Suicide in India: A preventable epidemic.

The WHO estimated worldwide suicide rate in 2016 as 10.5/100,000 which accounted for 7.6 in females and 13.5 per 100,000 in males1. Seventy nine per cent of global suicides (800,000/yr) occur in low- and middle-income countries2. In a meta-analysis of 71 longitudinal studies from 30 different countries, 90 per cent of studies were found to be conducted in North America and Europe. There was under-representation of data from low- and middle-income countries, which account for a large proportion of global suicidal deaths3.

According to the WHO report of 2016, the suicide rate in India was 16.5/100,000 population, which was higher than the global average of 10.5/100,0001. In India, 15-29 yr is the most vulnerable age group; data also report increased suicidal rate in males (18.5/100,000) compared to females (14.5/100,000)4. The National Crime Record Bureau (NCRB) data report 133,623 committed suicides, with a rate of 10.6/100,000 in 20155. NCRB report also shows lesser suicidal rate compared to the WHO report6. This discrepancy has led to serious criticism that NCRB data are not true representative of suicidal rates6. This is because for NCRB data systematic verbal autopsy is not used, but a passive surveillance is done. The data are mainly gathered from the First Information Report (FIR) from the police. The reporting of suicide faces many challenges such as stigma attached to suicide deaths, post-mortem procedure and legal issues involved in completed suicide7. However, the new Mental Healthcare Act 2017, Section 115, has decriminalized suicide8, facilitating help seeking.

Strategy approach to prevention of suicide

A National Imperative was published by the Institute of Medicine9, in which the prevention programmes were organized at three different levels; (i) universal (addresses the entire population irrespective of the level of risk of the individuals in the population), (ii) selective interventions (address at-risk groups with the goal of preventing the onset of suicidal behaviour), and (iii) indicated (interventions address individuals deemed high-risk by virtue of a prior suicidal attempt or suicidal ideation)9. Based on the similar strategy, we propose a model which could be adopted to our Indian setting.

Universal intervention for general public at large

It is crucial to improve accessibility and provision of mental health professionals in rural and urban India. There is a gross deficiency of psychiatrists in India. In 2014-2016, the WHO report showed that in India, psychiatrists per 100,000 of the general population was 0.29 when compared to the USA which had 10.5/100,00010. Also there was a significant deficiency of mental health nurses (0.796/100,000), social workers (0.065/100,000) and psychologists (0.069/100,000)10. In addition to increasing mental health professionals, it is wise to engage grassroot health workers such as accredited social health activist (ASHA), auxiliary nurse midwives (ANM), Anganwadi workers, school teachers, volunteers in gatekeeper training to recognize and get help for self-destructive behaviour and common mental health problems among general public. Anganavadi workers can be trained in school-based programme involving building self-esteem, increasing communication and problem-solving skills and referral to mental health services. The training by the National Registry of Evidence-based Programmes and Practices (NREPP) of gatekeepers (e.g., parents, friends, neighbours, teachers, Anganwadi worker, social worker, caseworkers and police officers) involves three important steps: (i) question the individual's desire or intent regarding suicide, (ii) persuade the person to seek and accept help, and (iii) refer the person to appropriate resources11.

Policies should target community-based interventions (community education, involving panchayat institutions and regular assessment of family burden and stigma) to destigmatize mental illness, increase acceptance, promote connectedness and also teach coping and problem-solving skills12. Community engagement activities are needed to reduce excessive alcohol use and regulate drugs and other addictive substances.

More research needs to be done to develop technology-based suicide prevention tools. For example, MY3 app created by the National Suicide Prevention Lifeline13 which helps define your network and your plan to stay safe. It can also be prepared to help person and reach out to others when they are having thoughts of suicide. Developing a technology similar to Uber services to help find the strategically positioned mental health organizations, mental health professionals, suicide gatekeepers to provide support or refer to the nearest mental health services; artificial intelligence and machine learning to detect specific words and phrases or posts or live videos where someone might be expressing thoughts of suicide.

Identifying and treating childhood psychiatric disorder such as attention deficit hyperactivity disorder, specific learning disabilities, depression and anxiety may help improve self-esteem and academic performance. In general, adolescents experience considerable stress in multiple areas irrespective of their academic ability and performance14. It is required to promote school-based mental health programme (Rashtriya Kishor Swasthya Karyakram) with the help of counsellors, visiting mental health nurse, psychologists aiming at health-promoting school environments, evaluating psychological problems and providing referral to appropriate service and also fostering life skills of students1516. There is an urgent need to make life skills training mandatory in all schools involving teachers and parents. Involving parents helps to generalize the learnt skills. Young people often express their suicidal feelings on social networking sites and blogs17. This makes social media a potential place to identify the high-risk individuals and deliver necessary emotional support to the individuals in need. Young people can be safely engaged in developing suicide prevention messages, which can be disseminated via social media18.

There is a need to establish mandatory screening checks for determinants of suicide risk such as suicidal ideas, suicidal thoughts, suicidal intent and suicide plan (similar to checking for vital signs) in routine outpatient clinics and emergency departments. Subsequent identification of the high-risk individuals through screening checks may be referred to the mental health services to get necessary psychopharmacological treatment.

Specific legislation should be in place for media in reporting suicide. This will help prevent mainstream social media indirectly glorifying the suicide or reducing copycat act by avoiding dramatic reporting or portrayal of suicide and avoiding specifying means used to commit suicide. Media should emphasize providing accurate facts about the causes of suicide instead of focusing on single social or economic factor and minimizing the role of mental health problems19.

Selective intervention strategy for high-risk groups

In a case-control study conducted at Bengaluru, India, it was found that in 36 per cent of females, the major risk factor for completed suicide was domestic abuse20. Empowering women is an important factor to reduce the domestic violence. This could be done through innovative initiatives like microcredit and microfinancing to alleviate the poverty and also mental health interventions such as stress management, peer support, etc21.

It is an important preventive measure. A national representative study from India reported suicides in 49 per cent of men and 44 per cent of women by pesticide poisoning22. Also, farmers suicide is a major public health problem. The overall suicide rate for farmers across India was 15.8/100,000 people23. Farmers’ suicide is due to both socio-economic factors and also mental health problems24. To minimize financial losses from agricultural investment, farmers should be encouraged to use subsidised governmental schemes (National Mission for Sustainable Agriculture); to grow food crops reducing the cash crops; to use government subsidised credit sources rather than private money lenders; and the reduction of trade barriers by access to electronic National Agriculture Market to have uniformity in agriculture marketing.

Majority of the farmers commit suicide by drinking organophosphorus (pesticide) preparation. Hence, limiting its access through community intervention called ‘pesticide banks’ or central storage facility25 at village level can help in the prevention of suicide.

Indicated surveillance

People with severe mental disorders with past history of suicide attempt are at high-risk of committing suicide in the future. Proactive intervention through long-term engagement in treatment and psycho-social intervention can play a crucial role in preventing suicide. Specifically targeting these groups using District Mental Health Programme, the operational wing of the National Mental Health Programme (), will be highly rewarding and cost-effective.

A suicidal person may not ask for help, but suicidal attempt is a desperate call for help to escape unbearable pain that the person can see no other option than completing it. Most suicidal individuals give warning signs or signals of their intentions. The best way to prevent suicide is to recognize these warning signs and knowing how to respond to such crisis situation. There should be a coordinated multi-dimensional, multi-agency, multi-phase and multi-departmental approach to bring this epidemic under control. This is not just a health issue, but a social issue, and it is everyone's duty to save the life. Everyone can save life, and it is time to act before it is too late.