SUICIDE PREVENTION: CURRENT PERSPECTIVE
Sharma Bhartendra,
Associate Professor, Faculty of Nursing, Desh Bhagat University, Mandi Gobindgarh, India.
Kaur Sukhvir,
Assistant Professor, Sri Guru Ram Dass College of Nursing, Amritsar, India.
ABSTRACT
Suicide is an important issue in the Indian context. Suicide in India is slightly above world rate.
Of the half million people reported to die of suicide worldwide every year, 20% are Indians, for
17% of world population. The majority of suicides (37.8%) in India are by those below the age
of 30 years. The fact that 71% of suicides in India are by persons below the age of 44 years
imposes a huge social, emotional and economic burden on our society. Suicide is perceived as a
social problem in our country and hence, mental disorder is given equal conceptual status with
family conflicts, social maladjustment etc. According to the official data, the reason for suicide is
not known for about 43% of suicides while illness and family problems contribute to about 44%
of suicide. Divorce, dowry, love affairs, cancellation or the inability to get married (according to
the system of arranged marriages in India), illegitimate pregnancy, extra-marital affairs and
such conflicts relating to the issue of marriage, play a crucial role, particularly in the suicide of
women in India. At present it is a serious social problem especially among youth. There is a
great need for the educators, social leaders, government administrators and others to focus on
this problem.
Introduction
the last two decades, the suicide rate has increased from 7.9 to 10.3 per 100,000, with very high
rates in some southern regions1. In a study published in The Lancet in June 2012, the estimated
lakh (one hundred thousand) lives are lost every year to suicide in our country. In the last two
decades, the suicide rate has increased from 7.9 to 10.3 per 100,000. There is a wide variation in
the suicide rates within the country. The southern states of Kerala, Karnataka, Andhra Pradesh
and Tamil Nadu have a suicide rate of > 15 while in the Northern States of Punjab, Uttar
Pradesh, Bihar and Jammu and Kashmir, the suicide rate is < 3. This variable pattern has been
stable for the last twenty years. Higher literacy, a better reporting system, lower external
aggression, higher socioeconomic status and higher expectations are the possible explanations
for the higher suicide rates in the southern states2.The majority of suicides (37.8%) in India are
by those below the age of 30 years. The fact that 71% of suicides in India are by persons below
the age of 44 years imposes a huge social, emotional and economic burden on our society3. The
near-equal suicide rates of young men and women and the consistently narrow male: female ratio
of 1.4: 1 denotes that more Indian women die by suicide than their Western counterparts.
Poisoning (36.6%), hanging (32.1%) and self-immolation (7.9%) were the common methods
used to commit suicide. Two large epidemiological verbal autopsy studies in rural Tamil Nadu
reveal that the annual suicide rate is six to nine times the official rate. If these figures are
extrapolated, it suggests that there are at least half a million suicides in India every year. It is
estimated that one in 60 persons in our country are affected by suicide. It includes both, those
who have attempted suicide and those who have been affected by the suicide of a close family or
friend. Thus, suicide is a major public and mental health problem, which demands urgent action4.
Although suicide is a deeply personal and an individual act, suicidal behavior is determined by a
number of individual and social factors. Ever since Esquirol wrote that “All those who committed suicide are insane” and Durkheim proposed that suicide was an outcome of social /
societal situations, the debate of individual vulnerability vs social stressors in the causation of
suicide has divided our thoughts on suicide5. Suicide is best understood as a multidimensional,
multifactorial malaise. Suicide is perceived as a social problem in our country and hence, mental
disorder is given equal conceptual status with family conflicts, social maladjustment etc.
According to the official data, the reason for suicide is not known for about 43% of suicides
Divorce, dowry, love affairs, cancellation or the inability to get married (according to the system
of arranged marriages in India), illegitimate pregnancy, extra-marital affairs and such conflicts
relating to the issue of marriage, play a crucial role, particularly in the suicide of women in India.
A distressing feature is the frequent occurrence of suicide pacts and family suicides, which are
more due to social reasons and can be viewed as a protest against archaic societal norms and
expectations. In a population-based study on domestic violence, it was found that 64% had a
significant correlation between domestic violence of women and suicidal ideation7. Domestic
violence was also found to be a major risk factor for suicide in a study in Bangalore. The
population-based study has been done in various cities in India, however the Bangalore study is
the only psychological autopsy study that focused on completed suicide and domestic violence.
Poverty, unemployment, debts and educational problems are also associated with suicide. The
recent spate of farmers' suicide in India has raised societal and governmental concern to address
this growing tragedy8.
Suicide Prevention
The view that suicide cannot be prevented is commonly held even among health professionals.
Many beliefs may explain this negative attitude. Chief among these is that suicide is a personal
matter that should be left for the individual to decide. Another belief is that suicide cannot be
prevented because its major determinants are social and environmental factors such as
unemployment over which an individual has relatively little control. However, for the
overwhelming majority who engage in suicidal behaviour, there is a probably an appropriate
alternative resolution of the precipitating problems9. Suicide is often a permanent solution to a
temporary problem.
Mrazek and Haggerty's framework classified suicide prevention intervention as universal,
selective or indicated on the basis of how their target groups are defined. Universal interventions
target whole populations with the aim of favorably shifting proximal or distal risk factors across
the entire population. Selective interventions target subgroups whose members are not yet
Indicated interventions are designed for people already beginning to exhibit suicidal thoughts or
behavior10.
HOW TO IDENTIFY PATIENTS AT HIGH RISK OF SUICIDAL BEHAVIOUR
A number of clinically useful individual and sociodemographic factors are associated with
suicide. They include:
•Psychiatric disorders (generally depression, alcoholism and personality disorders); •Physical illness (terminal, painful or debilitating illness, AIDS);
•Previous suicide attempts;
•Family history of suicide, alcoholism and/or other psychiatric disorders; •Divorced, widowed or single status;
•Living alone (socially isolated); •Unemployed or retired;
•Bereavement in childhood.
If the patient is under psychiatric treatment, the risk is higher in:
•Those who have recently been discharged from hospital; •Those who have made previous suicide attempts.
In addition, recent life stressors associated with increased risk of suicide include:
•Marital separation; •Bereavement: •Family disturbances;
•Change in occupational or financial status; •Rejection by a significant person;
•Shame and threat of being found guilty.
There are various scales to assess suicide risk in surveys, but they are less useful than a good
clinical interview in identifying the individual who is at immediate risk of committing suicide.
The physician may be confronted with a variety of conditions and situations associated with
suicidal behavior. An elderly male, recently widowed, treated for depression, living alone, with a
boyfriend has left her are two contrasting examples11. In reality, most patients fall between those
two extremes and they may fluctuate from one category to the other. When physicians have a
reasonable indication that the patient could be suicidal, they face the dilemma of how to proceed.
Some physicians are uncomfortable with suicidal patients. It is important for them to be aware of
that feeling and to seek help from colleagues, and possibly mental health professionals, when
confronted with such patients. It is essential not to ignore or deny the risk. If the physician
decides to proceed, the first and most immediate step is mentally to allocate adequate time to the
patient, even though many others may be waiting outside the room12. By showing a willingness
to understand, the physician starts to establish a positive rapport with the patient. Closed-ended
and direct questions at the beginning of the interview are not very helpful. Remarks like "You
look very upset; tell me more about it” are useful. Listening with empathy is in itself a major step
in reducing the level of suicidal despair13.
Myths and Reality
Patients who talk about suicide rarely commit suicide.
Patients who commit suicide have usually given some clue or warning beforehand. Threats must
also be taken seriously.
Asking about suicide in a patient may provoke suicidal acts.
Asking about suicide will often reduce the anxiety surrounding the feeling; the patient may feel
relieved and better understood.
How to ask?
It is not easy to ask patients about their suicidal ideas14. It is helpful to lead into the topic
gradually. A sequence of useful questions is:
1. Do you feel unhappy and helpless?
2. Do you feel desperate?
3. Do you feel unable to face each day?
4. Do you feel life is a burden?
It is important to ask these questions:
•After a rapport has been established;
•When the patient feels comfortable about expressing his or her feelings; •When the patient is in the process of expressing negative feelings.
Further questions
The process does not end with confirmation of the presence of suicidal ideas. It continues with
further questions aimed at assessing the frequency and severity of the idea and the possibility of
suicide. It is important to know whether the patient has made any plans and has the means to
commit suicide. If a patient mentions that the method planned is shooting, but has no access to a
gun, the risk is lower15. However, if a patient has planned a method and is in possession of the
means (e.g. pills), or if the proposed means are easily accessible, the suicide risk is higher. It is
crucial for questions not to be demanding or coercive, but to be asked in a warm way showing
the physician’s empathy with the patient.
Such questions might include:
•Have you made any plans for ending your life? •How are you planning to do it?
•Do you have in your possession [pills / guns / other means]? •Have you considered when to do it?
Nongovernmental Organizations (NGOS)
India grapples with infectious diseases, malnutrition, infant and maternal mortality and other
major health problems and hence, suicide is accorded low priority in the competition for meager
resources. The mental health services are inadequate for the needs of the country. For a
population of over a billion, there are only about 3,500 psychiatrists. Rapid urbanization,
there is an emerging need for external emotional support. The enormity of the problem combined
with the paucity of mental health service has led to the emergence of NGOs in the field of
suicide prevention.
The primary aim of these NGOs is to provide support to suicidal individuals by befriending
them. Often these centers function as an entry point for those needing professional services.
Apart from befriending suicidal individuals, the NGOs have also undertaken education of
gatekeepers, raising awareness in the public and media and some intervention programmes17.
However, there are certain limitations in the activities of the NGOs. There is a wide variability in
the expertise of their volunteers and in the services they provide. Quality control measures are
inadequate and the majority of their endeavors are not evaluated.
National Plan
The World Health Organization's (WHO's) suicide prevention multisite intervention study on
suicidal behaviors (SUPRE-MISS), an intervention study, has revealed that it is possible to
reduce suicide mortality through brief, low-cost intervention in developing countries.
There is an urgent need to develop a national plan for suicide prevention in India. The priority
areas are reducing the availability of and access to pesticide, reducing alcohol availability and
consumption, promoting responsible media reporting of suicide and related issues, promoting
and supporting NGOs, improving the capacity of primary care workers and specialist mental
health services and providing support to those bereaved by suicide and training gatekeepers like
teachers, police officers and practitioners of alternative system of medicine and faith healers6.
Above all, decriminalising attempted suicide is an urgent need if any suicide prevention strategy
is to succeed in the prevailing system in India.
10th September - World Suicide Prevention Day: The World Suicide Prevention Day was
formally announced on 10th September, 2003. Each year the International Association for
Suicide Prevention (IASP) in collaboration with WHO uses this day to call attention to suicide as
that suicide prevention and intervention strategies may be adapted to meet the needs of different
age groups4. It is hoped that the theme will focus on vulnerable, ignored and stigmatized groups
and also draw together researchers, clinicians, societies, politicians, policy makers, volunteers
and survivors in a concerted action.
Conclusion
Suicide is a multifaceted problem and hence suicide prevention programmes should also be
multidimensional. Collaboration, coordination, cooperation and commitment are needed to
develop and implement a national plan, which is cost-effective, appropriate and relevant to the
needs of the community. In India, suicide prevention is more of a social and public health
objective than a traditional exercise in the mental health sector. The time is ripe for mental health
professionals to adopt proactive and leadership roles in suicide prevention and save the lives of
thousands of young Indians.
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