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Using a global lens to situate suicide prevention in India

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The magnitude of the suicide crisis in India is deeply distressing. To put it in perspective, the National Crime Records Bureau (NCRB)-- the only source of data on suicide mortality in the country-- reported 164,033 deaths by suicides in 2021 – a 7.2% increase from the previous year. Many researchers have argued this is likely an underestimate, ranging anywhere from 30% to 100%. Most recent reports from the World Health Organization (WHO) estimate that in 2019, around 700,000 people died by suicide across the world. 77% of these deaths are in low- and middle-income countries, where India bears a significant portion of the suicide burden.

If we consider the conservative figures of the NCRB, India accounts for an astonishing 20% of the suicides in the world. When we base suicide deaths in India of a more accurate estimation from The Lancet’s Global Burden Disease (GBD) Study, 2016, this proportion increases to one-third i.e., almost 1 in every 3 people who die by suicide in the world are from India. And, while the global rates of suicide have seen a steady downward decline, particularly in high-income countries, in India, the suicide rate has risen in the last five years. Therefore, this crisis demands urgent action from the State and attention from the rest of the world. 

Today, our view on suicide is heavily influenced by global perceptions of the issue that have evolved over centuries. In the past, discourse on suicide was confined to religious and philosophical approaches– as Albert Camus once famously wrote "there is only one really serious philosophical problem, and that is suicide." Throughout history, suicide was universally condemned as immoral.

The act was brandished as criminal and written into literature as an individual tragedy. In the late 19th century, Emile Durkheim, the renowned sociologist tried to shed light on the social roots of suicide however, the main argument that the act was immoral, and a personal problem percolated through history. This largely influenced the more recent debates on suicide, shrouding it in stigma and fatalism that there is nothing one can do to prevent suicide. 

Suicide prevention as a global priority

In the last two decades, suicide is framed as a public health issue and suicide prevention has started attracting global attention. The first mention of suicide prevention on the global public health agenda was by WHO in 1999 with SUPRE (Suicide Prevention), a worldwide initiative that recognized the role of diverse individuals and sectors in providing support to individuals vulnerable to suicide.

In the years that followed, the WHO released a series of guidelines for stakeholders including healthcare professionals, law enforcement officials, media, and education practitioners that documented how they can aid in suicide prevention efforts. These guidelines recognized that the response to suicide should be intersectoral and move beyond the health sector. 

In 2013, suicide prevention was finally integrated into global development priorities. Both the WHO Comprehensive Mental Health Action Plan (2013-2030) and the later Sustainable Development Goals or SDGs acknowledged suicide prevention as a target for intervention. Under both initiatives, reducing the suicide mortality rate by one-third by 2030 became a global target. 

Fast forward to the present day, suicide prevention has become a policy priority in many countries. In 2019, the World Health Assembly through its approval of the revised Comprehensive Mental Health Action Plan (2013-2030) recognized that decriminalizing suicide is a necessary step toward suicide prevention.

Although around 20 countries still regard suicide as a criminal offence, India, through the Mental Healthcare Act, 2017 (MHCA), has attempted to decriminalise suicide. The MHCA presumes those attempting suicide are under duress and instead of charging them with a crime, they should be provided with mental health services.

In many countries, the decriminalising of suicide has slowly lifted the immoral cloak surrounding the act. Societal attitudes are steadily shifting away from the fallacy that suicides are dishonourable to a consensus that individuals attempting suicide or self-harm need support and care.

Apart from their support for decriminalisation of suicide, the WHO has also released an implementation guide for suicide prevention titled LIVE LIFE. The guide identifies four evidence-based interventions that all countries should implement based on global best practices. They include restricting access to means of suicide, encouraging responsible reporting on suicide among the media, imparting life skills education among young people and setting up systems to screen and refer people at risk of suicide to mental health services.

In South Asia, Sri Lanka has modelled the adoption of some of these practices. As a result, the country has successfully halved its suicide rate by decriminalizing suicides, developing a national suicide prevention strategy, and banning the sale of highly hazardous pesticides.

The National Suicide Prevention Strategy in India

Unfortunately, the COVID-19 pandemic further worsened the suicide crisis in many parts of the world. Unlike some high-income countries, with access to adequate income safety nets, the pandemic had a devastating impact on individuals in LMICs specifically in countries without social welfare measures and strong public health systems. In India, during the peak of the COVID-19 pandemic, the suicide rate increased drastically by 10% from 2019 to 2020, and then 7% from 2020 to 2021.

This was more than a three-fold increase as compared to the 3% rise observed in the period of 2017-18 and 2018-19. Many families were left alone to deal with the distress of having no income, debt due to unemployment, and debilitating healthcare costs. These negative ripple effects of the pandemic are still reverberating across India and are a likely reflection of the sharp rise in the suicide rate. 

The recently launched National Suicide Prevention Strategy (2022) is a welcome initiative. The strategy has integrated suicide prevention interventions into several intersectoral government programmes and initiatives.

This includes strategies outlined by the WHO in LIVE LIFE from reducing access to hazardous means to promoting responsible reporting on suicide. Its goal is to reduce suicide mortality by 10% in 2030 from suicide prevalence in 2020. The true test of its success will be how quickly and effectively the strategy is put into practice to achieve this goal. 

We have also learnt from the past two years that socio-economic measures are needed to support people experiencing distress and suicide ideation. Unless adequate social security nets are made available to individuals to weather shock events (such as the COVID-19 pandemic, economic recessions, and conflict) there is a likely possibility that its goal will remain unmet.

Global and national targets to reduce suicide hinge on the Government’s commitment to prioritize suicide prevention and implement the new strategy. If we are to realistically meet our goal of reducing suicide substantially, India must take cohesive action immediately at a national, state, and local level. 

Tanya Nicole Fernandes is a research associate, and Soumitra Pathare is a consultant psychiatrist and director; at the Centre for Mental Health Law & Policy, Indian Law Society, Pune.

Note: "Discussing suicides can be triggering for some. However, suicides are preventable. In case you feel distressed by the content or know someone in distress, call Sneha Foundation - 04424640050 (available 24x7) or iCall, the Tata Institute of Social Sciences' helpline - 02225521111, which is available Monday to Saturday from 8 am to 10 pm. (THE NEW INDIAN EXPRESS)

379 Days ago