Challenges facing individuals and researchers: suicide in India in the COVID-19 pandemic.

A recent article in a leading Indian newspaper, The Hindu, expressed concern about a potential rise in deaths by suicide during the COVID-19 pandemic. In this context, we were pleased to read the Comment by David Gunnell and colleagues in The Lancet Psychiatry, which emphasised the importance of identifying possible changes in the risk of suicide and acting towards its reduction by extending more help to people who are distressed.

In India, several factors are adding to the mental health impacts of the pandemic. A large proportion of the workforce in India comprises daily wage labourers and migrant workers, who have lost their jobs and have few or no savings. On May 14, 2020, the government announced some financial relief measures, the effect of which is still to be seen, but during the past weeks, many have reached a stage where they have very little to sustain their livelihoods, and are starving and stressed. Many people are trying to move out of the cities on foot or by one of the few available transport options to reach their families, who are in their hometowns or villages hundreds of miles away. Stigma is also playing a huge role in the way that communities are viewing individuals who are either affected or are at increased risk of COVID-19 infection. Some people are discriminating against individuals who do not have the illness but are at increased risk, because they are exposed as health workers or have returned from a city or country that has a high rate of infection. This discrimination is causing increased stress and anxiety among such individuals.

The absence of good quality data, including timely data on cause of death, was a challenge in India even before the COVID-19 pandemic. Our experience in our study sites and other anecdotal reports suggest that this is becoming even more challenging now. Reporting of death by suicide has often not been captured accurately by the National Crime Records Bureau of statistics, because of mental health stigma and fears of involving the police bureaucracy; family members often avoid mentioning the true cause of death. Our experience of collecting information on suicide attempts as a part of the SMART Mental Health Project in rural Andhra Pradesh and Haryana has shown how difficult it has become to collect information about any adverse event related to suicide. Challenges include the unavailability of proper administrative formalities of confirming the cause of death and ambiguity about the cause of death for someone who has died by suicide. One wonders whether the quality of data related to suicides is even worse now, given that there seems to be an increase in under-reporting and that there is even less monitoring, because most of the administration is focused on managing the pandemic.

We agree with Gunnell and colleagues that, particularly in countries such as India, multipronged approaches are needed to address self-harm and suicide during the COVID-19 pandemic. Mental disorders in communities should be identified and managed using strategies that are easy to implement within a mental health workforce lacking in numbers, such as using technology-enabled solutions that can be scaled up through suitably trained primary health-care workers, to make mental health care more accessible to larger sections of the community. The Indian Government should strengthen policies specific to the treatment and management of people who make suicide attempts. A stronger effort needs to be made to streamline the process of collating information about suicides, both in rural and urban areas and using confirmation from verbal autopsy or other robust methods. These efforts might help in understanding the number of suicides more accurately, especially in these times. More counselling centres or helplines should be provided. Family counselling and additional support needs to be given to people with alcohol and substance use disorders. Communities should be educated about mental health stigma and how mental health problems can be aggravated during this pandemic by ostracising anyone affected or at high risk of infection.