Portal de Periódicos da CAPES

Suicide in India – changing trends and challenges ahead

2015; Medknow; Volume: 57; Issue: 4 Linguagem: Inglês

10.4103/0019-5545.171835

1998-3794

R Ponnudurai,

Psychosomatic Disorders and Their Treatments

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 manner. To cite a few in India from the press reports, nine suicides were reported in a span of 6 months prior to September 2014 in the Bandra-Worli Sea Link in Mumbai,[37] about 1300 bodies were recovered in a period of 19 years in the Gandhi Sahar Lake, which has earned the dubious name "Suicide Lake" in Nagpur,[38] and the Marina/Elliot's beaches in Chennai has turned into a suicide point by consuming 24 persons in 2010.[39] Albert Bandura's social learning theory might be applicable to such imitative behavior of those who are already under emotional turmoil. Continuous press reports of suicidal attempts by followers of famous political and other personalities who are dead or under deep distress is another recent phenomenon in India. Apart from outpouring of grief and sympathy, other factors such as imitation, attention seeking, and altruism might explain these behaviors. Introduction of media guidelines on Viennese subway suicide reporting resulted in 75% decrease in the rate of subway suicides and a 20% decrease in the overall suicides in Vienna.[40] Lack of mechanisms in India to restrain the depiction of suicide behaviors in visual media and press emboldens them to highlight the suicides. In addition, frequent write-ups in press about suicide both by mental health and by nonmental health personnel might perhaps serve as "Suicide promotion" agencies on one hand. Whether restrictions on the press and visual media are possible in India, atleast, on the topics of suicide? Impact of internet and other communication networks on suicide Increasing cases of group suicides of strangers who meet over internet has been reported in Japan since last decade.[41] The victims are normally found to be young and meet over the internet through burgeoning number of suicide-related sites and chat rooms where participants are online, not to dissuade, but to support one another in their desire for suicide. Fears have been raised in the UK over link between suicide and internet, after 5981 internet suicides were reported in 2012.[42] Perhaps such people are still looking for companionship, even after death. Through interactions over mobile phones and internet, teenagers are being lured to meeting each other that may lead to risk-taking behaviors such as substance abuse and promiscuous sexual relationships. Such activities might end in suicide due to eventual psychosocial problems. Although the prevalence of such suicides in India is yet to be ascertained with accuracy, I suggest preventive measures before this problem becomes incurable. In this context, noteworthy is an Indian study which has reported that excessive users of internet were found to have high scores on anxiety and depression.[43] Implications on possible change in legal trends Euthanasia The much-awaited Supreme Court judgment delivered in 2011 that has legalized passive euthanasia in India might trigger more such pleas in future. Accordingly, the physicians and the concerned specialists would be entrusted with the responsibility of clinical assessment of the case. But, the evaluation of the mental status of the patient would be the inevitable task of the psychiatrist. The depressive and other psychotic features that might have contributed to such pleas, but nevertheless amenable to successful psychiatric intervention should be thoroughly examined. In addition, an in depth consideration of the ethical, legal, and also possible biases likely to be induced by extraneous circumstances including those by the family members, might be needed before the psychiatrist could give his opinion. Gay and lesbian marriages This issue is likely to become a subject matter of debate in the courts of law in future in our country. Apart from the usual factors that influence the suicidal behavior in same-sex oriented individuals, such as discrimination, humiliation, rejection by the parents, and society, an eventual marriage between these individuals might more often than not contribute some more factors. Those with ambivalence of will and cognition about their sexual orientation are likely to be motivated in giving their consent for gay/lesbian marriages under the influence of their partners. An explicit legal sanction might be a vital motivating factor promoting such bondages. But, in later life of such individuals conflicts may arise regarding their decisions, particularly in those having a predisposition for a heterosexual relationship also leading to guilt feelings and depression. Sexual orientation is reported to be a risk factor, with increased rates of suicidal behavior of 2–6 times among youth who identify themselves as gay, lesbian, or bisexual.[44] Mental health care bill 2010 If the bill becomes the act, an increase in suicide rate among our patients could be speculated. Escalation in the number of untreated and undertreated patients could be anticipated, as the psychiatrists may resort to defensive practice in the face of numerous ill-conceived restrictions imposed on diagnostic aspects and the treatment strategies proposed in this bill. An in-depth critical review of this bill has dwelt upon the disaster effects of this act on the care of the mentally ill.[45] Repeal of Section 309 Indian Penal Code While we welcome the move to repeal this section on attempted suicide, police officials fear that cases of homicide might be missed as they could be admitted as cases of attempted suicide. The police fear that vital clues that could have been obtained from preliminary enquiry may be lost, if it comes to light later as a case of homicide after the death of the patient. Such apprehensions indicate the demand for detailed history, meticulous medical examination including the necessary investigations and proper documentation by the physician and psychiatrist. Notwithstanding, since the psychiatrist is involved in the psychotherapeutic management, responsibility will rest on him also to report to appropriate authorities whenever suspicion arises over the alleged suicidal attempt. He might also be called upon to the court of law to depose over his findings in cases of doubt. In addition, it is claimed that police intervention will serve as a deterrent to those who had overtly or covertly abetted the suicide attempt. This intervention could, in fact, be an effective "adjuvant therapy," along with psychotherapeutic measures adopted by the psychiatrist, it is argued. Perhaps, the entire section of Indian Penal Code (IPC) 309 might warrant modification, keeping in view patient care and other issues raised above. Lacunae in Indian research on suicide In his editorial introduction, Simpson[46] has mentioned that throughout Durkheim's work on each and all of the topics subsidiary to suicide, is the basic theme that suicide which appears to be a phenomenon relating to the individual, is actually explicable etiologically with reference to social structure and its ramifying functions. Such psychosocial theories have been so much imprinted in the psyche of lay persons that even the investigating officers and Courts of law ignore the biological predisposition of suicide victims, while handing out punishments to the abetters of suicides under Section 306 of IPC. The biological determinants of suicide have also been the focus of research during the last few decades world over. However, in this aspect Indian researches have not made much headway, as it should have been except for a few interesting works.[4748495051] POINTERS FOR SUICIDE-PREVENTION STRATEGIES Development of strategies for suicide prevention applicable for our Indian culture and to suit the needs of different strata of our society is important. Furthermore, we have to develop programs and policies which can be implemented along with other national health, education, and welfare programs. The following few measures are suggested: Opening up of suicide prevention clinics in all the Medical College Hospitals, District Head Quarters Hospitals, and if possible in Taluk Head Quarters, and also in private hospitals. Such measures will at least help to prevent repeat attempts Opening up of special clinics such as De-addiction and Marital Counseling Clinics in all the major hospitals, might help to counter the factors arising due to substance abuse and family problems Conducting educational programs periodically for the medical officers and paramedical personnel of the above hospitals and also to those in general practice (through Indian Medical Association and other organizations), primary health cares, and rural areas, so that they can be trained for the detection and preliminary management of depression and other psychiatric conditions Promotion of consultation-liaison psychiatric services in all the hospitals Restricting the access to means of suicide including measures for control of availability of pesticides, medications, etc Adequate barriers to deter jumping from high places even when the Government or Private Agencies design such structures Opening up of students guidance clinics to be run by visiting psychiatrists not only to improve their psychological well-being, but also to enable them to explore their own potential to engage themselves in today's world with immense avenues, and also conducting guidance sessions for parents in schools and colleges Revamping the educational system with an objective to promote holistic development of the child, rather than the undue emphasis on scoring of marks in various subjects Opening up of employees guidance clinics in major industries Engaging the services of qualified and trained mental health professionals with a psychiatrist at the helm of the team in Women Police Stations and Family Courts since most of the cases of disputes between the spouses, and family problems are dealt with in these centers, where some of them could be solved with psychiatric intervention To assess by appropriate Indian studies, whether restrictions on media publicity on suicides and displays in any form by anybody including mental health, as well as by nonmental health professionals will be of use in suicide prevention My dear colleagues, I also suggest more Indian research in biological aspects of suicide, as presently they are only a few Finally, I appeal to our Indian Psychiatric Society and to my beloved dynamic team of psychiatrists in India for their proactive role in suicide prevention measures. This could also be done in collaboration with agencies such as suicide help lines and government, so that we can effectively deal with the changing trends in Indian suicides and face the challenges ahead to create suicide-free India. CONCLUSION Suicide is a tragic culmination of the interaction of a wide array of factors including biological, sociocultural, environmental, and psychological causes. Since our country has been plagued by astronomical suicide rate, suitable policies require to be taken to meet the challenges ahead for suicide prevention in India. "No man is an island, entire of itself; every man is a piece of the continent, a part of the main…. Any man's death diminishes me, because I am involved in mankind And therefore never send to know for whom the bell tolls; it tolls for thee." –For whom the Bell Tolls, John Donne "Cans't thou not minister to a mind diseas'd, Pluck from the memory a rooted sorrow, Race out the written troubles of the brain, And, with some sweet oblivious antidote, Cleanse the stuff'd bosom of that perilous stuff, Which weighs upon the heart?" –Macbeth, Shakespeare Play Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.