Suicide Country

IN FEBRUARY, THE Open Access journal PLOS One published a paper on the traits of members of the Idu Mishmi, a tribe in the Dibang Valley of Arunachal Pradesh, who had attempted suicide. The total population of the Idu Mishmi is around 15,000, but a PhD study that came out in 2011 recorded as many as 218 suicides over four decades. Dr VR Rao, an anthropologist and co-author of the PLOS One paper, had been piqued by this phenomenon when he had visited the area while with the Anthropological Survey of India. He decided to look into the biological and genetic aspects behind this tendency, in particular the influence of aggression and impulsivity.

There were a few things Rao’s study found which were striking. Of the 177 Idu Mishmis surveyed, as many as 22 per cent had attempted suicide, including those who had tried to do it twice and thrice. Many went to the forests in the night and hanged themselves. Once Rao was sitting in the house of a family when the mother pointed to her 10-year-old son and said he had tried to commit suicide twice. “I asked him why. He said there were voices from the forest calling him,” says Rao. Besides hanging, pesticide consumption was the most common method to kill oneself. When they looked at gender, 64 per cent of suicide attempters were female, while 36 per cent were male. Attempters were found to be much more aggressive than non-attempters; likewise for impulsivity. Here too, the genders differed, with female attempters being more impulsive but less aggressive. And then there was the fact that men were more successful in killing themselves while women tried to do it more often.

The Idu Mishmi study shows the complexity of understanding suicide in India. For instance, while their propensity to commit suicide is extraordinarily high, some of the patterns are the same as the rest of the country, like men being more successful at suicide and pesticide consumption being the most prevalent method. But when it comes to causes, even at the national level, not much has been ascertained. India, in fact, is the leading nation in the world for suicides. The National Crime Records Bureau in 2014, the last year for which an estimate is available, put the number of suicides in India at 131,000. Dr Lakshmi Vijayakumar, a Chennai-based psychiatrist and one of the foremost researchers in suicide prevention strategies, says, “I was an editor of the first World Suicide [prevention] Report published by the WHO in 2014. According to that, suicides in India were 2.35 lakh, almost double [the NCRB’s figure]. Which puts India as the country with the highest number of suicides. China [which also had a high number of suicides a decade ago] has been able to bring it down whereas India hasn’t.”

The numbers are steadily increasing. In 1979-80, the suicide rate was around 7.5 per 100,000 population; it has now gone up to about 10.5. The major cause, she says, is family conflict, followed by illness. But there is a huge black hole in our understanding. “If you look at NCRB stats, 30 per cent is unknown reasons and other causes is another 20 per cent. So for almost 50 per cent of suicides we do not know what really the reasons are. I did what is known as a psychological autopsy study in Chennai. When somebody dies, you do an autopsy to find out the reason; the same way, when suicide happens, you do a psychological autopsy study to find out what are the factors/events which push a person to suicide. We find out what the person has been through in the last one month. According to that, I found a combination of three factors important for suicides. One, depression or alcohol use. Then, immediate family or interpersonal conflict. Third, easy availability of a method to commit suicide. For women, it was kerosene or pesticides. All these three factors combined together leads to suicide. According to Western statistics, in psychological autopsies they find 80-90 per cent have depression. We found depression only in 30 per cent. Alcohol played a huge role. Domestic violence played a huge role. I would say in our country about 50-60 per cent is mental health issues and 40 per cent is impulsive situational social issues.”

In 2001, a project called as the Million Death Study was undertaken to look into the causes of death in India. The University of Toronto-sponsored Centre For Global Health Research (CGHR), a non-profit organisation focusing on healthcare research in developing countries, which was behind the study, worked with Indian medical organisations and the Registrar General of India to survey a million households. Families where a recent death might have occurred were interviewed about symptoms of the deceased. When it came to suicide, the study found that it accounted for 3 per cent of deaths in India. It noted in its findings, ‘A 15 year old in India had an approximate cumulative risk of 1.3% of dying before age 80 years by suicide; men had higher risk (1.7%) than women (1.0%), with especially high risks in South India (3.5% among men and 1.8% among women). Suicide risks were higher in educated versus illiterate adults. About half of the suicides were from poisoning, much of which was pesticide. At ages 15–29 years, suicide accounted for nearly as many deaths as transport accidents in men and maternal deaths in women.’

DR PRABHAT JHA of the CGHR, who led the study, says over email that Indian suicide death rates are comparable to global averages, for example in the US and China, but here it claims much younger lives. ‘Suicide occurs among older people in the US, many of whom have long-term psychiatric problems (Robin Williams, the late comedian, for instance). In India, a large number of suicides occur among young women and men, and this appears not to have as much background psychiatric disturbances. Rather, social circumstances around work and marriage are the likely drivers,’ he says.

Males committing more suicide, while women attempting more, holds true for many other countries too. Dr Vijayakumar posits a few reasons for this. For one, men in general use violent methods that increase the probability of dying. “Women use gentler methods. They prefer poisoning and can often be treated in time,” she says. “Secondly, depression is more in women and so suicide attempts are more.” She also points out that the age group with the highest suicide rate among Indian women is 18-29, when they are prone to the cultural stress that marriage puts on them. “After 30, the suicide rate comes down in women whereas in men it doesn’t. By the age of 30, the majority of women have a child, and that is a very strong protective factor against suicide,” she says.

The other curious element of suicide in India is the difference in rates between south and north India, with the former leading by a large margin. “India has been divided into three regions, the southern states have a suicide rate more than 15 per 100,000. The middle states like Maharashtra and Odisha have suicide rates between 5 and 15. In northern states like Bihar, UP, J&K, the suicide rate is less than 5. We did a study and found no other association except education. The more educated a state is, the suicide rate seems to be higher. I think with education there is a higher level of expectation, and if these expectations are unmet, suicide happens,” says Dr Vijayakumar.

An example of a southern region with an extraordinarily high suicide rate is Puducherry, which has almost five times the national average. Dr Vikas Menon, who is on the faculty at JIPMER, Puducherry, also works at a crisis intervention clinic there where all suicide attempters are referred to for counselling by hospital protocol. They have been trying to identify high-risk groups who attempt more severely, more impulsively and are likely to reattempt. “We are basically dividing our sample into meaningful sub groups and trying to look for differences,” says Menon. For example, they have a published a paper on impulsive versus non-impulsive attempters.

Another paper he authored looked at gender differences of suicide attempters who had come to their clinic. Menon lists the predominant findings: “Substance use was a major contributor to attempts among males but not among females. In mode of attempt, pesticides were more common among males, whereas some plant poison and medications were more common among females. Females who attempted suicide were much younger compared to males. And, of course, females were more likely to be unemployed, again a reflection of our culture more than anything else.”

Menon says we don’t know for sure and have only theories why south India has more suicides. “In south India, the literacy rate is higher, people are more achievement oriented; when they fail to meet their goals they turn to suicide. Better lifestyles, higher aspirations, failure to meet those aspirations, leading to suicide—that is one pathway,” he says. Another pathway could be that north Indians are more externalising compared to south Indians. Bottling up distress internally can spill over into depression or anxiety when the load becomes too much. But there is nothing to substantiate these theories, he says.

Dr AV Manjunatha of the Institute for Social and Economic Change, Bengaluru, was the principal investigator of an all-India study on farmer suicides whose findings were published last year. Suicide is an acute problem with indebted farmers in India and the study aimed to map its hotspots, and identify causes, the profile of victims and their households.

They looked at 46 districts in 13 states. Families and neighbours of victims were asked reasons for the suicide—whether the victim had been getting expected yield and price for his crop, whether he had loans, etcetera. One of the things Manjunatha noticed was that farmers in drought-prone areas were less prone to committing suicide than in areas which had irrigation. “When you are from a drought-prone area, you know adaptation and coping mechanisms. We found in drought-prone areas of Karnataka, the numbers were less. Mysore and Mandya of the Cauvery river belt had the highest number of suicides because there was not as much access to irrigation as before. If access to canal water is affected, they have relatively less coping strategies compared to drought-prone areas where they have coping mechanisms,” he says. Most of the farmer suicides were committed by hanging and consumption of chemicals like pesticides.

Because pesticides is the main method of suicide in rural areas, a prevention strategy being explored is to keep it out of reach of potential attempters. In 2013, Dr Vijayakumar did a study which tested in a few villages the idea of a community locker to keep pesticides. “This was the first study like that in India. It showed such efficacy that the WHO rated it one of the most cost-effective methods of suicide prevention,” she says. Further tests are now being done in villages of Tamil Nadu and Gujarat.

Another strategy for suicide prevention uses technology. “A lot of interest now is in how you can use mobile phones, text messages, to keep contact with suicide attempters and try to see whether risk of reattempts reduce after mobile-based intervention. The problem with our country is accessibility to health services. They cannot keep coming to the hospital every now and then. If you can keep sending mobile-based reminders or messages, it may show them there is a source of support available,” says Dr Menon.

What is also needed, says Dr Vijayakumar, is more research on causes. “We are not sure why the other 40-50 per cent who do not have a mental health issue are committing suicide,” she says, “Is there anything that can be done to stop them?”

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