108 Suicide prevention in India: Considering religion and culture

India is the seventh largest country in the world and the largest democracy. The population of India is 1.08 billion, which means that one in every six human beings are Indian. There are twenty-eight states and seven Union Territories, eighteen official languages and eight hundred dialects. India is truly a multicultural, multilingual, multi-religious melting pot.

India is now emerging as an economic power. The software and IT sector, modernization of telecommunications and in-creased pace of privatization, has brought about a paradigm shift in the lifestyle of the urban Indian. However, the growth is not equitable, and the urban/rural divide is wide. There is also a huge disparity in the availability of infrastructure and resources, not only between the different states of India, but also within a state. As an illustration, there are only 60 doctors per 100,000 population, but there are 50 Internet users per 1000 population. Suicide is an important issue in this emerging Indian context.

More than one lakh (one hundred thousand) lives are lost every year due to suicide in India. During the last three decades (from 1975 to 2005), the suicide rate has increased by 43 per cent. The rates were approximately the same in 1975 and 1985, and from 1985 to 1995, there was an increase of 35 per cent, from 1995 to 2005, the increase was 5 per cent (Figure 108.1). However, the male:female ratio has been stable at around 1.4:1. There is a wide variation of 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 socio-economic status and higher expectations are possible explanations for the higher suicide rates in the southern states.

The majority of suicides (37.8 per cent) in India are committed by those below the age of 30 years. The fact that 71 per cent of suicides in India (Ministry of Health Affairs 2005) are by persons below the age of 44 years imposes a huge social, emotional and economic burden on the society. Suicide rates are nearly equal among young men and women (Mayer and Ziaian 2002), with a consistently narrow male to female ratio at 1.4:1.

Statistics show that more Indian women die by suicide than their Western counterparts. Poisoning (36.6 per cent), hanging (32.1 per cent) and self-immolation (7.9 per cent) were the most common methods used to commit suicide (Ministry of Home Affairs 2005). However, two large epidemiological verbal autopsy studies, in rural Tamil Nadu, revealed that the annual suicide rate is six to nine times higher than the official rate (Joseph et al. 2003; Gajalakshmi and Peto 2007). If these figures are extrapolated, it suggests that there are at least half a million suicides in India every year. It is estimated that 1 in 60 persons 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 action.

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 other conflicts relating to the issue of marriage play a particularly crucial role in the suicide of women in India. A distressing feature is the frequent occurrence of suicide pacts and family suicides, which are mostly 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 per cent of cases had a significant correlation between domestic violence of women and suicidal ideation (World Health Organization 2001). Domestic violence was also found to be a major risk factor for suicide in a study conducted in Bangalore (Gururaj et al. 2004). Poverty, unemployment, debts and educational problems are also associated with suicide. The recent spate of farmer suicides in India has raised societal and governmental concerns to address this growing tragedy.

Mental disorders occupy a premier position in the matrix of causation of suicide. Studies show that around 90 per cent of those who die by suicide have a mental disorder (Vijayakumar et al. 2005a). Two case–control studies, using the psychological autopsy technique, have been conducted in Chennai and Bangalore, in India (Vijayakumar and Rajkumar 1999; Gururaj et al. 2004), and among those who died by suicide, 88 per cent in Chennai and 43 per cent in Bangalore had a diagnosable mental disorder.

In India, attempted suicide is a punishable offence. Section 309 of the Indian Penal Code states that ‘whoever attempts to commit suicide and does any act towards the commission of such an offense shall be punished with simple imprisonment for a term which may extend to one year or with a fine or with both’.

However, the aim of the law to prevent suicide by legal methods has proved to be counterproductive. Emergency care to those who have attempted suicide is denied, as many hospitals and practitioners hesitate to provide the needed treatment, for fear of legal difficulties. The actual data on attempted suicides becomes difficult to ascertain as many attempts are described as accidental to avoid entanglement with the police and courts.

India grapples with infectious diseases, malnutrition, infant and maternal mortality, and other major health problems; thus, suicide is accorded as a low priority in the competition for meagre resources. The mental health services are inadequate for the needs of the country. For a population of over a billion, there are only about 3500 psychiatrists. Rapid urbanization, industrialization and emerging family systems are resulting in social upheaval and distress. The diminishing traditional support systems leave people vulnerable to suicidal behaviour. Hence, there is an emerging need for external emotional support. The enormity of the problem, combined with the paucity of mental health services, 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 centres 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, as well as implementing some intervention programmes. However, there are certain limitations in the activities of the NGOs. There is a wide variability in the expertise of volunteers and in the services they provide. Quality-control measures are inadequate, and the majority of their endeavours are not evaluated (Vijayakumar and Armson 2005).

A social and public health response to suicide is crucial in India, and should complement a mental health response. Mental illness is a risk factor for suicide in India, just as it is in developed countries. However, additional risk factors are prominent in India. These tend to relate to societal structures and specific stressors. A social and public health approach acknowledges that suicide is preventable, and promotes a framework in an integrated system of interventions across multiple levels within society, which includes the individual, the family, the community, and the health-care system. A key step in such an approach involves modifying attitudes toward suicide, via educational efforts and, in some cases, legal levers (e.g. decriminalizing suicide) (Vijayajumar et al. 2005b).

The World Health Organization's suicide prevention multi-site intervention study on suicidal behaviour (SUPRE-MISS) was initiated in seven culturally different sites, in order to evaluate the effectiveness of brief interventions, and contacts for those who have attempted suicide and seen in the emergency care setting. The results from the Chennai, India site revealed that attempted suicide and completed suicide were significantly lower in the intervention group, signifying that low cost community interventions are effective in preventing suicidal behaviour (Fleischmann et al. 2008).

SNEHA (meaning ‘friendship’), a premier NGO in suicide prevention, initiated a study to assess the usefulness of trained volunteer delivered befriending sessions for those bereaved by the Asian tsunami in 2004. A non-randomized control design, involving all adults aged 18 years and over who have lost at least one close family member during tsunami from two coastal areas in Chennai, was recruited. After baseline assessments, participants in the intervention site received monthly befriending support by volunteers. One year after the baseline assessment, all participants in the intervention and control group were interviewed. The results revealed that participants receiving consistent befriending intervention from trained volunteers were less likely to report depressive symptoms and general psychological disorders. Further suicide attempts were lower in the intervention group (Vijayakumar and Suresh Kumar 2008).

Suicide prevention efforts are at a nascent stage of development in India. Active lobbying by NGOs has resulted in the inclusion of suicide prevention in the re-drafted national mental health policy. However, there is an urgent need to develop a national plan for suicide prevention in India. Suicide prevention initiatives in India should bring together traditional knowledge and modern science to develop acceptable, cost-effective and appropriate strategies, but above all, decriminalizing attempted suicide is an urgent need if any suicide prevention strategy is to succeed in the prevailing system.