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GUEST EDITORIAL

Suicide and its prevention: The urgent need in India

Lakshmi Vijaykumar
SNEHA and VHS, Chennai, India

Suicide is an important issue in the Indian context. More than the debate of individual vulnerability vs social stressors
one lakh (one hundred thousand) lives are lost every year to in the causation of suicide has divided our thoughts on
suicide in our country. In the last two decades, the suicide suicide. Suicide is best understood as a multidimensional,
rate has increased from 7.9 to 10.3 per 100,000. There is multifactorial malaise. Suicide is perceived as a social

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a wide variation in the suicide rates within the country. problem in our country and hence, mental disorder is
The southern states of Kerala, Karnataka, Andhra Pradesh given equal conceptual status with family conflicts, social

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and Tamil Nadu have a suicide rate of > 15 while in the maladjustment etc.[5] According to the official data, the

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Northern States of Punjab, Uttar Pradesh, Bihar and Jammu reason for suicide is not known for about 43% of suicides

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and Kashmir, the suicide rate is < 3. This variable pattern while illness and family problems contribute to about 44%
has been stable for the last twenty years. Higher literacy, of suicides.

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a better reporting system, lower external aggression,

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higher socioeconomic status and higher expectations are
the possible explanations for the higher suicide rates in the
Divorce, dowry, love affairs, cancellation or the inability to
get married (according to the system of arranged marriages
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southern states. in India), illegitimate pregnancy, extra-marital affairs and such
conflicts relating to the issue of marriage, play a crucial role,
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The majority of suicides (37.8%) in India are by those below particularly in the suicide of women in India. A distressing
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the age of 30 years. The fact that 71% of suicides in India[1] feature is the frequent occurrence of suicide pacts and
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are by persons below the age of 44 years imposes a huge family suicides, which are more due to social reasons and
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social, emotional and economic burden on our society. The can be viewed as a protest against archaic societal norms
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near-equal suicide rates of young men and women[2] and and expectations. In a population-based study on domestic
the consistently narrow male: female ratio of 1.4: 1 denotes violence, it was found that 64% had a significant correlation
that more Indian women die by suicide than their Western between domestic violence of women and suicidal ideation.[6]
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counterparts. Poisoning (36.6%), hanging (32.1%) and self- Domestic violence was also found to be a major risk factor
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immolation (7.9%) were the common methods used to for suicide in a study in Bangalore.[7] The population-based
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commit suicide.[1] Two large epidemiological verbal autopsy study has been done in various cities in India, however the
studies in rural Tamil Nadu reveal that the annual suicide Bangalore study is the only psychological autopsy study
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rate is six to nine times the official rate.[3,4] If these figures that focused on completed suicide and domestic violence.
are extrapolated, it suggests that there are at least half Poverty, unemployment, debts and educational problems
a million suicides in India every year. It is estimated that are also associated with suicide. The recent spate of farmers’
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one in 60 persons in our country are affected by suicide. It suicide in India has raised societal and governmental concern
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includes both, those who have attempted suicide and those to address this growing tragedy.
who have been affected by the suicide of a close family or
friend. Thus, suicide is a major public and mental health MENTAL DISORDERS AND SUICIDE
problem, which demands urgent action.
Mental disorders occupy a premier position in the matrix of
Although suicide is a deeply personal and an individual act, causation of suicide. Majority of studies note that around
suicidal behaviour is determined by a number of individual 90% of those who die by suicide have a mental disorder.[9]
and social factors. Ever since Esquirol wrote that “All those The number of published reports specifically studying the
who committed suicide are insane” and Durkheim proposed psychiatric diagnoses of people who die by suicide has been
that suicide was an outcome of social / societal situations, relatively small (n = 15629). The majority (82.2%) of such
Correspondence: Dr. Lakshmi Vijayakumar,
reports come from Europe and North America with a mere
SNEHA and VHS, Chennai, India. 1.3% from developing countries.[8] Two case control studies
E-mail: dr_svk@vsnl.com using psychological autopsy technique have been conducted
in Chennai[10] and Bangalore[7] in India. Among those who
How to cite this article: Vijayakumar L. Suicide and its died by suicide, 88% in Chennai and 43% in Bangalore
prevention: The urgent need in India. Indian J Psychiatry
had a diagnosable mental disorder. However, diagnostic
2007;49:81-4.
evaluations were not done in the Bangalore study.

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Vijayakumar: Suicide and its prevention

Countless experts have found that affective disorders are given to these suicides by the media has led to suicides in a
the most important diagnosis related to suicide. In Chennai, similar manner. Copying methods shown in movies are also
25% of completed suicides were found to be due to mood not uncommon. This is a serious problem especially in India
disorders. However, the suicide rate increased to 35% when where film stars enjoy an iconic status and wield enormous
suicide cases with adjustment disorder with depressed mood influence especially over the young who often look up to
were also counted. The crucial and causal role of depression them as role models.
in suicide has limited validity in India. Even those who were
depressed, were depressed for a short duration and had The implementation of the recommendation of the Mandal
only mild to moderate symptomatology. The majority of Commission to reserve 27% of the positions for employment
cases committed suicide during their very first episode of in Government created unrest in the student community
depression and more than 60% of the depressive suicides and a student committed self-immolation in front of a group
had only mild to moderate depression.[10] Although social of people protesting against such a reservation. This was
drinking is not a way of life in India, alcoholism plays a sensationalized and widely publicized by the media. There

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significant role in suicide in India. Alcohol dependence and was a spate of student self-immolation (n = 31) around
abuse were found in 35% of suicides. Around 30-50% of male the country. These copycat suicides caused public outcry

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suicides were under the influence of alcohol at the time of and was considered one of the reasons for the fall of the

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suicide and many wives have been driven to suicide by their government in power at that time.[12]
alcoholic husbands. Not only were there a large number of

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alcoholic suicides but also many had come from alcoholic Social change

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families and started consumption of alcohol early in life and The effects of modernization, specifically in India, have led to
were heavily dependent. The odds ratio (OR) for alcoholism sweeping changes in the socioeconomic, sociophilosophical
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was 8.25 (confidence interval: CI 2.9-3.2) in Chennai[10] and
4.49 (CI 2.0-6.8) in Bangalore.[7] About 8% of suicides in India
and cultural arenas of people’s lives, which have greatly
added to the stress in life, leading to substantially higher
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are committed by persons suffering from schizophrenia. rates of suicide.[13] In India, the high rate of suicide among
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Srinivasan and Thara found that the male to female ratio young adults can be associated with greater socioeconomic
for schizophrenic suicides is more or less equal.[11] Although stressors that have followed the liberalization of the
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diagnosable mental disorders were found in 88% of suicides economy and privatization leading to the loss of job security,
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in the Chennai study, only 10% had ever seen a mental health huge disparities in incomes and the inability to meet role
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professional. According to a government report, only 4.74% obligations in the new socially changed environment. The
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of suicides in the country are due to mental disorders. breakdown of the joint family system that had previously
provided emotional support and stability is also seen as an
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Personality disorder was found in 20% of completed suicides. important causal factor in suicides in India.[14]
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The OR was 9.5 (CI 2.29-84.11). Cluster B personality

disorder was found in 12% of suicides. Comorbid diagnosis Religiosity
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was found only in 30% of suicides.[10] A history of previous Religion acts as a protective factor both at the individual
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suicide attempt(s) increases risk of subsequent suicide. and societal levels. The often-debated question is whether
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The OR for previous suicide attempts was 5.2 (CI 1.96- the social network offered by religion is protective or
17.34) in Chennai and 42.62 (5.78-313.88) in Bangalore. In whether it is the individual’s faith. A study in Chennai
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the Bangalore study, family history of completed suicides found that the OR for lack of belief in God was 6.8 (CI 2.88-
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showed a greater risk of suicide (OR 7.69 CI 2.13-32.99) 19.69).[15] Those who committed suicide had less belief in
as compared to the suicidal risk indicated by the family God, changed their religious affiliation and rarely visited
history of attempted suicides. In the Chennai study, 12% places of worship. Eleven per cent had lost their faith in
had a family history of suicide (OR 1.33; CI 0.6-3.09) in first- the three months prior to suicide. Gururaj et al. also found
degree relatives and 18% in second-degree relatives (Fisher that lack of religious belief was a risk factor (OR 19.18, CI
Exact Probability test (FET) P = 0.001). 4.17-10.37).[7]

Clusters of suicides Legal issues

The media sometimes gives intense publicity to “suicide In India, attempted suicide is a punishable offence.
clusters” - a series of suicides that occur mainly among Section 309 of the Indian Penal Code states that “whoever
young people in a small area within a short period of attempts to commit suicide and does any act towards the
time. These have a contagious effect especially when they commission of such an offense shall be punished with
have been glamorized, provoking imitation or “copycat simple imprisonment for a term which may extend to one
suicides”. This phenomenon has been observed in India on year or with a fine or with both”.
many occasions, especially after the death of a celebrity,
most often a movie star or a politician. The wide exposure However, the aim of the law to prevent suicide by legal

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Vijayakumar: Suicide and its prevention

methods has proved to be counter-productive. Emergency NGOs have also undertaken education of gatekeepers, raising
care to those who have attempted suicide is denied as awareness in the public and media and some intervention
many hospitals and practitioners hesitate to provide the programmes. However, there are certain limitations in the
needed treatment fearful of legal hassles. The actual data activities of the NGOs. There is a wide variability in the
on attempted suicides becomes difficult to ascertain as expertise of their volunteers and in the services they provide.
many attempts are described to be accidental to avoid Quality control measures are inadequate and the majority of
entanglement with police and courts. their endeavors are not evaluated.[17]

SUICIDE PREVENTION NATIONAL PLAN

The view that suicide cannot be prevented is commonly The World Health Organization’s (WHO’s) suicide
held even among health professionals. Many beliefs may prevention multisite intervention study on suicidal behaviors
explain this negative attitude. Chief among these is that (SUPRE-MISS), an intervention study, has revealed that it is

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suicide is a personal matter that should be left for the possible to reduce suicide mortality through brief, low-cost
individual to decide. Another belief is that suicide cannot intervention in developing countries.

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be prevented because its major determinants are social and

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environmental factors such as unemployment over which There is an urgent need to develop a national plan for
an individual has relatively little control. However, for the

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suicide prevention in India. The priority areas are reducing
overwhelming majority who engage in suicidal behaviour, the availability of and access to pesticide, reducing alcohol

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there is a probably an appropriate alternative resolution of availability and consumption, promoting responsible
the precipitating problems. Suicide is often a permanent
solution to a temporary problem. ow w do media reporting of suicide and related issues, promoting
and supporting NGOs, improving the capacity of primary
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care workers and specialist mental health services and
Mrazek and Haggerty’s[16] framework classified suicide providing support to those bereaved by suicide and training
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prevention intervention as universal, selective or indicated gatekeepers like teachers, police officers and practitioners
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on the basis of how their target groups are defined. of alternative system of medicine and faith healers. Above
Universal interventions target whole populations with the
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all, decriminalising attempted suicide is an urgent need

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aim of favorably shifting proximal or distal risk factors if any suicide prevention strategy is to succeed in the
across the entire population. Selective interventions target
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prevailing system in India.

subgroups whose members are not yet manifesting suicidal
behaviour but exhibit risk factors that predispose them to 10th September - World Suicide Prevention Day: The World
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do so in the future. Indicated interventions are designed Suicide Prevention Day was formally announced on 10th
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for people already beginning to exhibit suicidal thoughts September, 2003. Each year the International Association
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or behaviour. for Suicide Prevention (IASP) in collaboration with WHO

uses this day to call attention to suicide as a leading cause
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NONGOVERNMENTAL ORGANIZATIONS (NGOS) of premature and preventable death. The theme for the
year 2007 is “Suicide Prevention—Across the Life Span”. It
India grapples with infectious diseases, malnutrition, calls attention to the fact that suicide occurs at all ages and
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infant and maternal mortality and other major health that suicide prevention and intervention strategies may be
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problems and hence, suicide is accorded low priority in adapted to meet the needs of different age groups. It is
the competition for meager resources. The mental health hoped that the theme will focus on vulnerable, ignored and
services are inadequate for the needs of the country. For stigmatized groups and also draw together researchers,
a population of over a billion, there are only about 3,500 clinicians, societies, politicians, policy makers, volunteers
psychiatrists. Rapid urbanization, industrialization and and survivors in a concerted action.
emerging family systems are resulting in social upheaval
and distress. The diminishing traditional support systems CONCLUSION
leave people vulnerable to suicidal behavior. Hence, there
is an emerging need for external emotional support. The Suicide is a multifaceted problem and hence suicide
enormity of the problem combined with the paucity of prevention programmes should also be multidimensional.
mental health service has led to the emergence of NGOs in Collaboration, coordination, cooperation and commitment
the field of suicide prevention. are needed to develop and implement a national plan, which
is cost-effective, appropriate and relevant to the needs of
The primary aim of these NGOs is to provide support to the community. In India, suicide prevention is more of a
suicidal individuals by befriending them. Often these centers social and public health objective than a traditional exercise
function as an entry point for those needing professional in the mental health sector. The time is ripe for mental
services. Apart from befriending suicidal individuals, the health professionals to adopt proactive and leadership

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Vijayakumar: Suicide and its prevention

roles in suicide prevention and save the lives of thousands 8. Bertolote JM, Fleischmann A, De Leo D, Wasserman D. Suicide and mental
disorders: Do we know enough? Br J Psychiatry 2003;183:382-3.
of young Indians. 9. Vijayakumar L, John S, Pirkis J, Whiteford H. Suicide in developing countries
(2): Risk factors. Crisis 2005;26:112-9.
10. Vijayakumar L, Rajkumar S. Are risk factors for suicide universal? A case
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6. World Health Organization. World Health Report. Mental Health - New and treatment of suicidal behaviour. Hawton K, editor. Oxford University
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7. Gururaj G, Isaac M, Subhakrishna DK, Ranjani R. Risk factors for completed
suicides: A case-control study from Bangalore, India. Inj Control Saf Promot

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2004;11:183-91.
Source of Support: Nil, Conflict of Interest: None declared

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