Mental disorders occupy a premier position in the list of causes of suicide. Majority of studies note that around 90% of those who die by suicide have a mental disorder (Vijayakumar et al, 2005). The number of published reports specifically studying the psychiatric diagnoses of people who die by suicide has been relatively small, number around 15500 total thus far compared to a suicide rate of 1,00,000 per year in India alone. The majority (82.2%) of such studies come from Europe and North America with a mere 1.3% from developing countries (Bertolote, 2003). Two case control studies using psychological autopsy technique have been conducted in Chennai (Vijayakumar, 1999) and Bangalore (Gururaj, 2004) in India. Among those who died by suicide, 88% in Chennai and 43% in Bangalore had a diagnosable mental disorder. However, diagnostic evaluations were not done in the Bangalore study.
Countless experts have found that affective disorders are the most important diagnosis related to suicide. In Chennai, 25% of completed suicides were found to be due to mood disorders. However, the suicide rate increased to 35% when suicide cases with adjustment disorder with depressed mood were also counted. The crucial and causal role of depression in suicide has limited validity in India. Even those who were depressed, were depressed for a short duration and had only mild to moderate symptomatology. The majority of cases committed suicide during their very first episode of depression and more than 60% of the depressive suicides had only mild to moderate depression (Vijayakumar, 1999). Although social drinking is not a way of life in India, alcoholism plays a significant role in suicide in India. Alcohol dependence and abuse were found in 35% of suicides. Around 30-50% of male suicides were under the influence of alcohol at the time of suicide and many wives have been driven to suicide by their alcoholic husbands. Not only were there a large number of alcoholic suicides but also many had come from alcoholic families and started consumption of alcohol early in life and were heavily dependent. The odds ratio (OR) for alcoholism was 8.25 (confidence interval: CI 2.9-3.2) in Chennai (Vijayakumar, 1999) and 4.49 (CI 2.0-6.8) in Bangalore (Gururaj, 2004). About 8% of suicides in India are committed by persons suffering from schizophrenia. Srinivasan and Thara found that the male to female ratio for schizophrenic suicides is more or less equal (Srinivasan, 2003). Although diagnosable mental disorders were found in 88% of suicides in the Chennai study, only 10% had ever seen a mental health professional. According to a government report, only 4.74% of suicides in the country are due to mental disorders.
Personality disorder was found in 20% of completed suicides. The OR was 9.5 (CI 2.29-84.11). Cluster B personality disorder was found in 12% of suicides. Comorbid diagnosis was found only in 30% of suicides (Vijayakumar, 1999). A history of previous suicide attempt(s) increases risk of subsequent suicide. The OR for previous suicide attempts was 5.2 (CI 1.96-17.34) in Chennai and 42.62 (5.78-313.88) in Bangalore. In the Bangalore study, family history of completed suicides showed a greater risk of suicide (OR 7.69 CI 2.13-32.99) as compared to the suicidal risk indicated by the family history of attempted suicides. In the Chennai study, 12% had a family history of suicide (OR 1.33; CI 0.6-3.09) in first-degree relatives and 18% in second-degree relatives (Fisher Exact Probability test (FET) P = 0.001).
Clusters of suicides
The media sometimes gives intense publicity to “suicide clusters” – a series of suicides that occur mainly among young people in a small area within a short period of time. These have a contagious effect especially when they have been glamorized, provoking imitation or “copycat suicides”. This phenomenon has been observed in India on many occasions, especially after the death of a celebrity, most often a movie star or a politician. The wide exposure given to these suicides by the media has led to suicides in a similar manner. Copying methods shown in movies are also not uncommon. This is a serious problem especially in India where film stars enjoy an iconic status and wield enormous influence especially over the young who often look up to them as role models.
The implementation of the recommendation of the Mandal Commission to reserve 27% of the positions for employment in Government created unrest in the student community and a student committed self-immolation in front of a group of people protesting against such a reservation. This was sensationalized and widely publicized by the media. There was a spate of student self-immolation (n = 31) around the country. These copycat suicides caused public outcry and was considered one of the reasons for the fall of the government in power at that time (Vijayakumar, 2004).
The effects of modernization, specifically in India, have led to sweeping changes in the socioeconomic, sociophilosophical and cultural arenas of people’s lives, which have greatly added to the stress in life, leading to substantially higher rates of suicide (Gehlot, 1983). In India, the high rate of suicide among young adults can be associated with greater socioeconomic stressors that have followed the liberalization of the economy and privatization leading to the loss of job security, huge disparities in incomes and the inability to meet role obligations in the new socially changed environment. The breakdown of the joint family system that had previously provided emotional support and stability is also seen as an important causal factor in suicides in India (De Leo, 2003).
Religion acts as a protective factor both at the individual and societal levels. The often-debated question is whether the social network offered by religion is protective or whether it is the individual’s faith. A study in Chennai found that the OR for lack of belief in God was 6.8 (CI 2.88-19.69) (Vijayakumar, 2002). Those who committed suicide had less belief in God, changed their religious affiliation and rarely visited places of worship. Eleven per cent had lost their faith in the three months prior to suicide also found that lack of religious belief was a risk factor (OR 19.18, CI 4.17-10.37) (Gururaj et al, 2004).
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 counter-productive. Emergency care to those who have attempted suicide is denied as many hospitals and practitioners hesitate to provide the needed treatment fearful of legal hassles. The actual data on attempted suicides becomes difficult to ascertain as many attempts are described to be accidental to avoid entanglement with police and courts.
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Source: Suicide and its prevention: The urgent need in India. Indian J Psychiatry. 2007 Apr-Jun; 49(2): 81–84.