Suicide in India – changing trends and challenges ahead

Dear Colleagues, I would like to begin my oration with my humble homage to the doyen in the field of psychiatry, Prof. D. L. N. Murti Rao in whose name this prestigious oration has been installed. Unfortunately, he was snatched away from us by an untimely demise on the last day of 1962. But, for us he has left behind volumes of his scholarly works. One such work that had prompted me to pursue was on suicide. At this juncture, my humble homages are also to my beloved teacher Prof. A. Venkoba Rao at whose feet I learned not only the ABCD of psychiatry, but also got the inspiration to pursue his pioneering works on suicide, and the same drive has indeed made me choose this topic for my oration. Moreover, I owe my gratitude to my mentors revered Prof. M. Sarada Menon and Prof. O. Somasundaram for their constant guidance in my academic activities. INTRODUCTION Suicide in ancient India has largely been influenced by sacrificial motives, for the sake of honor, religious, and sociocultural beliefs apart from psychiatric and other causes. Ramayana and Mahabharata are the twin epics of India and down centuries they have influenced the thoughts, temper, conduct, and culture of our people. From the pages of Ramayana, it is learned that stung by a baseless accusation that he had accepted his wife after her stay in Ravana's abode, Lord Rama unleashed: “I shall abandon my own life; take my life and should be glad to kill you all.” Lord Rama's foremost devotee, Hanuman when his initial search for Sita proves futile, for a moment decides to commit suicide. He would rather give up his life than return without clues or news of Sita.[1] In Mahabharata, on hearing the news about the death of his son Abhimanyu in the battle, Arjuna wanted a huge fire to be prepared for him to commit suicide; however, that was prevented by Lord Krishna by reminding Arjuna about his own earlier advice to another old man who tried to commit suicide by falling into fire on the death of his son.[1] Chandra Gupta Maurya in 298 BC together with one of his Jain saints and many other monks went to South India; there he ended his life by deliberate slow starvation in the orthodox Jain manner.[2] Here, the individual kills himself purely for the sake of sacrifice because even with no particular reason, renunciation in itself is considered praiseworthy. The great Chola king Koperunchola renounced the kingdom in favor of his son and decided to undertake the traditional fast unto death in one of the small islands surrounded by river Cauvery in the vicinity of the sacred Vaishnava shrine in Srirangam. All the elements mentioned by Durkeim probably played a part in this suicide viz., egoistic, altruistic, and anomie.[3] In the practice of “Sati,” the self-immolation of the widow is classified as obligatory altruistic suicide by Durkeim. Sociocultural beliefs and partly religious beliefs play the role here. In modern times too altruistic suicides have been witnessed. The great leader Potti Sriramulu gave up his life by fasting unto death for the creation of Andhra Pradesh. RECENT DRIFT IN SOCIODEMOGRAPHIC PROFILE OF SUICIDE IN INDIA Suicide rate Over centuries changes in several domains that have contributed to suicide have been witnessed. India is labeled as “Suicide Capital of South-East Asia’ as it has recorded the highest number of suicides in South-East Asia in 2012, according to a WHO report.[4] Are we going to dismiss this report as ill-founded? If you look at the progress of the rate of suicide[6] [Table 1], in 1967 the suicide rate in India was 7.8, but it has steadily increased to 11.0 in 2013, with a peak rate of 11.4 in 2010.Table 1: Suicide rates in IndiaAge group There is a shift in the predominance of the number of suicides from the elderly to the younger people all over the world. However, this is most noticeable in our country. India is reported to be brimming with 356 million youths, and has the world's largest youth population despite having a smaller population than China.[5] A report of the Government of India in 1999 revealed that more than 65% of all suicides are committed by persons between ages of 15 and 24 years.[6] Not surprisingly, higher suicide rate in youth was already observed by several Indian studies too.[78910111213141516] Adolescents in their late stage are likely to experience more stress and emotional turmoil as they face the threshold of adulthood. In this period, many stressors, to name a few, poor scholastic performance, rising expectations from parents, getting involved in relationships much before they are mature enough to handle them, and ensuing frustrations when it is rejected by either side or by their parents, employment status, marriage issues, and so on might create pressures on them. But, more recently it is observed that such a higher rate is by no means consistently exclusive for the youth only, for in the recent report published by National Crime Records Bureau (NCRB) even as 34.4% of all suicides was between 15 and 29 years, almost equally, i.e. 33.8% of all suicides was also between 30 and 44 years [Figure 1a and b]. But, the problems faced by the middle-aged group might be of a different kind such as, family problems including interpersonal difficulties with spouses, unemployment, and debts.Figure 1: (a) Age group. (b) Age group (Contd.)Students suicide Suicide of students has risen from 5.5% of all cases in 2010 to 6.2% in 2013.[6] The vulnerability of the student population depends on several factors. The findings that students with a parent not alive and those whose mothers were working were at a higher risk for suicidal behavior suggests the importance of parent's support and their availability for ensuring the adolescent capacity to prevail over various stresses in life.[17] On the contrary, it must also be noted the parents’ over expectations on their academic achievements and criticisms on their underperformance could be contributing factors for suicidal behavior. Humiliations meted out in schools and problems in sexual relationships could also be among other factors. In the current scenario in India, employment opportunities are shrinking. Policies including for self-employment require to be framed, quality of education needs to be strengthened, and the feeling that education has not made them employable needs to be addressed. Farmers suicide The number of farmers who had committed suicide in 2010 has reached a peak with 15,964 deaths as against 11,096 in 2009. Although there is a decline in 2013 (11,772), the figure is still higher than in the earlier years. The state of Maharashtra seems to have more number of victims more recently.[6] It has been observed that the farmers who committed suicide were under huge debts, and the income from agriculture was not adequate to repay the borrowed money. In the absence of any help, these farmers perhaps chose to end their lives. This phenomenon is imposing a challenge not only to mental health professionals, but also to political and social reformers. What are the strategies to be adopted here? A multipronged approach including financial, material, and psychological support is needed to reduce the incidence of suicide among the farmers who are the back bone of our country. Suicide in armed forces According to a Government of India report, 597 military personnel have committed suicide in the last 5 years.[18] Whether this trend in armed forces was already an existing one or it is only a recent occurrence is not clear. Soldiers posted in far flung areas and on prolonged deployment undergo tremendous mental stress for not being able to take care of the problems faced by their families back home. This could be compounded by the lack of basic amenities, ineffectual leadership, and sometimes humiliation at the hands of their officers. On analyzing 22 cases of attempted suicides in armed forces,[19] it was observed the noteworthy problems as service-related in eight personnel, disciplinary proceedings in two, bad peer relationship in six, and family issues in three. Family suicides Taking cognizance of an increase in press reports of family members committing suicide together, the government has begun enumerating such suicide pacts from the year 2009. Accordingly, in 2010 the number of such victims was 290 and in 2013 it was 108. Certainly the figures might be far less, as the government sources have confessed that 11 States have not furnished this information.[6] At any rate, most of such family suicides are reported to be the end result of extreme poverty and debts, although other factors such as intractable ailments of important family members, humiliating incidents to the family, and superstitious beliefs might also be contributory. FACTORS GAINING MOMENTUM IN INFLUENCING SUICIDE IN INDIA Substances abuse Although substance abuse has been well documented from the pre-Christian era; their role in suicidal behavior has drawn the attention of the researchers only from the previous century. One of the earliest reports revealed, 10.3% among the male suicides to be under the influence of alcohol and drug abuse.[11] This observation was strengthened by some of the subsequent studies, although their number was a little less.[202122232425] While a few studies have not reported any case of substance abuse in their sample,[1326] some recent studies have reported the alarmingly high proportion of such cases.[2728] At any rate, such observations have to be interpreted with caution as there is no uniform policy on alcohol or drug use in different States in India. Many of the substance abusers attempt suicide while under the influence of alcohol. Perhaps, the conflicts regarding various domestic and other problems, feelings of guilt, and death wish come to the fore uninhibited at this stage. That apart, neurobiological changes occurring under intoxication, development of complications such as psychotic disorder, depressive disorder, delirium, and physical illnesses might drive them to this end. Problems with parents-in-law and spouses One of the earliest studies on suicide noted domestic problems as an important factor.[7] In the year 1967, when the NCRB first commenced its enumerations, quarrels with parents-in-law and spouses formed 16.3% of all causes, whereas in 2013 this figure has risen to 24% [Figures 2 and 3]. The problems with parents-in-law and spouses have been the foremost among the causes over several decades. But, more recently there is a spurt in this proportion. The incidence of divorces, separation of the spouses due to interpersonal problems, broken homes, and maladjustment among family members could be cited as some of the important emerging causes.Figure 2: Problems with parents-in-law family and spousesFigure 3: Percentage share of causes of suicide during 2013Elsewhere, it was reported marital maladjustment as the cause of suicides in 6.3% males and 23% females (total 14%).[12] Similar was the finding (13.3%) in another study.[21] It is distressing to note that even higher prevalence has been observed by some.[101329] On analyzing exclusively the cases of burns, marital problems was observed in 51% of victims.[30] While observing that among female suicides, 12.3% were due to alcohol and drug abusing husbands,[11] the behavior problems and symptoms such as delusional jealousy manifested by the alcoholics were noted to be important driving factors. Hence, the need for popularizing family and marital counseling has been advocated.[3031] Mental illness Although there is no perceptible variation in the proportion of medical disorders leading to suicides over the recent years, except perhaps cases of HIV taking the place of sexually transmitted disease cases, an increasing proportion of mental disorders should be a cause for concern. As per the NCBR data, the percentage of suicides due to mental illness in 1999 was 4.8%, whereas this figure has increased to 5.9% in 2013 with a peak of 7.0% in 2010.[6] Not surprisingly, the government enumerators’ concept of mental illness reflects the common man's assumption which is usually a psychotic disorder, perhaps including a severe depressive disorder. Hence, the government's figure might be much less. Moreover, it does not include substance abuse, as it has been listed separately. CHANGING TRENDS IN THE PREFERENCES FOR THE METHODS ADOPTED FOR SUICIDE Cut and stab injuries Among the various modes adopted, cut and stab injuries also seem to have gained popularity, albeit, mostly for a deliberate self-harming motive with lesser suicidal intent, but some end fatally. A study[25] had reported knife injuries in 21 out of 87 of their cases. Of these, 14 were nonfatal with superficial cut injuries, but the rest seven had a fatal end (depressive disorder-6, schizophrenia-1). Among the various types of injuries, wrist cutting, throat slitting, and stabbing of abdomen are noteworthy. These methods have been reported from other centers too.[212328293233] Hanging mode Among the suicides, a surge in hanging mode is noticed in comparison to other methods. NCRB report of 1967 indicated that 18.75% of suicides were by hanging, whereas this figure has risen to 25.11% and 39.8% in 1987 and in 2013, respectively [Figure 4]. As you all know, this is a well-known method from the pre-Christian era, but recently many of the successful victims have chosen this method. Easy accessibility, least expense, and a comparatively sure end over other methods could perhaps be motivating factors. At least in most of the cases, adoption of hanging mode might be indicative of the severity of suicidal intent.Figure 4: Suicide methodsCHALLENGES AHEAD Media messages and publicity of suicide Ramadas et al.[34] in the “position statement and guideline for media coverage of suicide” have described the Werther effect[35] following the publication of the novel “The Sorrows of Young Werther” that has led to a spate of suicides in Europe. The authors also pointed out the imitation of the methods following the publication of the book “Final exit” by Derek Humphrey in New York.[36] Imitation in suicidal behavior was observed in Indian studies also.[11] After a press report of suicide from a particular spot narrating the method adopted, a spate of suicides have been found to have occurred in the same spot and in the similar a few in India from the press suicides were reported in a of to in the in about were in a of years in the which has the name “Suicide in and the in has into a suicide by 24 persons in social might be to such behavior of those who are already under emotional press reports of suicidal by of political and other who are or under is another recent phenomenon in India. from of and other factors such as attention and might these of media on suicide in in the rate of suicides and a in the suicides in of in India to the of suicide in media and press them to the In in press about suicide by mental health and by health personnel might perhaps as “Suicide on one Whether on the press and media are in India, on the of of and other on suicide cases of group suicides of who over has been reported in last The victims are found to be and over the number of and are not to but to support one another in their for suicide. have been in the over between suicide and after suicides were reported in such people are still for even after over and are being to other that to such as substance abuse and sexual might end in suicide due to Although the prevalence of such suicides in India is to be with I before this In this noteworthy is an Indian which has reported that of were found to have high on and on in The in that has in India might more such in Accordingly, the and the would be with the of of the But, the of the mental of the would be the of the The depressive and other psychotic that might have contributed to such but to successful psychiatric should be In an in of the and also likely to be by including those by the family members, might be needed before the could give his and This is likely to a of in the of in in our country. from the factors that influence the suicidal behavior in such as by the parents, and an marriage between these might more than not some more factors. with of and about their sexual are likely to be in their for under the influence of their might be a motivating such But, in life of such conflicts regarding their in those having a for a relationship also leading to feelings and is reported to be a risk with increased rates of suicidal behavior of times among youth who as or Mental health care 2010 If the the an increase in suicide rate among our could be in the number of and could be as the to practice in the face of on and the strategies in this of this has the of this on the care of the of Indian While we the to this on attempted suicide, that cases of might be as they could be as cases of attempted suicide. The that clues that could have been from be it to as a case of after the death of the the for medical including the and by the and the is involved in the rest on him also to report to over the suicidal He might also be to the of to over his findings in cases of In it is that as a to those who had or the suicide This in be an with adopted by the it is Perhaps, the of Indian might in care and other issues in Indian on suicide In his has mentioned that work on and all of the to suicide, is the basic that suicide which to be a phenomenon to the is with to social and its have been so much in the of persons that even the and of the of suicide while out to the of suicides under of The of suicide have also been the of during the last few However, in this Indian have not made much as it should have been except for a few FOR of strategies for suicide for our Indian culture and to the needs of different of our is we have to and which be with other and The following few are up of suicide in all the and in and also in at least to up of such as and in all the might to the factors due to substance abuse and family problems for the medical and personnel of the and also to those in practice Indian and other health and so that they be for the and of and other psychiatric of psychiatric in all the the to means of suicide including for of availability of to from high even when the Government or such up of students guidance to be by not only to their psychological but also to them to their own to in with and also guidance for in schools and the with an to development of the rather than the on of in various up of guidance in the of and mental health with a at the of the in and Family most of the cases of between the spouses, and family problems are with in these some of them could be with psychiatric by Indian studies, on media publicity on suicides and in any by including mental as well as by health be of use in suicide I also more Indian in of suicide, as they are only a few I to our Indian and to my beloved of in India for their role in suicide This could also be in with such as suicide and so that we with the in Indian suicides and face the to create India. Suicide is a of the of a of factors including and psychological causes. our has been by suicide rate, require to be to the for suicide in India. man is an of man is a of the a part of the man's death because I involved in to for the it for the not to a from the a out the of the with some the of that the support and of There are no conflicts of