Yesterday was the World Suicide Prevention Day. Since 2003, every year the World Health Organization (WHO), in conjunction with International Association for Suicide Prevention (IASP), observes September 10 as the World Suicide Prevention Day with singular focus at taming the curse of suicide, suicide attempt and persistent suicidal ideation.
This day, for last three decades, has assiduously focused on stamping out the deep-rooted stigma associated with suicide and creating awareness at the cross section of the entire gamut of stakeholders, “including but not limited to individual, familial, societal, organisational, non-governmental, governmental and media level… imparting the singular message that every single suicide is preventable and must be prevented through purposive focused action at every level”.
“Creating hope through action” is the triennial theme for the World Suicide Prevention Day from 2021 to 2023. This theme puts in perspective the fact that there is an alternative to suicide, which is life; the theme aims to inspire confidence and light in all of us to pursue that alternative doggedly.
I submit — though the aetiology of suicide is complex, and its collateral damage is comprehensive, substantive, and debilitating, irrespective of its proximate obvious and real root causes — suicide is an unwarranted and undesirable final solution to a temporary problem, and it is possible to change the narrative and substantially reduce the number of suicides through composite, coordinated action.
Indubitably, it is the action time — to usher in hope from the present state of hopelessness.
Why should India care? The sad truth is that the country already sits atop the global suicide table and the curse of suicide is spreading its tentacles fast.
I begin with the examination of the incidence and severity of suicide in India, officially compiled, and collated annually by the National Crime Records Bureau (NCRB), based on dataset provided by police departments of states and union territories. Here we go:
One, as per the findings of the recent NCRB report ‘Suicides in India (2021)’, in 2021, 1,64,033 Indians died by suicide, which connotes an increase of 7.2 percent from 1,53,052 suicides in 2020. It marks huge spike of 28.25 percent in five years from 1,29,887 suicide deaths in 2017 to 1,64,033 in 2021.
Also, against the earlier trend of one Indian dying by suicide every 4 minutes, as per 2021 NCRB data, the incidence of suicide has exacerbated to “one suicide death every three minutes”.
Two, the male-female ratio of suicide victims in 2021 was 72.5:27.4 (Male 118,979, female 45,054) as compared to 70.9:29.1 in 2020. It is instructive to note that this NCRB data is not in sync with other studies by the WHO and Lancet that report a more even men-women suicide distribution.
Three, Indians dying by suicide die young and unsung. The incidence of suicide between 18 and 30 years of age is whopping 35 percent of total suicides and those in 30-45-year group is high 32 percent.
Unsurprisingly, then in 2021, the burden of suicides in the age group 18-45 years, with 67 percent of the total suicides, makes the age group most vulnerable group prone to taking own life. Once, we add the incidence of suicides in the 45-60 year (18 percent) age group, “suicides amongst the working/productive age population (18-60 years) are dangerously high 85 percent of total suicides”.
And this is not all, the death by suicide in age groups less than 18 years (6.5 percent) and those above 60 (9 percent) are showing fast uptick. More worrying is the student’s suicide 8 percent of the total suicide and growing fast.
The trend of abnormally high suicides in relatively lower age group in India, not only changes “our population dividend from boon to bane”, but also militates against the global trend of elderly “aged 60 years and above” being at the highest risk of suicide deaths.
Also, such an annual loss of productive and working age population by suicide inflicts monumental collateral damage with humongous consequences — emotional, economic, and financial at individual, familial and societal level. It is a travesty then that Suicide Prevention Policy, Strategy and Measures have not yet become the priority of the governments — Centre and States.
Four, there exist massive inter-state variations in suicides reported —Maharashtra 22,207 (13.5 percent) Tamil Nadu 18,925 (11.5 percent), Madhya Pradesh 14,965 (9.2 percent), West Bengal 13,500 (8.2 percent) and Karnataka 13,056 (8 percent) top the 2021 suicide table. “These states have stayed put on top over last few years and amongst themselves constitute to more than half (50.4 percent) suicides reported in 2021 in the country.”
Contrarily, many eastern and northern states, namely Bihar, Uttar Pradesh, Jharkhand, Uttarakhand, Punjab, Haryana, Rajasthan, and Jammu and Kashmir have persistently reported low or very low incidence of suicide.
Clearly there is more than what meets the eye in the dataset of states reporting low incidence of suicides. Low education and socio-economic level, very high stigma attached to suicide, and callous system of medical classification of deaths (only twenty percent deaths are medically certified for causes of death) ensure that bulk of people dying by suicide in these states simply are not counted, thereby camouflaging the actual incidence of suicides.
Clearly, when it comes to suicide prevention policy, policy, strategy, and measures, India needs state-centric tailor-made approach: One size will not fit all.
Five, Delhi, the most-populous union territory (UT), has the highest incidence of suicides (2,840) among UTs, followed by Puducherry (504). Amongst metropolises Suicides in Chennai have grown fastest.
Six, though there is no clarity on overall rural-urban split in the suicide dataset, in 2021, 25,891 suicides — i.e., 16 percent of total 164,033 — were reported from 53 million plus cities of the country, with the contribution of four mega-metropolises (Delhi, Mumbai, Chennai and Bengaluru) itself accounting for 35.5 percent of these suicide cases.
It is no rocket science to safely conclude that the total number of suicides in all cities and towns of the country will far exceed suicides reported from rural India. Also, lesser reported rural suicides have more to do with opaqueness, stigma, and non-reporting of the data. “This is reflected in lower reported suicides from states like Bihar and Uttar Pradesh.”
Seven, like previous years, 2021 NCRB report provides disparate 20 types of reasons for reported deaths by suicides, with the top three reasons being family problems (33.2 percent), other causes and causes not known (18.9 percent), and illness (18.6 percent). This classification hides the true reasons behind suicides, whether premediated or at the spur of the moment: “The pathological distress, extreme penury, and fast-growing menace of the diagnosed or undiagnosed, treated, or untreated mental illnesses (unrelenting depression, chronic bipolar disorder, unremitting Schizophrenia, substance abuse to name the few).”
Eight, going by the NCRB report, of total 1,18,979 male suicides, daily wage earners (37,751) accounted for the maximum, followed by self-employed (18,803) and unemployed (11,724). Of total 45,026 female suicide, biggest chunk was of housewives (23,178), followed by students (5,693) and daily wage earners (4,246). A total of 28 transgender also died by suicide.
Two most worrisome implications in the above datasheet are the spike in suicides by daily wage earners and self-employed in the men category and sharp increase in the suicides of students in the female category.
Also, the above classification nosology is simplistic, parroting of the type of people dying by suicide. The country sorely needs more accurate data set and more robust analysis by the interdisciplinary team of experts.
How reliable are the government data?
They reveal little and conceal lot — both the system of collecting data and the people who collect data are flawed. The country simply does not have the wherewithal to conduct psychological autopsy of the dead. And we seldom try to find out exact number of suicides.
The interest in epidemiology of suicides in India is of recent origin. In last one-decade epidemiological studies have emerged that have looked at incidence of suicides more closely and have tried to put the subject at the national mainstream.
The first representative study on the prevalence of suicide in India that I have managed to lay my hands on was by Dr Vikram Patel and colleagues, published in reputed British medical journal Lancet in 2012. This study estimated that as against 134,000 reported suicides by NCRB in 2010, actual number of Indians above 15 years of age who died by suicide in 2010 was 187,000 (115,000 men and 72,000 women) i.e., 61 percent men and 39 percent women with the age-standardised suicide rate per 100,000 of 26.3 for men and 17.5 for women.
More worrying finding of the study was that 40 percent (45,100 of 114,800) of suicide deaths in men and 56 percent (40,500 of 72,100) in women belonged to the young population — 15 and 29 years of age.
Two, the above is bad enough but the findings of a subsequent first-of-its-kind comprehensive report by WHO ‘Preventing Suicide: A Global Perspective (2014)’ is more damning. The report estimated that in 2012, 258,057 Indians (158,098 men and 99,977 women, 61.26%:38.74%) died by suicide, the largest number for any country in the world.
The WHO report also echoed findings of the Lancet study about very high suicide rate in the 15-29 age group.
The findings of the WHO study were bad enough, but the worse was its damning caveat that the incidence and the rate of suicide in developing countries, including India, was highly underreported.
Three, another comprehensive study — ‘Gender differentials and state variations in suicide deaths in India: The Global Burden of Disease Study 1990–2016’ — published in Lancet in 2018, estimated that there were 230,314 suicide death in India in 2016 with the resultant share of India to global suicide deaths increasing from 25·3 percent in 1990 to whopping 36·6 percent in 2016 among women, and from 18·7 percent to 24·3 percent among men.
Four worrying aspects of the study finding were:
First, suicide was the leading cause of death in India in 2016 for those aged 15-39 years: 71·2 percent of the suicide deaths among women and 57·7 percent among men were in this age group. This is a red-flag India just cannot ignore.
Two, SDR in women was 2·1 times higher in India than the global average in 2016 and SDR in men was 1·4 times higher in India than the global average in 2016.
Three, there was a ten-fold variation between the states in the SDR for women and six-fold variation for men in 2016.
Four, men-to-women ratio of SDR for India was 1·34 in 2016, ranging from 0·97 to 4·11 between the states. The highest age-specific SDRs among women in 2016 were for ages 15-29 years and 75 years or older, and among men for ages 75 years or older.
The report conclusion was clear, if the trends observed between 1990 and 2016 continue, there is zero probability that India will come anywhere closer to achieving the Sustainable Development Goal (SDG) regarding SDR reduction target in 2030.
So, where we stand? And what we need to do?
Quite obviously we as a nation are atop the global suicide table: With 17 percent of global population, India accounts for 25 percent of global annual suicides — more suicides than any other country in the world. It is sobering to note that all available data — official NCRB dataset, WHO data and the data from two studies — are converging fast. Conservatively, it is safe to assume that annual suicide numbers are more than two lakhs and not less — ‘at 23 suicides per hour, tantalisingly close to one suicide every two minute’.
Worse, the country’s proportional contribution to the global suicide deaths is increasing alarmingly fast. ‘We just don’t know how to measure our suicide deaths or are simply not interested.’
It is time for the clarion call to develop a comprehensive suicide prevention, policy, strategy and tailor-made action plan that considers gender-specific and state-specific variations in order to address this major public health problem.
Before that, it’s time to step back and ask the fundamental question: Why do people take such an extreme step? Here, one needs to know that the number of suicide attempts annually is 20-25 times more than the completed suicide and the number of suicidal ideations has been many times more.
I should know the answer: My now-high, now-low bipolar disorder has forced me to be in 24×7 watch by doctors, family, and friends for suicide ideation and more than one failed suicide attempts. Also, life has forced me to handle the aftermath of completed suicides of friends and colleagues, including on the first day of my working career.
In addition, I have over the last twelve years, slowly but surely, emerged as a keen student, knowledge worker and thought leader, on the aetiology and epidemiology, causes and consequences of suicides.
However, the aetiology of suicide is so complex that I am still scratching the surface while the number of suicides and suicide attempts have been galloping fast.
Let me accept that the problem is gigantic and causes complex, and the suicide numbers big enough to hang our heads in collective shame as a nation, considering the many people we’ve failed.
What are the pathways to the solutions? There are many. I recapitulate here the more important ones:
First, to understand the gravity of the problem, we need to start from ground zero and start counting our suicides and suicide attempts correctly. Only when we know the quantum and severity of the problem, we can look for sustainable pathways for absolute reduction in annual suicides.
Second, draconian Section 309 of the Indian Penal Code (IPC) that criminalises suicide attempts, continue to exist in the statute book and is the fundamental reason why we are unable to correctly count and analyse the numbers and reasons behind the suicide attempts. It is time to stamp out Section 309 IPC.
Third, suicide prevention urgently has to be made part of the of national discourse. It is time to change the narrative at the national, state, city and village level. “it is about time for all the stakeholders to herd together, take a vow to make decisive change and forge ahead.”
Fourth, the key issue is how to change the narrative. Here comes my oft-repeated proposed solution, it is time now to embrace “Mission Zero Suicide India” with the eventual goal being elimination of suicide through systemic reduction in a fixed time frame. For this to happen we first need to change our national mindset that in the country of 140 crore a couple of lakhs are bound to take their life annually. Once we accept that suicides and suicide attempts are a national public health emergency and create a national framework for their elimination like pulse polio, smallpox, and other diseases which either we have been able to eliminate or substantially reduce next remains making robust strategies and start acting on the same.
Fifth, as I have written elsewhere (‘Rising Urban and Professional Suicides’, The Economic Times, 23 January 2010), (‘Wake Up India, Suicide is Biggest Epidemic; and Tomorrow will be Too Late’; News18, 10 September 2017) and (‘Zero Suicide: Not a Utopian Goal’, The Hindu, 6 September 2017), apart from the reasons of new humanitarian and social compact, mission zero suicide has to be looked from the prism of a different calculus — huge economic and GDP windfall to the nation arising out of suicide elimination programme. A 2017 analysis by me puts the life-cycle cost of persons committing suicide in just one year at humungous Rs 25,000 crore and every passing year this number gets compounded. This is reason enough in itself for undertaking the mammoth task of suicide elimination.
It is time to invert this key public health issue that is also the most neglected issue. Make no mistake, there is huge windfall for taking such an approach.
How will the change happen? Let me recapitulate:
First, it is time to make the elimination of suicide not just a national mission but also every citizen’s mission. Every citizen has to become a gatekeeper of suicide prevention. Often just talking to the distressed person in non-judgemental manner brings the person from the brink of suicide. Forget talking, just being there for the person in need is enough to prevent suicide.
It is time to eliminate suicide, one at a time.
Second, the problem of the suicide and suicide attempt is so monumental that merely the government-only approach will not work. It is time now to create a National Umbrella for Suicide Prevention with the active participation of all the stakeholders in public, private and NGO-coalition mode.
If the task is to eliminate suicide, partnership holds the key.
Third, suicide has a complex aetiology with multiple factors acting on the same person that drives him/her to suicide. It is time for massive collaborative investment in multidisciplinary research on the subject.
This will lead to finding the evidence-based pathways for suicide elimination.
Fourth, as we have seen above, there are major inter-gender and inter-state variations to the suicide and its key characteristics and determinants. It is time now for the country to think global but act local- bring local solutions. With Indian states of north and east being radically different than those in south and west, only state-centric and city- and village-centric solutions will work.
Fifth, the subject matter of suicide is so complex and its impact so severe that the nation urgently needs multidisciplinary Task Force for Suicide Elimination at the national and state levels to formulate suicide prevention policy, actionable strategies and tailor-made programmes.
What India needs is an evidence-based practicable interventions for suicide elimination and prevention.
Sixth, reduction of access to the means of suicide has worked both globally and even in the Indian context. Similar has been the impact of simple to recall three number National Help Lines in many countries. It is time to roll out both and mainstream them.
Seventh, there are many global best practices for suicide prevention; what India needs is learning from all, but create its own ‘Next Practices’ (phrase borrowed from late CK Prahalad) for suicide elimination, including by effective use of technology.
Let me end with my prognosis, if India has to tame the devil thy name is suicide and suicide attempt, the multi-prong action is needed today. Tomorrow will be too late.
Akhileshwar Sahay is Principal Instigator, Action Group Mission Zero Suicide India. He was also Member of Government of India Mental Health Policy Group and Member of Central Mental Health Authority (CMHA). The views expressed in this article are those of the author and do not represent the stand of this publication.
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