Occupation-related suicide.

Suicide in farmers has been grabbing headlines in India for the past decade. In addition to farmers, suicide also occurs frequently among students, the self-employed, unemployed, and homemakers. A great deal of discussion and debate that has taken place on this topic, in print and electronic media, is high on rhetoric but short on reasoned analysis. Let us attempt to make a rational analysis.

Official figures of suicide in India are available from the National Crime Records Bureau. Comparison of total suicides in 2000 and 2015 indicates a whopping 23.05% increase in total suicides, which should grab the headlines and send alarm bells ringing [Table 1]. However, in the same period, the estimated population of India has increased by 25.65%. Therefore, while the total number of suicides has certainly increased, this is in proportion to the increase in population, and there has been no increase in the rate of suicides.[1234]

Table 1

Number of suicides, growth of population, and rate of suicides in India during 2000-2015

Year	Total number of suicides	Mid-year projected population (in crores)	Rate of suicides
2000	108,593	100.21	10.8
2001	108,506	102.7	10.6
2002	110,417	105.06	10.5
2003	110,851	106.82	10.4
2004	113,697	108.56	10.5
2005	113,914	110.28	10.3
2006	118,112	111.98	10.5
2007	122,637	112.65	10.8
2008	125,017	115.31	10.8
2009	127,151	116.94	10.9
2010	134,599	118.57	11.4
2011	135,585	121.02	11.2
2012	135,445	121.34	11.2
2013	134,799	122.88	11.0
2014	131,666	124.40	10.6
2015	133,623	125.91	10.6

Data from National Crime Records Bureau Rate of Suicides=Incidence of suicides per one 100,000 of population

The figures do not indicate significant rise in suicide rates as per available data. In fact, the suicide rate in India in 2000 was 10.8/100,000, and despite some rise in-between, the rate was 10.6/100,000 in 2015 [Table 1]. Similarly, the suicide rate in the United Kingdom during 2011 and 2015 was 12/100,000, whereas in the United States during the period 2001–2017, the suicide rate increased from 10.7 to 14.0/100,000.[56]

Suicide is a complex multifactorial phenomenon. Among the many causal factors, occupation does figure prominently. Most studies agree that unemployment is an important cause of suicide. Among the working population, studies indicate that certain occupations are associated with a higher suicidal risk than others. Despite the importance of the topic, the literature is sparse.[7]

The first literature review of occupation and suicide was by Bedeian who highlighted that suicide rates vary according to the occupation, although his review was limited to health-care workers, managerial and professionals, and military and paramilitary personnel.[8] Subsequently, the literature from 1982 to 1995 was reviewed by Boxer et al. who reported a higher risk of suicide in police officers, chemists, and farmers. In addition, both male and female doctors have an increased risk of suicide.[9] Both the authors highlighted numerous methodological limitations of the early studies including small samples, specific location, limited to specific occupations or industries, and ignoring potential confounders such as age and gender. The systematic review and meta-analysis of 34 studies performed by Milner et al. used a rigorous methodology that was an improvement on the past narrative reviews. However, their study examined the relation of suicide risk and occupational skill level and not specific occupations. They observed an increased suicide risk in skilled agricultural, forestry, and fishery workers compared to the working-age population (rate ratio: 1.64, 95% confidence interval: 1.19–2.28).[10]

Most of the studies carried out to evaluate the relation of suicide with occupation and industry were limited in scope to workers of one or few industries or occupation. The distribution of suicide in India according to profession shows that the highest suicide risk was in daily wage earners followed by homemakers, farmers, those in business-related activities, and the unemployed [Table 2]. Some earlier studies from the USA have observed an increased risk for suicide among miners, forestry and construction workers, chemists, police officers, physicians, social workers, and artists.[11]

Table 2

Distribution of suicide in India according to profession

Profession	2000 (%)	2005 (%)	2010 (%)	2015 (%)
Homemaker	20.5	21.2	20.5	16.7
Daily wage earner	17.7	16.5	15.1	17.8
Farming	15.3	15.0	15.3	9.4
Service	9.8	11.1	12.4	7.9
Unemployed	9.0	7.7	9.0	8.2
Business	7.0	7.9	7.0	9.1
Student	4.9	4.5	4.9	6.7
Retired	0.8	0.8	0.8	0.8
Others	15.0	15.3	15.0	23.4

Data from the National Crime Records Bureau Rate of Suicides=Incidence of suicides per one 100,000 of population

Data from the Office of National Statistics reveal that in England in adults below the age of 50, the leading cause of death is suicide. The suicide risk in male low-skilled laborers, especially construction workers, was three times higher than the male national average, whereas the risk among males in skilled trades was 35% higher. Among male skilled tradesman, the highest suicide risk was in building finishing trades, namely plasterers, painters, and decorators. The suicide risk was higher than the national average for both males and females in culture, media, and sports occupations. The suicide risk for female health professionals was 24% higher than the female national average, largely due to high suicide risk in female nurses. Females in the teaching profession had a lower suicide risk, but primary and nursery school teachers had an elevated risk. The highest-paid occupation – group managers, directors, and senior officials – had the lowest suicide risk.[5]

In the U.K., high suicide risk is associated with the following occupations: farmers, doctors, nurses, dentists, veterinarians, pharmacists, the police, the military, sailors, and artists. A major determinant of high suicide rates in most of these occupations is the ease of accessing the means to commit suicide (medicines, chemicals, guns, or drowning). Socioeconomic forces now seem to be a major determinant of high occupational suicide rates in Britain.[12]

A Japanese study of working-age men (25–59 years) revealed that for the year 2010, the highest incidence rate of suicide was in agriculture (54.7) followed by service (51.3), administrative and managerial (46.8), construction and mining (28.5), transport and machine operation (22.9), professional (22.2), and security (19.4). A unique feature of Japan is that unlike in many other countries, managers, professionals, and government officers have a higher risk of suicide.[13] A recent systematic review and meta-analysis of 32 studies revealed a significantly higher risk of suicide in agriculture, forestry, and fishery, and this may be even higher in Japan.[7]

In general, results from these studies suggest that stress and access to lethal compounds contribute to suicide. Stressors noted derive from such factors as work overload, threats to job security, malpractice lawsuits, various forms of harassment, and exposure to neurotoxic substances. Other investigators indicate that economic factors, such as low income and job loss, increase the risk of suicide.[121314] However, among Indians, family disputes and chronic illnesses were the major risk factors accounting for 69.59% of suicides, while surprisingly, other risk factors such as problems relating to marriage, love affairs, substance use disorders, failure in examination, bankruptcy, unemployment, and poverty had a relatively lesser share.[15]

Evidence-based intervention strategies to prevent suicide include general measures such as reducing stigma and improving access to psychiatric care, restricting access to means of suicide, responsible media reporting and improving knowledge about mental health, use of addictive substances, and suicide. In addition, specific intervention for vulnerable populations include gatekeeper training among teachers, police and military officers, and human resource staff and managers. Other industry-specific initiatives include the Construction Industry Alliance for Suicide Prevention and intervention in military and veteran population in the USA.[1617] A successful workplace suicide prevention program was the multifaceted, comprehensive police suicide prevention program in Montreal that resulted in a 79% decrease in the suicide rate among police personnel. The police suicide prevention program comprises half-day training on suicide focusing on risk identification and how to provide help to officers in the police force, while supervisors and union representatives received a full day of training. A telephone helpline was established for police personnel. Simultaneously, a publicity campaign was launched on the importance of working together in suicide prevention and providing resources for help.[18]

The consensus is that despite wide regional disparities, certain occupations are associated with a higher suicide rate including agriculture, construction, mining, service, transport, security, medical, and paramedical staff. However, in India, homemakers seem to be at particular risk. Identification of occupations and industries associated with a higher risk of suicide will help us in carrying out focused studies to evaluate the causal factors and formulate targeted comprehensive suicide prevention interventions to combat the risk of suicide. There is a need for carrying out larger multicenter studies which should be repeated periodically to assess changing trends and also the effects of interventions. There are no quick-fix solutions, and a sustained long-term strategy is needed.