Roy Abraham Kallivayalil
Department of Psychiatry, Co-operative Medical College, Cochin
Suicide is a preventable event, although at times its occurrence is unpredictable. It is a tragedy that causes tremendous pain to patients and families. Suicidal behaviours include suicidal ideation, attempts and completed suicide. Suicide is a major public health problem of our times. It is one among the 10 leading causes of death.
Suicide is a preventable event, although at times its occurrence is unpredictable. It is a tragedy that causes tremendous pain to patients and families. Suicidal behaviours include suicidal ideation, attempts and completed suicide. Suicide is a major public health problem of our times. It is one among the 10 leading causes of death. More than a million people die of suicide every year in the world. It is the third major cause of ‘Life Years Lost’, next only to heart disease and cancer.
WHO defines suicide as a deliberate act of self harm with fatal outcome and suicide attempt as an injury with varying degrees of lethal intent. Suicide is a complex problem with biological, psychological, social, spiritual, economic, political and philosophical underpinnings.
Suicides have become important public health problem world over. In a large country like India, suicide rates vary in different regions, and South India has the largest incidence of suicides. Not only psychiatrists and psychologists, but also medical professionals, sociologists, NGOs, media, religious leaders and politicians have come up with opinions highlighting their own view points. Various suicide prevention strategies have also been proposed and implemented with these biases.
Although 90% of suicides in the West are regarded to be due to mental illness, alcohol dependence or substance abuse, the situation in India appears to be different. Although mental illness like depression is an important cause for suicide here, adjustment disorders, stress disorders, financial difficulties, unemployment and poverty are also considered relevant. Hence mental health professionals alone are unlikely to succeed remarkably in bringing down suicide rates. It needs the active involvement of the Governments at the Centre and the States, the policy makers, planners, administrators, the media and above all the “community gate keepers” like teachers, social workers, health professionals and public activists.
Public awareness of this tragedy is very important. World Federation for Mental Health had observed the year 2006 specially to bring down suicide rates with the slogan “Building awareness- Reducing risk: Mental illness and Suicide”. We must not give simplistic explanations – like denial of bank loan or reprimand from the school teacher or at home – as the reason for suicide. Most often, such people would be suffering from depression or personality problems. If we know this, we can treat them and help them. We should also fight against the stigma associated with suicide by seeing it, not as an act against society but as the cry of a sick person. We must talk with the family members of the suicide victims with compassion and sensitivity, respecting their privacy.
If a person has attempted suicide and is unsuccessful, he or she is likely to attempt again, and the maximum risk period is in the first three months. This should be recognized and help should be made available. Suicide Prevention Clinics, Crisis Intervention Centres and telephonic helplines are very helpful. NGOs, educationalists, religious leaders, public activists all have an important responsibility in spreading awareness and supporting efforts at suicide prevention. We need to work together to give a helping hand, so that valuable lives can be saved.
World Health Report (2001) underlines the fact that prevention and treatment of mental disorders decrease suicide rates. Early detection and treatment of illnesses like depression, alcohol dependence, substance use, schizophrenia etc are vital to our success. Diagnosis and treatment of a common illness like depression has to be ensured at the primary care level. Our strategies should be aimed at not only individuals but also families, schools and the community in general. The importance of life events, social support, coping strategies and quality of life in suicide prevention has to be emphasized. Developing coping skills and crisis management may be included in the school curriculum which will increase self esteem and healthy decision making in our children.
It is interesting to note that more than 40% of all suicides in India occur in the southern states of Kerala, Karnataka, Andhra Pradesh and Tamil Nadu. The very low rates in educationally and socio economically backward northern states could be interpreted considering the reporting practices. A detailed look at the statistics also some striking differences with western figures. For example, 1 each in every 3 suicides occurs in the 15-29 and 30-44 age groups in contrast to the predominance of elderly. 1 suicide for every 5 suicide is committed by a housewife and 71.5% of the persons who completed suicides were married disputing the hypothesis of protection conferred by marriages in western society. The increasing incidence of dowry deaths and other sociocultural factors affecting women require further exploration.
Suicides in Kerala
Kerala is unique in many ways with its high population density (around 750/ sq km), high rate of literacy, steadily increasing life expectancy, low rates of infant, under five and maternal mortality rates and total immunization coverage. Kerala model of health care has been acclaimed as nearing the levels of a developed society despite comparatively lower level of income, per capita. This sharply contrasts with increasing divorce rates, comparatively high rates of alcohol consumption and breakdown of traditional support systems. This is the social paradox of Kerala and may reflect the rapid social changes. Highest number of family suicides (murder-suicides) were reported from Kerala It is heartening to note that number of suicides in Kerala have recently come down due to the concerted efforts of health professionals and others.
Are suicides really preventable? If they are, what should be the appropriate strategy based on available scientific evidence? Are strategies used in developed world appropriate in Indian situation? It is well known, 80% of people who commit suicide do so, due to emotional and mental problems. Depression is the single biggest cause for suicide. We must know Depressive Disorders are eminently treatable. Getting them professional help, thus remains crucial. We have several instances, when even medical personnel have not referred people with severe depression for psychiatric help. This may be due to stigma or because we are not trained to communicate properly regarding diagnosis of mental problems to patients. Many doctors may not like to take up the responsibility of communicating unpleasant truths. Family members should also share an equal blame. Often they allow the depressed person to suffer in silence, without getting him psychiatric help. This may end up in suicide, thus ending a valuable and productive life. This irreparable loss will shatter the family. Another leading cause for suicide is alcoholism and drug addiction. We must know that 10% of all alcoholics end their life in suicide. Thus public awareness about the risk of alcohol and drug abuse is very important. There is a tendency in the media to sensationalized and glorify suicides. Media may also give undue prominence to suicide. By concerted efforts, these can be minimized.
Self – destructive behaviour, completed suicide and similar violent actions channeled towards the self have always been a mystery to mankind. How can a blessing like life be negated, denied and abused? Yet, it is a reality that has to be confronted. Medical professionals know that typically suicide is associated with mental illness. Very few are the cases where negation of life arises out of philosophical, existential or traumatic situations alone. It is, therefore, important to identify the psychopathological substrate that is likely to lead to suicidal behavior or completed suicide, in an effort to implement prevention. Educating community gatekeepers like teachers, clergy, social workers and promoting mental health in work places, prisons and offices are important. Providing help after a suicidal attempt, opening crisis intervention centres, suicide prevention centres and telephone helplines are all very useful. Individual interventions and providing psychiatric treatment alone will not be enough. Understanding human misery, poverty and denial of human rights should engage our attention. Undoubtedly population based interventions are the key to success in suicide prevention.
Dr. Roy Abraham Kallivayalil,
Principal and Professor, Department of Psychiatry, Co-operative Medical College, Cochin- 683 503. Phone : 94470 20020,
Conflict of Interest: None declared
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