Warning: This mentions suicide and may be triggering to survivors. Discretion advised.
Suicide is a crucial but often neglected public health issue in India. It is surrounded by stigma, myths, and taboos. Each death by suicide is a tragedy that impacts not only individuals (victims/survivors) but also families and communities at large. Each year, more than 700,000 people die by suicide, many after many previous suicide attempts. This amounts to about one death every 40 seconds.
Since the World Health Organization declared COVID-19 a pandemic in March 2020, more and more people have been experiencing loss, loneliness, suffering, grief and mental stress. In such a new normal focusing on suicide prevention becomes even more important. People increasingly need mental health and suicide prevention support. Institutions need to work on building social connections, raising awareness, and providing hope. At a personal level one can reach out to loved ones for supporting their mental health and wellbeing which could prove to be life-saving.
A 2015 study conducted by the Médecins Sans Frontières (MSF) – an international humanitarian medical non-governmental organization said that “45 per cent of Kashmiri population is in distress.” From the year 2010 to 2020, Kashmir witnessed 3024 cases of suicide—with the pandemic year of 2020 leading the decade with 457 suicides. These are just the reported numbers cited in response to an RTI query.
India recorded over 139 thousand deaths due to suicides in 2019, and these are the “recorded” and reported numbers. Some of the major causes for suicides in the country were due to professional problems, abuse, violence, family problems, financial loss, sense of isolation and mental disorders. Every seventh person in India suffers from some form of mental disorder. Today, depressive disorders are regarded as the leading contributor not only to disease burden and morbidity worldwide, but even suicide if not addressed.
Tackling the complexity of suicidal behaviors starts with identifying the risk and protective factors. Major risk factors range from lack and accessibility of healthcare systems and society to community, relationships, and individual challenges. Several barriers include hurdles in access to health care, disasters, war and conflict, previous suicide attempts, etc. All such factors often act cumulatively to increase a person’s vulnerability to suicidal behavior. Though the link between suicide and mental disorders is well established by extensive research, many suicides can also happen impulsively in moments of crisis, such as financial loss. For instance, in India the two major social groups that witness death by suicides are farmers and housewives, most having no history of a mental disorder or issue but pushed to the crisis due to socio-economic factors like financial distress or domestic violence. In 2018, the leading cause for suicide deaths in India was due to family problems. The second leading cause was due to illness. Some of the risk factors, relative to developing mental disorders including depressive and anxiety disorders, include bullying victimization, poverty, unemployment, childhood sexual abuse and intimate partner violence.
The WHO data on suicide in India states that for each suicide, there are more than 20 suicide attempts.
Pandemic and Suicide Prevention
Suicide has been a leading cause of death with devastating and long-lasting emotional and societal costs. Almost all suicide deaths are preventable and this remains critical global public health issue. Several preliminary studies have indicated that the ongoing pandemic may increase the risk of suicide deaths due to its effects on several well-established suicide risk factors.
Prior to the COVID19 pandemic also many countries were actively engaging in suicide prevention strategies, and although the overall global burden of suicide deaths has increased, efforts in this direction in some countries were beginning to deliver positive results. However, what remains a major concern is the gap between growing mental health needs and available services in most nations. With this additional global challenge to physical and mental health and various socio-economic burdens imposed by the pandemic, many countries worldwide may experience increased suicide risk.
Data and events during the first 6 months of the pandemic reveal specific effects on suicide risk. However, increases in suicide rates are not a foregone conclusion even with the negative effects of the pandemic.
According to a WHO report from 2018 among all the countries in the world, only 38 have a national suicide prevention strategy, which is clearly not enough. India also has no such clearly defined strategy, policy and logistics in place.
It has been observed by various researchers that particular groups of population are more likely to have elevated suicide risk during COVID-19 because of baseline vulnerabilities, inequitable effects of the pandemic, or for reasons that present barriers to disclosing hardships and seeking help.
These include all marginalized people especially those with lower access to mental health care, those with mental health conditions at baseline or other suicide risk factors; people in unsafe homes related to domestic violence or abuse; people with socioeconomic disadvantage, people from rural areas, people from marginalized racial/ethnic and sexual groups, all for whom economic, educational, and health disparities are being accentuated by the pandemic. Even frontline health and essential workers; youth and elderly populations; parents with school-age children; and male individuals have been found to experience increased suicidal ideation during this period. People who represent intersectionality across risk areas are of particular concern.
The overall social stress and anxiety is at an all-time high and a huge matter of concern for all in the suicide prevention and awareness space.
What can be done collectively?
Suicide is a serious public health problem; however, suicides are preventable with timely, evidence-based and often low-cost interventions. For national responses to be effective, a comprehensive multisectoral suicide prevention strategy is needed.
The Mental Healthcare Act, 2017 decriminalizes suicide, assuring adequate medical relief to those attempting it. This is a landmark development ensuring dignity and a humane perspective to the issue. The National Mental Health Program and Health and Wellness Centers under the Ayushman Bharat Program are efforts to provide quality care at the primary health care level. Deaddiction centers and rehabilitation services are also available.
Some protective factors at the familial and societal level include strong interpersonal relationships, religious or spiritual beliefs, and positive coping strategies and wellbeing practices. Mitigating risk factors to reduce the means of suicide or enhancing protective factors to build resilience can effectively reduce suicide rates. For example, impulsive suicide can be prevented by restricting access to lethal means.
Yet, suicide prevention has not been adequately addressed in many countries due to a lack of awareness of suicide as a significant public health concern, which prevents people from seeking help. Under-reporting and misclassification are more significant problems in suicides than in other causes of death due to its sensitivity and illegality in some countries. The challenge is real, and actions must be taken.
The WHO is now urging countries across the world to up their suicide prevention strategies, noting that there are a few demonstrably effective approaches. These include:
• Responsible reporting of suicide cases in the media, this includes use of images with consent and discretion, use of sensitive language. For example, most of Indian media still says “committed” suicide whereas the better usage is death by suicide.
• Nationwide programs in educational institutions and communities that help the younger generation to develop relevant life skills, including mental health selfcare, peer support and seeking help for mental health.
• Identifying those most at risk of suicide and offering them the coping strategies and logistics for the same.
• Restricting common people’s access to the means for suicide
What can Individuals Do?
Community-based suicide prevention strategies like “Gatekeeper” — a program that trains people to know the signs of suicide — are not developed or prevalent. It basically trains common people to identify warning signs of suicide and also response and referral techniques. The entire training can be completed in a few hours and be imparted online too. Healthcare workers, doctors, police, educators and human resource personnel also lack proper sensitization regarding cases of mental health crisis.
Some simple strategies to help someone in suicidal ideation: -
• Asking the question “Are you thinking about suicide?” communicates that you’re open to speaking about suicide in a non-judgmental and supportive way. Asking in this direct, unbiased manner, can open the door for effective dialogue about the distress and what can be done next.
• Be there for the person in crisis. This could mean being physically present for someone, speaking with them on the phone when you can, or any other way that shows support for the person at risk.
• Keep them safe. After the “Ask” step, and you’ve determined suicide is indeed being talked about, it’s important to find out a few things to establish immediate safety.
• Help them connect. Helping someone with thoughts of suicide connect with ongoing supports like helplines and counselling can help them establish a safety net for those moments they find themselves in a crisis. Additional components of a safety net might be connecting them with support and resources in their communities.
• Always follow-up. After your initial contact with a person experiencing thoughts of suicide, and after you’ve connected them with the immediate support systems they need, make sure to follow-up with them to see how they’re doing. Leave a message, send a text, or give them a call.
The COVID-19 pandemic presents clear threats to the mental well-being of most and suicide risk for some. However, increases in suicide rates are not inevitable. Because suicide risk is multifactorial with well-established risk factors and a growing body of evidence for effective suicide prevention strategies, outcomes related to suicide will be greatly influenced by investments and actions taken now and in the coming months on the part of policy makers, health care and community leaders, and citizens. This is a moment in history when suicide prevention must be prioritized as a serious public health concern. If specific strategies can be maximally implemented with COVID-19–specific threats to population mental health and suicide risk in mind, this pandemic may not only provide a sense of urgency, but a path forward to address suicide risk at national and community levels.
The National Health Portal by the Ministry of Health and Family Welfare of the Indian Government states-
“We all as a family, friends, co-workers, community members, educators, religious leaders, healthcare professionals, political officials and governments have a role to play and together we can collectively act for the challenges presented by suicidal behavior in society today.”
In addition, places like the valley that have witnessed unfortunate incidents of violence for decades need more and more constant psychosocial trauma-informed support for its common people.
Anyone in psychosocial distress can use the following resources:
KIRAN – 1800 599 0019 (24×7) — 13 Indian languages
NIMHANS – 080 – 4611 0007 (24×7) — Multiple languages
AASRA (24x7Helpline +91-9820466726) - Hindi/English
Vandrevala Foundation- +91 9999 666 555 (24x7)
ICall – 9152987821 (Monday-Saturday 10:00 a.m. to 7:00 p.m.)
Pallium India – +91 759 405 2605 (Monday-Saturday 9:00 a.m. to 6:30 p.m.) — Eight Indian languages
CoHope Helpline – +91 98185 40802 (10:00 a.m. to 10:00 p.m.)