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Attempted Suicides in India: A

Comprehensive Look
a b c
Sahoo Saddichha , M. N. V. Prasad & Mukul Kumar Saxena
a
National Institute of Mental Health & Neurosciences (NIMHANS),
Bangalore, India
b
Division of Applied Research, Emergency Management and
Research Institute (EMRI), Hyderabad, India
c
Division of Clinical Research, Emergency Management and Research
Institute (EMRI), Hyderabad, India

Available online: 27 Jan 2010

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 Archives of Suicide Research, 14:5665, 2010
Copyright # International Academy for Suicide Research
ISSN: 1381-1118 print=1543-6136 online
DOI: 10.1080/13811110903479060

Attempted Suicides in
India: A Comprehensive
Look
Sahoo Saddichha, M. N. V. Prasad, and Mukul Kumar Saxena

Suicide continues to be one of the biggest killers in the world, with suicide rates
varying between 8.1 and 58.3=100,000 population for different parts of India.
Downloaded by [Andhra University] at 07:59 31 October 2011

Andhra Pradesh, the fourth largest state in India, is responsible for more than
11% of these. Unfortunately, most suicides are under-reported and there is scant
data on attempted suicides. This study aimed to comprehensively study the character-
istics of attempted suicides in Andhra Pradesh and using the primary data, make
secondary projections for the forthcoming years. Using Patient Care Record
(PCR) forms of all emergencies serviced by 108, the first comprehensive emergency
service in India, an analysis of all cases was done to detect possible suicides during
the period JanuaryDecember 2007. A follow up 48 hours later was then done to
confirm status and diagnosis. A total of 1007 cases were recorded as confirmed
suicides. Hanging and insecticide poisoning (72%) were the most common methods
used. Males preferred hanging and insecticide poisoning while females preferred
self-immolation and hanging as common methods. Self-immolation and insecticide
poisoning had the highest mortality (41.6%). Estimates of attempted suicides for
the year 2008 revealed a mean of 3.23.8 per 1000 population for males,
3.33.7 per 1000 population for females and 6.47.6 per 1000 population
combined. A serious epidemic of suicides seems to be in store in the coming years
unless preventive steps in the form of policy changes are undertaken. Restricting access
to poisonous substances or prescription drugs and taking into consideration the
prevailing social, economic and cultural factors could help in reducing numbers.
Starting tele-help services or offering brief interventions during hospital stays are other
programs which may be considered.

Keywords attempted suicides, prevention, suicides

INTRODUCTION which implies an annual global mortality

Suicides continue to be one of the largest
contributors to the global mortality rate
with approximately one million people
dying from suicide each year (WHO,
2003). The World Health Organization
(WHO) estimated that there were 877,000
suicides worldwide in 2002 (WHO, 2003)
of about 14.5 per 100,000 population.
Suicide is the thirteenth leading cause of
death worldwide and it is predicted that
the current rate of one death every 40
seconds will increase to one every 20
seconds by 2020 (WHO, 2003). The rates
are no different for India, with suicide rates
varying between 8.1 and 58.3=100,000

56

population for different parts of India
(Gururaj & Isaac, 2001).
In India, suicide is a multi-dimensional
issue with inter-sectoral reach cutting
across diverse disciplines such as health,
religion, spirituality, law and welfare. The
number of suicides in the country during
the last decade (19962006) has recorded
an increase of 33.9% from 88,241 in 1996
to 118,112 in 2006. The official adjusted
suicide rate in India, according to National
Crime Research Bureau (NCRB) was esti-
mated to be 10.5 per 100,000 population
(NCRB, 2007), although these are widely
Downloaded by [Andhra University] at 07:59 31 October 2011
believed to be under-reported. India
currently occupies the 45th position
globally and the 2nd position in the SEAR
region with respect to suicides committed
(WHO, 2003). The latest data reveal an
alarming rise of suicides with 118,112
persons having committed suicide in 2006
(NCRB, 2007). If the trend continues, the
projected figures for 2007 would be around
119,350 deaths due to suicide. In India,
however, suicide is declared legally punish-
able so there is a great degree of under-
reporting (Joseph, Abraham, Muliyil et al.,
2003). Many deaths, particularly in the rural
areas, are not registered at all (Jha,
Gajalakshmi, Gupta et al., 2006), partly
because of an inefficient registration system
(Bose, Konradsen, John et al., 2006) and
partly because families fear the social and
legal consequences associated with suicide.
Andhra Pradesh (AP), the fourth
largest state in India, with a population of
81,554,000 (Population Projection, 2006)
ranks third in the number of suicides in
India (13,276)contributing more than
11% of the total suicides in India. The
annual prevalence rates of suicide in AP
are 16.4 per 100,000 population which is
distinctly higher than the national average
of 10.5 per 100,000 population (NCRB,
2007). The southern part of India, in which
this region is located, has in fact, documen-
ted to have the highest rates of suicide
(Aaron, Joseph, Abraham et al., 2004),
ARCHIVES OF SUICIDE RESEARCH
S. Saddichha et al.
making it essential to study this region,
not just for suicides but also for attempted
suicides.
Although there are data available,
however insufficient, on suicides, there is
a serious dearth of knowledge on attempted
suicides. Different small studies around
the world have observed a frequency of
suicide attempts as being up to 1040 times
more than completed suicides (Platt, Bille-
Brahe, Kerkhof et al., 1992; Schmidtke,
Bille-Brahe, De Leo et al., 2004). The bur-
den of such attempts is expected to increase
to 2.4% in 2020 with about 5% to 25% of
the population harboring suicidal thoughts
at any given time and the ratio between an
act, an attempt and a thought believed to
be in the range of 1:10:100, respectively
(WHO, 2003). Cross-national comparisons
of suicide attempts have shown lifetime
prevalence rates to be between 0.7% and
5.9% (Weissman, Bland, Canino et al.,
1999; Welch, 2001). The SUPRE-MISS
study across 10 sites across the world also
observed a 0.44.2% prevalence across the
sites (Bertolote, Fleischmann, De Leo
et al., 2005). Although this study was one
of the largest ever to report on attempts,
it was limited by its urban focus which
may not have been a true representation
of the actual scenario.
With existing resources designed to
identify suicides being few and far between,
health care and registration systems cater-
ing only to completed suicides, and with
the fear of social and legal consequences,
it is even more imperative that attempted
suicides be studied. This study aims to
add to the existing knowledge by compiling
the first ever comprehensive report on
attempted suicides, hoping to reduce the
lacunae currently existing. Since the
Emergency Management and Research
Institute (EMRI) runs a state wide emerg-
ency response services, attempted suicides
get recorded as medical emergencies. The
institutional database which has been
recording all emergencies since mid-2006,
57

therefore serves as a valuable resource to
compile data on attempted suicides. The
research team at the institute therefore
aimed to study the demographics of
attempted suicides in Andhra Pradesh,
and compared then with existing suicide
data for the state and India. Further, as
secondary data analysis, estimated projec-
tions of attempts were made for the
year 2008, using databases of EMRI and
NCRB.
METHOD
Downloaded by [Andhra University] at 07:59 31 October 2011
Emergency Management and Research
Institute (EMRI), since mid-2005, has been
running the first professional and compre-
hensive free emergency services in India, in
partnership with different state govern-
ments, by running a single toll-free
number, 108. Currently, 108 services
several states including the whole state of
Andhra Pradesh which is the fifth largest
state in India with an area of 276,754
sq. km, accounting for 8.4% of Indias
territory. With a fleet of nearly 600 mobile
emergency units and an emergency data-
base since mid-2006, the research team at
the institute compiled data from January
December 2007 for all cases recorded as
possible suicide attempts.
As a routine, all medical emergencies
are attended by the EMRI Emergency
Services after the call is recorded on dialing
108. The paramedics attending such calls
are dispatched to the scene of emergency
and then provide medical interventions
while filling in all details in the ambulance
patient care record (PCR) form. After the
patient is attended to and delivered to a
hospital if required, these PCRs are
returned to the Institute. Follow up calls
are made for each and every patient 48
hours later to determine the clinical status
of the individual. The calls, in cases of sus-
pected suicides, also confirm the clinical
suspicion of suicide attempt. The PCR is
58 VOLUME 14  NUMBER 1  2010
Attempted Suicides in India
also scrutinized, collated and data entered
into a central database.
As part of the research project, all
PCRs were reviewed by the research team
for the period JanuaryDecember 2007,
with case records included if they involved
emergencies which could be a possible
suicide. Since, as has been noted above,
relatives are wary of reporting suicides,
such an exercise was necessary to broaden
the database. Once the PCRs had been
reviewed, data were evaluated for com-
pleteness. At the end of the exercise, a total
of 1007 cases were left for which complete
data was available and this was compared
with existing resources for the state of
Andhra Pradesh and India.
We recorded all details of the victims,
including socio-demographics, methods of
suicide and 48 hour follow up. Data analy-
sis was performed for the primary dataset
as well as secondary comparisons with
NCRB data. Using external data obtained
from AP population projections, NCRB
figures for AP as well as total emergencies
attended to by EMRI for the period of
JanuaryDecember 2007, we attempted to
estimate the attempted suicides for the per-
iod of 2008 using a 2 stage sampling based
on the following formula (Cochran, 1997):
The sample mean per subunit in the ith
primary unit,
X
m
yij
yi
j
1
m
where, yij Value obtained for the jth
subunit in the ith primary unit (Recorded sui-
cides), m Total number of subunits selec-
ted in the sample from each primary unit.
Overall sample mean per subunit,
X
n
yi
y
i
1
n
where, yi The sample mean per subunit
in the ith primary unit, n Total number
of primary units selected in the sample.
 S. Saddichha et al.

b representing number of suicides can

Y RESULTS
be estimated as,
We recorded a total of 1007 attempts at
bN y
Y
suicide. The male:female ratio was about
1.27:1 (Table 1). The age distribution
where N is the Population of Andhra revealed a trend towards the younger
Pradesh (in 000). age group, with most suicide attempts

TABLE 1. Socio-Demographic Characteristics of Attempted Suicides with State and National

Comparisons of Completed Suicides

AP (EMRI) AP (NCRB 2006) All India (NCRB 2006)

Gender
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Male 566 (56.2%) 8863 (66.8%) 75702 (64.1%)

Female 441 (43.8%) 4413 (33.2%) 42410 (35.9%)
Age distribution
Below 14 years 30 (3.0%) 364 (2.7%) 2464 (2.1%)
1529 years 496 (49.3%) 4683 (35.3%) 42216 (35.7%)
3044 years 333 (33.1%) 4635 (34.9%) 40699 (34.5%)
4559 years 99 (9.8%) 2615 (19.7%) 23606 (20.0%)
Above 60 years 49 (4.9%) 979 (7.4%) 9127 (7.7%)
Location of suicide
Residence 711 (70.6%)
Roadside 131 (13.0%)
Others 165 (16.4%)
Occupation
Daily wage worker 521 (51.7%) 5108 (38.4%) 37862 (32%)
Housewife 176 (17.5%) 2156 (16.2%) 25063 (21.2%)
Self-employed 90 (8.9%) 1468 (11.0%) 10577 (9.0%)
Student 56 (5.6%) 512 (3.9%) 5857 (5.0%)
Unemployed 94 (9.3%) 429 (3.2%) 8886 (7.5%)
Others 70 (7.0%) 3603 (27.1%) 29867 (25.3%)
Method of suicide
Hanging 516 (51.2%) 2759 (20.8%) 38706 (32.8%)
Drugs and poisons 142 (14.1%) 1634 (14.9%) 20773 (17.7%)
Burns 114 (11.3%) 1016 (7.7%) 10243 (8.7%)
Insecticide Poisoning 210 (20.9%) 5347 (40.3%) 22947 (19.4%)
Others 25 (2.5%) 2510 (16.3%) 25443 (21.4%)
Victim status at 48 hrs
Left hospital 556 (56.2%)
All right and discharged 131 (13.0%)
All right but still in hospital 105 (10.4%)
Critical 154 (15.3%)
Expired 61 (6.1%)

ARCHIVES OF SUICIDE RESEARCH 59


occurring in the 1545 year age group.
Most of the recorded attempts were at
the residence of the victims (71%), com-
mitted mainly by daily wage workers
(52%) using hanging and insecticide poi-
soning as the most common methods
(72%). When followed up at 48 hours,
about a half of all victims had left hospital
with no further details available, and 61 had
expired.
Completed suicide data available from
the National Crime Research Bureau for
the state of Andhra Pradesh and for the
entire country has also been provided for
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easy comparisons (Table 1). As can be
noted, the gender and age distribution of
attempted suicides as recorded by us and
completed suicides as recorded by NCRB
are similar. However, we noted a higher
prevalence of attempts among daily wage
workers than was noted by the NCRB data
set, although all other groups were similar.
Similarly, in methods of suicide, we noted a
higher prevalence of hanging with other
groups remaining near-similar.
Using co-relations between various
groups and method of attempts (Table 2),
it was observed that there was a significant
difference in gender, with males preferring
hanging and insecticide consumption as
methods while females preferred hanging
and self-immolation as methods of self-
harm (p < 0.001). An analysis of occupa-
tions showed that although hanging was
the commonest method across all occu-
pational groups, there were significant
differences in other methods (p 0.017).
While laborers, students and the unem-
ployed preferred insecticide consumption,
housewives preferred self-immolation and
students overused drugs and poisons as
common methods of attempting suicide.
Area-wise distribution revealed hanging to
be once again the most common method
followed by insecticide poisoning across
all areas, however, significantly, there were
no cases of self-immolation or overdose of
drugs in tribal areas (p 0.007). Similarly,
60 VOLUME 14
NUMBER 1
2010
Attempted Suicides in India
there were significant differences noted
among different age-groups. While the
younger victims (those below 14 years)
used drugs and insecticide poisoning, the
elderly age-group (those above 60 years)
used hanging and drug overdoses as pre-
ferred methods (p < 0.001). The rest of
the age groups commonly used hanging
as the most common method of suicide.
Forty-eight hour follow up status revealed
the highest mortality with self-immolation
and insecticide poisoning. Drug overdoses
and other methods of poisoning appeared
to be the most non-lethal methods.
Since the distribution of total attempts
matched the number of total emergencies
serviced by us and the total suicides in
AP according to NCRB (Table 1), we then
attempted to estimate the number of
attempts for the forthcoming year 2008.
Using the formula mentioned in the meth-
odology, the estimated numbers across
various age groups (per 1000 population)
for both genders and for the total popu-
lation has been given in Figures 1(a, b &
c). The mean estimated attempts for males
was 3.23.8 per 1,000 population, for
females was 3.33.7 per 1,000 population
and for the total population was 6.47.6
per 1,000 population.
DISCUSSION
Suicide is an important, largely preventable
public health problem. Suicide attempters
often outnumber completed suicides by a
ratio of 10:1 (WHO, 2003). As literature
on this phenomenon is relatively rare
(Diekstra, 1993; Latha, Bhat & DSouza,
1996; Schmidtke, Bille-Brahe, De Leo
et al., 1996; Thanh, Jiang, Van et al.,
2005), we believe that our study, being
the first comprehensive study of suicide
attempters in India, could shed light on a
hitherto unexplored area. Since the only
other study came from Chennai, which is
a single metropolitan city in South India
 Downloaded by [Andhra University] at 07:59 31 October 2011

TABLE 2. Co-Relations of Variables with Methods of Attempted Suicides

Hanging No Drugs and Insecticide

(%)/Mean Poisons No (%)/Mean Burns No (%)/ Mean Poisoning No (%)/Mean Others No (%)/ Mean
Factors (
S.D.) (
S.D.) (
S.D.) (
S.D.) (
S.D.) X2 dF P

1) Gender
Male 283 (50.0) 88 (15.5) 46 (08.1) 132 (23.3) 17 (3.0) 19.1 4 0.001
Female 233 (52.8) 54 (12.2) 68 (15.4) 78 (17.7) 8 (1.8)
2) Occupation
Laborer 266 (51.1) 70 (13.4) 55 (10.6) 118 (22.6) 12 (2.3)
Housewife 96 (54.5) 25 (14.2) 26 (14.8) 29 (16.5) 0 (0) 35.5 20 0.017
Business 52 (57.8) 18 (20.0) 6 (6.7) 11 (12.2) 3 (3.3)
Student 25 (44.6) 7 (12.5) 5 (8.9) 16 (28.6) 3 (5.4)
Unemployed 47 (50.0) 12 (12.8) 14 (14.9) 20 (21.3) 1 (1.1)
Others 30 (42.9) 10 (14.3) 8 (11.4) 16 (22.9) 6 (8.6)
3) Area
Rural 445 (50.7) 131 (14.9) 98 (11.2) 187 (21.3) 17 (1.9) 21.2 8 0.007
Urban 58 (54.2) 11 (10.3) 16 (15.0) 16 (15.0) 6 (5.6)
Tribal 13 (59.1) 0 (0) 0 (0) 7 (31.8) 2 (9.1)
4) Age of patient
Below 14 1 (3.3) 16 (53.3) 4 (13.3) 9 (30.0) 0 (0.0)

ARCHIVES OF SUICIDE RESEARCH

Years
1529 years 253 (51.0) 71 (14.3) 56 (11.3) 102 (20.6) 14 (2.8) 70.5 16 <0.001
3044 years 185 (55.6) 32 (9.6) 43 (12.9) 67 (20.1) 6 (1.8)
4559 years 58 (58.6) 12 (12.1) 7 (07.1) 21 (21.2) 1 (1.0)
60 and above years 19 (38.8) 11 (22.4) 4 (08.2) 11 (22.4) 4 (8.2)
10) Victim status at 48 hours (n 451)
All right & discharged 79 (35.6) 17 (36.2) 4 (05.2) 25 (27.8) 6 (40.0) 53.5 12 <0.001
All right but still 54 (24.3) 13 (27.7) 9 (11.7) 25 (27.8) 4 (26.7)
in hospital
Critical 67 (30.2) 14 (29.8) 44 (57.1) 25 (28.9) 3 (20.0)
Expired 22 (9.9) 3 (6.4) 20 (26.0) 14 (15.6) 2 (13.3)

61
Note.  p < 0.05.

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FIGURE 1. (a) Estimated attempts for male population of AP; (b) Estimated attempts for female population of AP; and (c)
Estimated attempts for total population of AP.
(Bertolote, Fleishmann, De Leo et al.,
2005), we believe that it may not have
represented the true picture of suicide
attempters. This study has, we believe,
tapped all suicide attempters which have
been attended to by our 108 service,
thereby making it possible that it may have
succeeded in compiling a comprehensive
report on attempts which may have escaped
the catchment of previous studies. More-
over, since earlier studies have demon-
strated that most suicides in India come to
medical attention (Bertolote, Fleishmann,
De Leo et al., 2005), we believe that the
number of victims missed may have been
small. This sample of attempted suicides
identified by our emergency services is like
those identified in developed countries in
other studies (Diekstra, 1993; Latha, Bhat,
& DSouza, 1996; Schmidtke, Bille-Brahe,
De Leo et al., 1996; Thanh, Jiang, Van
62 VOLUME 14
NUMBER 1
2010
Attempted Suicides in India
et al., 2005), primarily composed of young
adults. The male:female gender ratio is
around 1.27:1, which is similar to that of
the NCRB data set available for the state
and India (NCRB, 2007) and the WHO=
EURO multicentre study which observed
a ratio of 1:0.7 to 1:2.3 (Schmidtke,
Bille-Brahe, De Leo et al., 2004).
Similar to other countries, self-
poisoning and hanging were observed as
the most common methods of suicide
attempts. The ingestion of insecticides,
medications or other poisons accounted
for more than a third of all suicide attempts
identified by the emergency services,
similar to other studies from India (Arun,
Yoganarasimha, Kar, et al., 2007; Bhatia,
Aggarwal, & Aggarwal, 2000; Gajalakshmi
& Peto, 2007; Joseph, Abraham, Muliyil
et al., 2003). Although suicide by pesticide
poisoning is a common method adopted

by developing countries, particularly in
China, India, and Sri Lanka (Eddleston &
Phillips, 2004; Gunnell & Eddleston,
2003; Latha, Bhat, & DSouza, 1996;
Phillips, Yang, Zhang et al., 2002;
Somasundaram & Rajadurai, 1995), we
have also observed an increasingly signifi-
cant number attempting suicide by hanging.
This may possibly be due to the fact that
many of our suicide attempters are from
the urban areas where the use of pesticide
is uncommon. However, it appears that sui-
cide by hanging is equally preferred across
all age groups except for the extremes of
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ages. It is possible to conjecture that mod-
eling (based on media coverage) may play a
role in this choice of method, but as it is
less lethal than the other methods, it poss-
ibly reflects the lack of planning for such
victims who may have decided on attempt-
ing suicide on an impulse (Kim & Singh,
2004). This calls for developing prevention
programs for those who express suicidal
thoughts with or without a plan since every
attempt is a cry for help.
Among the other methods, self-
immolation was also one of the methods
favored mainly by women, which is a
unique phenomenon in the Indian subcon-
tinent (Batra, 2003), and unfortunately also
the most lethal. This calls for a different
approach as women use easily available
means to end their lives, therefore, restrict-
ing access to poisonous substances or
prescription drugs may be less effective in
preventing suicidal behavior. However, in
such circumstances, the role of psycho-
education and community-based agencies
can be of immense help to those in distress.
Based on the projected estimates, the
mean estimate for males calculates to
around 3.23.8 per 1000 population and
that for females around 3.33.7 per 1000
population, giving a mean of around 7
per 1000 for the entire population. This
amounts to a serious epidemic of suicides
in the coming years, which could result in
a number of deaths that can be easily be
ARCHIVES OF SUICIDE RESEARCH
S. Saddichha et al.
prevented with certain public health
policies. Since restricting the access to and
the availability of prevailing methods such
as insecticides and drugs can be effective in
reducing the frequency of suicide attempts
(Bowles, 1995; Roberts, Karunarathna,
Buckley et al., 2003), there is an urgent need
to regulate the distribution, packaging and
sale of these substances since these are read-
ily available at low cost in the market. It is
also important to improve treatment facili-
ties available without increasing the stigma
since many of those who attempt suicide
require medical attention and they are at high
risk for completed suicide. Policies also need
to take in consideration the prevailing social,
economic and cultural factors when attempt-
ing to tackle suicides due to impulsivity and
stress and factor in the apparent widespread
acceptability of such an option in society
(Jacob, Jayakaran, & Manoranjitham, 2006).
After medical intervention, brief
intervention in the form of individual
information sessions at time of discharge
and appropriate follow up has proved
effective even in developing countries
(Fleischmann, Bertolote, J.M., Wasserman
et al., 2008). In addition, a tele-help
service could also significantly reduce the
number of suicide deaths by providing
support and counseling with maintenance
of complete anonymity and confidentiality
(De Leo, Dello Buono, & Dwyer, 2002).
This article presents, for the very first
time, the unique characteristics of
attempted suicides for a large population
comprising both urban and rural areas,
something which has been lacking in litera-
ture. Numerous difficulties of a logistic and
methodological nature have to be accepted,
and the present data will have to undergo
rigorous and critical appraisal before any
attempt can be made to specifically address
the issues of comparing the results with
those of other studies, or of making gener-
alizations of the results. We also believe
that our data may be limited by the fact that
the study may have missed cases of
63

attempted suicide which are self-referred to
the hospitals or brought there by other
agencies. However, such numbers are
usually very small, and we believe that this
study is largely representative of the general
population, since comparisons with the
NCRB data set, for both the state and the
country, have shown similar findings
(Table 1). Although the data presented here
may be used as the foundation to develop
preventive policies, one has to realize that
not all suicides are due to mental illnesses;
recent adverse life events, interpersonal
stress and relationship difficulties, severe
Downloaded by [Andhra University] at 07:59 31 October 2011
financial distress, the use of alcohol and
issues related to gender have all been asso-
ciated with suicide (Prasad, Abraham, Minz
et al., 2005). In any case, there is a need to
further study the risk factors for suicide
and to develop appropriate programmes
to reduce deaths caused by suicide.
AUTHOR NOTE
Sahoo Saddichha, Resident in Psychiatry,
National Institute of Mental Health & Neu-
rosciences (NIMHANS), Bangalore, India.
M. N. V. Prasad, Research Consultant,
Division of Applied Research, Emergency
Management and Research Institute
(EMRI), Hyderabad, India.
Mukul Kumar Saxena, Senior Partner,
Division of Clinical Research, Emergency
Management and Research Institute
(EMRI), Hyderabad, India.
Correspondence concerning this article
should be addressed to Sahoo Saddichha,
Resident in Psychiatry, National Institute
of Mental Health & Neurosciences
(NIMHANS), Bangalore, India. E-mail:
saddichha@gmail.com
REFERENCES
Aaron, R., Joseph, A., Abraham, S., et al. (2004).
Suicides in young people in rural southern India.
Lancet, 363, 11171118.
64 VOLUME 14
NUMBER 1
2010
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