Hunger, fear, and isolation - A qualitative analysis of media reports of COVID-19-related suicides in India.

BACKGROUND: India's suicide rates are among the highest in the world and may increase further as a consequence of COVID-19. There is a need to examine which pandemic related stressors may be contributing to suicide, in order to inform the deployment of suicide prevention strategies, for the current as well as future pandemics. AIM: To understand pandemic related stressors contributing to suicide in India.
METHODS: We identified and conducted a thematic analysis of Internet media reports of COVID-19 related suicides in India between February 1, 2020 (2 days after the first COVID-19 case), and May 31, 2020, (the end of phase four of the nationwide lockdown).
RESULTS: Ten pandemic stressors spanning both disease and lockdown-related factors were identified in 291 suicides. Economic hardship was present in a third; other notable stressors were: fear of the virus; isolation; desperation to be connected with loved ones or return home; and craving for alcohol. Men and young people seemed particularly vulnerable to these stressors.
CONCLUSIONS: COVID-19 related suicides appear to be precipitated by social and economic adversities, mainly associated with containment strategies. These findings need to be confirmed by national suicide data. Suicide prevention strategies should mitigate the impact of recognized stressors in the long term, target high-risk individuals, and offer mental health care alongside containment strategies. Copyright:

INTRODUCTION

The first COVID-19 case in India was reported on January 30, 2020, and a stringent lockdown was implemented for 1.3 billion people with four hours’ notice on March 24, 2020. The Central Government invoked the “Disaster Management Act 2005,”[1] which included the closing of international, state and regional borders; banning of public transport; and restrictions of all movement by private individuals and businesses except for ‘essential’ services.[234] This phase lasted 3 weeks and was progressively lifted until the end of May when lockdowns became locally implemented. During this period, tens of millions of poor urban workers were left with no means of livelihood and unable to return to their homes;[56] millions of Indians lost their jobs;[7] fear led to persons suspected of having COVID-19 facing persecution and hostility from neighbors;[89] and there were reports of incidences in domestic abuse[1011] and increases in mental health problems.[1213] These disruptions were not unique to India – the UN called it a “a global mental health crisis.”[14]

Could such a crisis have led to suicide in India - a country whose suicide rates are already among the highest in the world, and which was home to 1/3 of all female and 1/4 of all male suicides before the pandemic?.[15] Mental health problems, unemployment, and economic uncertainty – the felt impacts – are established risk factors for suicide,[16] and there have been increases in suicides following other global epidemics such as the Spanish Flu (1918)[17] and SARS (2003).[18] It is, as yet, too early to derive reliable quantitative estimates of the impact on suicide mortality as official suicide data from the National Crime Record Bureau is expected to be released later. However, there has been extensive reporting of these early suicides in the media which offer a unique opportunity to understand what pandemic-related stressors may have been contributing factors; such an understanding will not only inform the deployment of suicide prevention strategies to prevent further suicides but also help us anticipate and address these stressors proactively in future pandemics.[19]

MATERIALS AND METHODS

A Google “Advanced search” was conducted to identify online media articles from February 1, 2020 (2 days after the first reported COVID-19 case) to May 31, 2020 (the end of the fourth, and final phase of the nationwide lockdown). Keywords used were “suicide” and “India.” This was followed by a second search to identify any articles missed previously, by using search terms specifically related to the pandemic, for example, “sars-cov-2,” “coronavirus,” or “lockdown.” Identified articles were supplemented with those from an online, public database of all deaths in India during the lockdown period.[20]

Articles in languages other than English were translated using Google Translate. Each identified article was examined in detail, and only those pertaining to COVID-19-related suicides were included for analysis i.e. if they explicitly mentioned the pandemic, or if the suicide occurred in the context of circumstances not present before (e.g. during “quarantine”). Excluded articles describing non-COVID suicides were checked and verified by an independent reviewer. Care was taken to avoid duplications in the identified suicides, by re-readings of all articles and constant comparisons of “new” suicides identified with those extracted previously. If there were any doubts, those persons were discarded from the list.

All included articles were imported into QDA Miner Lite (v2.0.7)[21] and analyzed using thematic analysis, which involved: (1) reading and re-reading all articles; (2) coding relevant information systematically across the entire dataset; (3) collating codes into themes; (4) checking if the themes captured the meaning of the coded extracts, and combining, splitting or re-ordering themes; (5) defining and naming the final themes; and (6) selecting data extracts that best reflected the themes. If a suicide had more than one stressor, it was coded under multiple themes (for example, if a person feared the virus and was under quarantine, his/her suicide was coded under both “fear,” and “isolation”). The analysis was undertaken by MB, with steps 3 and 4 being independently reviewed by VP. Any discrepancies were resolved through discussion, and the final themes (steps 5, 6) were constructed by both authors. In addition, a descriptive quantitative analysis was conducted using MS Excel and SPSS 25 (IBM Corp, New York, USA), to categorize all identified suicides, and generate frequencies for the pandemic-related stressors.[22]

Since the source of data was publically available media articles, and the study did not involve the participation of any persons, ethics approval is not applicable.

RESULTS

A total of 370 articles were included for analysis [Figure 1]. These covered 291 discrete suicides [Appendix Table 1 and Table 1]; there were 1, 45, 80, and 161 suicides in February, March, April, and May respectively (dates are not available for four suicides). 85.9% of the suicides were by men. Nearly 50% occurred in persons between 20 and 39 years of age. There were eight couples. Hanging was the most common method (63.2%). Two states, Uttar Pradesh and Maharashtra accounted for the highest number of identified suicides.

Figure 1

Flow chart of article inclusion

Table 1

Demographic data of identified suicides

Demographic data	Categories	n (%)
Gender	Male	250 (85.9)
	Female	40 (13.7)
	Transgender	1 (0.3)
Age category	10-19	15 (5.2)
	20-29	66 (22.7)
	30-39	71 (24.4)
	40-49	43 (14.8)
	50-59	31 (10.7)
	60 and above	21 (7.2)
	Unspecified	44 (15.1)
Suicide method	Cutting	2 (0.7)
	Drowning	14 (4.8)
	Drug overdose	1 (0.3)
	Electrocution	1 (0.3)
	Firearm	1 (0.3)
	Hanging	184 (63.2)
	Jumping	18 (6.2)
	Pesticide	14 (4.8)
	Poison	12 (4.1)
	Railway	6 (2.1)
	Self-immolation	11 (3.8)
	Unspecified	27 (9.3)
North India	Haryana	13 (4.5)
	Himachal Pradesh	2 (0.7)
	Chandigarh	2 (0.7)
	Punjab	17 (5.8)
	Delhi	3 (1.0)
	South Kashmir	1 (0.3)
	Uttarakhand	6 (2.1)
	Uttar Pradesh	46 (15.8)
North East India	Arunachal Pradesh	1 (0.3)
	Assam	2 (0.7)
East India	Bihar	8 (2.7)
	Jharkhand	14 (4.8)
	Odisha	7 (2.4)
	West Bengal	4 (1.4)
Central India	Chhattisgarh	5 (1.7)
	Madhya Pradesh	4 (1.4)
West India	Gujarat	27 (9.3)
	Rajasthan	7 (2.4)
	Maharashtra	39 (13.4)
South India	Kerala	17 (5.8)
	Karnataka	21 (7.2)
	Andhra Pradesh	6 (2.1)
	Telangana	23 (7.9)
	Tamil Nadu	15 (5.2)
	Puducherry	1 (0.3)

There were 10 pandemic-related stressors in connection to 284 suicides [Figure 2]. Seven suicides could not be classified.

Figure 2

Pandemic stressors in identified suicides

Disease-related stressors

Fear of the virus

Several persons died by suicide, after fearing the virus. Some had tested positive shortly before, for example, Case 168 who “was tense... went into depression” (The Indian Express, 10.05.2020). Others feared contracting the virus, or perceived they had been infected, despite reassurances or evidence to the contrary. For example, Case 1 “started panicking when his cold, cough and fever did not subside even after taking medicines;” his son said, “even the other villagers told him that if he really had coronavirus, the doctors would have quarantined him… (but) my father was worried that the virus would spread to us. He hanged himself to save us” (Hindustan Times, 12.02.2020). Some who underwent testing panicked before receiving their results, for example, Case 2. Others feared for their loved ones; for example, Case 282 “set herself ablaze fearing her husband who works abroad was affected with COVID-19” (Mathrubhumi, 31.05.2020).

Isolation

Many suicides occurred during quarantine or shortly after, in those testing positive or “suspected” of having COVID-19 and/or who had travelled recently. Excerpts indicate that this experience may have cut off sources of support, and led to loneliness and rumination, especially for those worried about the virus or the lockdown. For example, Case 75 who was admitted to an isolation ward hanged himself “out of frustration and loneliness” (Pune Mirror, 11.04.2020); Case 41 who had escaped from a quarantine center to meet his family had “started panicking… despite repeated attempts by officials to make him understand that it was just a precautionary measure” (Hindustan Times, 02.04.2020); and Case 254 who was quarantined at home had been “worried as he had no money left” (News18, 22.05.2020). Some persons voluntarily secluded themselves to prevent spreading the infection to others, for example Case 112 (OpIndia, 22.04.2020), whereas others were forced into isolation by their families; for example, Case 20 who returned to India from Maldives, “had gone into depression after his parents and elder brother refused to let him into the house” (The Times of India, 28.03.2020).

Discrimination and rejection

Some persons who returned home, or had symptoms were forced by their local community to get tested or pestered to vacate their accommodation. For example, Case 45 “killed himself after people in the neighbourhood insisted that he cannot continue to live there since he was a ‘corona patient’” (A friend said). “When he kept coughing, the neighbours informed the police who took him to a hospital for testing”.(Livemint, 14.04.2020). Their family members also faced harassment. For example, a relative of Case 63 (who had “admitted himself in the hospital as per the wishes of villagers”) said, “People were not buying milk from us. It was the only source of income” (The New Indian Express, 05.04.2020). In another instance, a man who was quarantined after returning to village, and his wife (Cases 103, 104) died by suicide after he “had been prevented from going home… although he had no symptoms” and “some villagers had been mounting pressure on __ [wife] to leave the village over suspicions that her husband had contracted the disease”.(The Telegraph, 17.04.2020). Some persons were rejected by their own families. For example, Case 221 who had returned home was “kept in a separate room… his wife looked at him through the window, but did not go near… because of fear of Corona… (his) loneliness was irritating him… (he) repeatedly begged his wife to come to him. But she did not listen….(he) was so hurt that he hanged himself” (News Nation TV, 15.05.2020). In one instance, Case 208, a medical supervisor, elaborated in his suicide note about how “he was harassed and pressurised by the locals asking him not to allow COVID-19 swab test centre” (Mumbai Mirror, 14.05.2020).

Lockdown-related stressors

Economic hardship

Several individuals experienced economic hardships; these included threats to or loss of livelihood; reduced or no income; difficulty supporting family; going into or difficulty paying off debt; and acute impoverishment. For example, Case 217 “slipped into depression” after his employer “refused to help him financially and didn’t even give him salary… (he) had borrowed money to meet the household expenditure during the lockdown and the lenders were asking him to return their money” (The Tribune, 16.05.2020). A policeman investigating Case 182, reported, “When we visited their tin-shed home, the small room had barely anything. Even the plastic bottles were empty. They had neither food grains nor pulses nor anything else left to eat. They were drinking only water. They were crying because of starvation and asking their elder sister [case] to give them food. The girl's father was a daily-wager. Since the lockdown, he had no work. The neighbours gave them food, but she was ashamed of her plight and was humiliated by the fact that she had to beg every day” (The New Indian Express, 12.05.2020). Problems compounded, and some persons saw no way out. Case 231, for example, wrote, “I continue to suffer without work and do not have money even for food, but my landlord is demanding room rent. He is harassing me every day and I cannot take it anymore” The Logical Indian (20.05.2020). Low-income groups, migrant and daily wage laborers, owners or operators of small businesses, and persons employed in nonessential businesses seemed most affected [Appendix Table 1].

Desperation to be connected with loved ones or return home

Social distancing measures and travel restrictions separated people from their loved ones. For example, Case 199, a young housemaid, was “disheartened that she was unable to go home… her sister had given birth to a child and (she) was apparently upset by her inability to pay a visit” (Sakshi, 13.05.2020); and Case 72 “was missing his wife who had gone to visit her parents, and couldn’t move back” (Jagran, 09.04.2020). Migrant workers who had lost their livelihood were especially desperate to return to their hometowns. Case 167 “had run out of food and money several days before. not once but twice he had managed to book train tickets to his hometown… but both times, it had been cancelled.” His family reported him to be “scared and restless, just wanted to go home… thought he will never be able to go back” and so “depressed” that “he even planned to walk back home”. They said that the “uncertainty killed him” (The Wire, 13.05.2020). Case 128, who walked from Hyderabad, where he worked, to his home in Maharashtra's Gondia district (650 km away) hung himself on a tree about 160 km from home, as he “lost his will to complete the remaining part of the journey” (The Indian Express, 02.05.2020). Case 152 “hurled himself in front of a goods train” after being “overwhelmed with depression after missing the only special train that would have taken him home” (The Times of India, 09.05.2020).

Craving for alcohol

Liquor stores were shut during the first 40 days, as alcohol was not an “essential” commodity. This resulted in suicides by “addicts” experiencing craving and withdrawal symptoms. For example, Case 39 was “visibly depressed” (Telangana Today, 01.04.2020) and Case 13 “had turned violent” (Asianet News, 27.03.2020). Such suicides were observed mainly in the Southern States [Table 1], which account for over 40% of India's alcohol consumption.

Domestic disputes

Some had argued with their family shortly before they died. In a few cases, the arguments were related to disobedience of lockdown rules or behavioral changes following the lockdown; for example, Case 136 was “angered” after his “father reprimanded him for repeatedly going to see his girlfriend outside the house” (Navbharat Times, 02.05.2020), and Case 113's “had started playing PUBG (online game) regularly… (was) furious at being scolded by his family members for playing the game for several hours” (Hindustan Times, 26.04.2020). Lockdown-induced financial problems also led to quarrels; in one instance involving a married couple (Cases 137 and 138), the policeman said “(Wife) had taken 5 lakhs as loan from a local committee for hiring a truck for their livelihood. She used to repay the instalment to the committee with the income from the truck… (but) the amount of loan accumulated as plying of vehicles was stopped. On the other hand, the lenders started pressurising her for early payment. The non-payment of loan led to dispute between the husband and the wife” (The Times of India, 04.05.2020). In two particularly disturbing incidents (Cases 56, and 239), men murdered their families, and then killed themselves. According to Case 56's daughter, “They [parents] could not bear being with each other and were frustrated to be together 24 h. They were having regular quarrels since last ten days and had even started hitting each other. Today, they had been fighting since morning. In the evening, my mother said something and my father rushed to the kitchen in rage. He repeatedly hit her and she died” (The Week, 03.04.2020).

Aspirational disappointments

For some people, the lockdown meant a delay or a failure in achieving major aspirations related to relationships or work, and the loss of their life's dreams and efforts. For example, teenagers Cases 67 and 68, “took the step as their families didn’t approve of their relationship and they couldn’t flee home due to the lockdown” (Outlook, 07.04.2020); Case 124 “was depressed over the uncertainty about her foreign study plans due to the lockdown” (The Times of India, 01.05.2020); and Case 266 (an actress) “wrote in a suicide note that she couldn’t live with ‘broken dreams’” (Hindustan Times, 27.05.2020). Six persons committed suicide following postponement of their engagement or wedding. Case 178 for example was “quite upset” when the nationwide lockdown was first implemented, as “after a very long search for a suitable life partner, [she] was finally going to get engaged.” When the lockdown continued, she “could not handle it anymore” (Ahmedabad Mirror, 13.05.2020). Notably, all aspirational disappointments were only seen in persons 30 years or younger.

Restrictions to behavior

Staying indoors, and the resulting behavioural restrictions triggered some suicides. For example, Case 268 “wasn’t allowed to step outside the house… used to go cycling and playing in the park every evening…. before killing himself, he had spoken to a friend on WhatsApp about being bored” (Mumbai Mirror, 29.05.2020); and Case 263 “had been suffering from depression ever since he was unable to go for a morning walk” (The Times of India, 24.05.2020).

Police violence and harassment

Some persons who had broken quarantine or lockdown rules were harassed or beaten by police officials and were upset and humiliated. For example, Case 44, who had left the quarantine center to help his sister-in-law said that a “constable beat me up severely.” In an audio clip he released to the public, he talked about his trousers being “stained in blood” and said “I don’t want to live now. Because of him (constable), I am killing myself.” His brother confirmed this and also said that the Police had “shot a video of the incident to shame him” (The Wire, 13.04.2020). Similarly, Case 60 who had travelled to his native district on a bicycle, was “arrested” by the Police, “they released him….(but the) vehicle remained in police custody.” He made a video in which he says, “(The) Police… are responsible for my death” (Newsd, 03.04.2020).

DISCUSSION

We report the findings of a qualitative analysis of media reports of suicides in India in the 4-month period after the first COVID-19 case and identify several disease and lockdown stressors. These stressors have also been observed in other countries, for example, the earliest reported COVID-19 suicides in Bangladesh and Pakistan[2324] were related to fears of the infection and/or economic distress. Similar findings have also been reported in previous epidemics. Spanish flu-related suicides, for example, have been attributed to contagion measures such as the closing of schools, religious institutions, and theatres, and the banning of social, sport and political gatherings, which resulted in decreased social integration and isolation, as well as fear in those affected and persons who had come into contact with them.[17] Similarly, social disengagement and fears of contracting the disease were seen in SARS-related suicides.[25] Unlike these pandemics, however, economic stressors were more predominantly seen in our sample; this can be largely attributed to the potential impact of containment strategies on migrant works, daily wage laborers, and others who work in the unorganized sector, who form over 90% of the country's labor force.

We observed an increase in suicides over this early phase, indicating a potential for further increase as the epidemic continues to unfold and economic recession bites deeper. We also observed a large number of suicides in men, and young people, indicating that these populations may be high-risk groups. However, official data are needed to confirm these findings.

We acknowledge that our narrative data may be subject to sensationalism and other reporting biases by journalists.[26] However, our method was the only reasonable one available, given both the confidentiality of suicide reports and the COVID-19 situation, which made it impossible to identify and meet with families of the deceased, for psychological autopsy investigations. We minimized these limitations through a systematic search of all media articles; using data from the deceased wherever available (suicide notes, etc.); and employing rigor in data extraction and analysis (using stringent inclusion criteria, and having two coders arrive at themes). Our methods are comparable with that of other studies which have used media reports to study suicides and other public health outcomes, including during the current pandemic.[2728]

Our study provides valuable insights as to what pandemic stressors may lead to suicide in India, which point to strategies for prevention – not just for COVID-19, but also future pandemics. These can target the whole population as well as high-risk groups, and include: government led virus-relief efforts; accurate, nonthreatening and nonstigmatizing communication about pandemics; strengthening of nonpandemic health services; more mental health support, for example, crisis centers, digital interventions, and allocations of resources towards combating long-term impact; screening for mental health problems, and provision of psycho-education and community support for symptomatic, alone and quarantined individuals, and involvement of family and general practitioners in this process; provision of psychological support for frontline workers; etc. Pandemic control strategies must be sensitive to potential adverse impacts on mental health, and be guided by the following principles: (1) considering the pandemic as a humanitarian crisis rather than a law-and-order problem; (2) conducting a detailed assessment of policies before implementation to ensure that the needs of the most vulnerable groups are addressed in advance; (3) preparing the community with sufficient planning and time; and (4) engaging a wide range of stakeholders, including media and health communities, to build public support and trust.

CONCLUSION

COVID-19 related suicides appear to be precipitated by social and economic adversities, mainly associated with containment strategies. These findings need to be confirmed by national suicide data. Suicide prevention strategies should mitigate the impact of recognized stressors in the long term, target high-risk individuals, and offer mental health care alongside containment strategies.

Financial support and sponsorship

Nil.

Conflicts of interest

Vikram Patel is an International Advisory Board Member at the Indian Journal of Psychiatry.