers associated with help-seeking, socio-cultural beliefs and flawed media portrayals of suicide. The WHO and Press Council of India (PCI) have clearly set guidelines of media reporting in cases of suicide, which are but rarely practiced.
So, what can be done? These realities imply that suicide prevention entails far more than increasing the number of psychiatrists or prescription medication. Suicide prevention requires economic development, financial assistance, strengthening of communities and social ties, providing moral support and escape routes from abusive relationships and recognising those in need and helping them seek professional help. Right from individuals to administration, it’s a collective responsibility.
Suicide affects society and all the people in it. A single death by suicide causes a ripple effect that goes on to deeply impact all the people tied to that individual. People who die of suicide are not heroes, they are not cowards and they are not criminals. Informed perspectives can guide the conversations around suicides. These conversations should not be limited to World Suicide Prevention Days or World Mental Health Days. These conversations are not intended to be exotic or scandalous. Let us be realistic as well as empathetic in saving lives.
(Views are personal and have no bearing on the authors’ employers/organisations)
Dr Aishwariya Jha, Psychiatry Resident, NIMHANS, Bengaluru; Dr Debanjan Banerjee, Consulting Geriatric Psychiatrist, Kolkata (dr.djan88@gmail.com)