As psychiatrists, we were trained to deal with complex conditions which had intersecting medical, psychological and social strands. Two such conditions are heavy alcohol use and suicide. As researchers and programme implementers, we have had an opportunity to take a birds-eye view of the relationship between alcohol and suicidal behaviour, at individual and societal levels. In this piece, we attempt to consolidate our observations and draw conclusions from the existing research evidence, with a particular focus on the steps to address these issues in India.
After tobacco, alcohol is the second most common substance of use in India. Worryingly, India accounts for most of the increase in per capita alcohol consumption for South-East Asia, a region poised to account for the highest increase in total adult alcohol per capita consumption by 2025. Most of this projected increase in India will be accounted for by frequent-heavy or episodic-heavy drinking of spirits, which is associated with adverse health and social outcomes. Synthesis of substantial global research over the years shows that heavy drinking increases the risk of suicidal ideation, attempted suicide, and completed suicide; and the few studies conducted in India examining this relationship have also shown a similarly increased risk. In fact, according to the National Crime Records Bureau data, in 2021, after ‘family problems and ‘illness’, drug and alcohol use was the most common cause for suicide in India.
Despite these sobering (pun unintended) numbers, we do not pay much attention to these two conditions which directly and indirectly adversely affect large swathes of the Indian population in an adverse manner. To this day, we remain amazed by the reluctance of our policymakers to deal with a substance that is causally related to more than 60 different medical conditions and a phenomenon that is one of the biggest killers of young people in our country.
While there are various reasons for people dying by suicide, one that is not much deliberated on is the role of alcohol. The idea that alcohol and suicidal behaviour are linked is not a new one, and indeed this relationship has been substantiated by a number of research studies. If we quantify the risk, we know that after recent consumption of alcohol, the likelihood of a suicide attempt is on average seven times greater as compared to someone who has not consumed alcohol. The limited studies from India show that the risk is much higher in our country. In addition, heavy alcohol use is also closely associated with other risk factors for suicide such as poor socio-economic circumstances, interpersonal, social and cultural conflicts, financial problems and unemployment.
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Another key indirect mechanism that connects alcohol use to suicide in women is domestic violence. In India, domestic violence has been implicated in one-third of suicides among women, and alcohol consumption by the husband has been shown to be strongly associated with the perpetration of violence against the wife. Thus alcohol, directly and indirectly, has a substantial impact on suicides.
Broadly we could categorise these driving forces that connect alcohol use and suicidal behaviour into those that exist within individuals and those that exist outside of them. Both these interact with each other to moderate the effects on suicide. First, let us look at those that exist outside of individuals, mainly in the form of socio-cultural and economic contexts within which personal choices are exercised.
With its rapidly burgeoning young population, India continues to be a tempting target for a strategic and insidious campaign by multi-national alcohol companies to target a huge emerging market. Consequently, bucking global trends, alcohol consumption in India increased by a whopping 38 per cent between 2010 and 2017. Generally, suicide rates in a country go up as the per capita consumption of alcohol rises. However, this needs to be foregrounded against the ‘drinking culture’ in a country as that can influence the association between heavy drinking and suicide. ‘Dry’ drinking cultures such as India are more strongly associated with suicides than ‘wet’ drinking cultures.
What do we mean by a ‘dry’ drinking culture? In such cultures, alcohol consumption is not common during everyday activities (e.g., part of meals), access to alcohol is more restricted, there is low per capita consumption, alcohol control policy is more restrictive, wine consumption is less common, and overall abstinence is more common. However, when drinking does occur, it is characterised by heavy drinking over short periods, resulting in greater rates of drunkenness or intoxication. And as mentioned earlier, the state of intoxication increases the risk of suicide.
Complexities within the policy environment
Let us shift our attention from ‘culture’ to the alcohol policy environment and its role in connecting alcohol use and suicide. Research has shown that higher taxation and consequently the higher price of alcohol, lower the suicide rate. Similarly, zero-tolerance drunk driving laws are associated with a reduction in suicides.
On the other hand, research also shows that communities with easier access to alcohol through a greater density of liquor outlets have higher suicide rates. Russia is an example of a country where the introduction of policies aimed at controlling the production and distribution of alcohol led to a reduction in male suicides. In Canada, policies that promoted privatisation of the retail sale of alcohol led to a rapid rise in private liquor outlet density and an increase in suicide mortality rates. However, it would be wrong to assume a simple linear relationship between a favourable alcohol policy environment and suicide rates.
In 2008, the East European nation of Lithuania introduced policies aimed at regulating alcohol advertising, limiting alcohol accessibility, and drunk driving control. However, in subsequent years Lithuania had a paradoxical increase in suicide rates. Looking at the data more closely, it was apparent that Lithuania was experiencing an economic recession at the same time, and the resulting spike in unemployment and psychological distress resulted in increased suicide rates, despite the reduced alcohol availability. It again highlights the need for a multi-sectoral approach to suicide prevention and no single intervention by itself will reduce suicides and attempted suicides.
Driving forces within individuals
Among the driving forces that connect alcohol use and suicidal behaviour that exist within individuals is impulsivity – the greater the impulsivity higher the probability of suicidal behaviour. Some stressors that are very frequently observed both in people who die by suicide, as well as those who drink heavily, include interpersonal losses and conflicts, chronic physical illness, mental illness and financial problems. This indicates common pathways which connect heavy drinking, suicide and these various risk factors.
Many times, heavy alcohol use works additively or synergistically with these risk factors, resulting in a disproportionately high suicide risk. Faced with adversities such as the ones outlined above, heavy alcohol use reduces the ability to see potential alternative solutions beyond a binary (immediate solution vs dying by suicide) resulting in suicidal behaviour. Additionally, acute heavy alcohol use (e.g. intoxication) leads to disinhibition and increased impulsivity, a potent combination that can lead to behaviours without due consideration to consequences – in this case enhancing the chances of suicidal thoughts being acted out. Finally, those who are intoxicated are more likely to attempt suicide using more lethal means (e.g. firearms) and consequently have a lower probability of survival.
Besides alcohol as the direct method for suicide (e.g. taking an overdose and drinking to intoxication), the suicide-related alcohol expectancies (one’s beliefs about how alcohol may affect one’s behaviours) that lead to the incorporation of alcohol into the suicide plan include gaining courage, numbing of fears about the means of suicide, and anaesthetising the pain of dying; all of which might resolve the ambivalence that often precedes suicidal behaviour, and also allow people to choose a more violent, and definitive means of dying by suicide. Bottomline, the greater the number and intensity of these internal factors, the higher the risk of suicide in the presence of heavy alcohol use.
Thus, the complex association between alcohol use and suicide is influenced by an interaction of individual-level internal factors and the ecosystem within which we live. Hence, any targeted action to reduce alcohol use and suicide should be deployed at the level of the individual as well as communities. Considering the various factors acting at several levels, a purely health systems response (as is the case in India) is reductionist and futile. A more complete and coordinated response will require both individual-level and policy interventions delivered through the collaboration of stakeholders from sectors such as health, law enforcement, education, and hospitality.
Abhijit Nadkarni is a Consultant Psychiatrist and Director of the Addictions Research Group, at Sangath, Goa; Soumitra Pathare is a Consultant Psychiatrist and Director at the Centre for Mental Health Law & Policy, Indian Law Society, Pune.
Discussing suicides can be triggering for some. However, suicides are preventable. In case you feel distressed by the content or know someone in distress, call Sneha Foundation - 04424640050 (available 24x7) or iCall, the Tata Institute of Social Sciences' helpline - 9152987821, which is available Monday to Saturday from 10 am to 8 pm.