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Attempted Suicides in India: A Comprehensive Look

Sahoo Saddichhaa; M. N. V. Prasadb; Mukul Kumar Saxenac 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 Online publication date: 27 January 2010

To cite this Article Saddichha, Sahoo , Prasad, M. N. V. and Saxena, Mukul Kumar(2010) 'Attempted Suicides in India: A

Comprehensive Look', Archives of Suicide Research, 14: 1, 56 65 To link to this Article: DOI: 10.1080/13811110903479060 URL: http://dx.doi.org/10.1080/13811110903479060

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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. 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 characteristics 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

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INTRODUCTION

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)

which implies an annual global mortality 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

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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 estimated to be 10.5 per 100,000 population (NCRB, 2007), although these are widely 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 punishable so there is a great degree of underreporting (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, documented to have the highest rates of suicide (Aaron, Joseph, Abraham et al., 2004),

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, BilleBrahe, Kerkhof et al., 1992; Schmidtke, Bille-Brahe, De Leo et al., 2004). The burden 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 catering 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 emergency response services, attempted suicides get recorded as medical emergencies. The institutional database which has been recording all emergencies since mid-2006,

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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 projections of attempts were made for the year 2008, using databases of EMRI and NCRB.
METHOD
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Emergency Management and Research Institute (EMRI), since mid-2005, has been running the first professional and comprehensive free emergency services in India, in partnership with different state governments, 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 database 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 suspected suicides, also confirm the clinical suspicion of suicide attempt. The PCR is

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 completeness. 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 analysis 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 period of 2008 using a 2 stage sampling based on the following formula (Cochran, 1997): The sample mean per subunit in the ith primary unit, yi
m X yij j1

where, yij Value obtained for the jth subunit in the ith primary unit (Recorded suicides), m Total number of subunits selected in the sample from each primary unit. Overall sample mean per subunit, y
n X yi i1

where, yi The sample mean per subunit in the ith primary unit, n Total number of primary units selected in the sample.

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b Y representing number of suicides can be estimated as, b YN y

RESULTS

where N is the Population of Andhra Pradesh (in 000).

We recorded a total of 1007 attempts at suicide. The male:female ratio was about 1.27:1 (Table 1). The age distribution revealed a trend towards the younger age group, with most suicide attempts

TABLE 1. Socio-Demographic Characteristics of Attempted Suicides with State and National Comparisons of Completed Suicides AP (EMRI) Gender Male Female Age distribution Below 14 years 1529 years 3044 years 4559 years Above 60 years Location of suicide Residence Roadside Others Occupation Daily wage worker Housewife Self-employed Student Unemployed Others Method of suicide Hanging Drugs and poisons Burns Insecticide Poisoning Others Victim status at 48 hrs Left hospital All right and discharged All right but still in hospital Critical Expired AP (NCRB 2006) All India (NCRB 2006)

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566 (56.2%) 441 (43.8%) 30 496 333 99 49 (3.0%) (49.3%) (33.1%) (9.8%) (4.9%)

8863 (66.8%) 4413 (33.2%) 364 4683 4635 2615 979 (2.7%) (35.3%) (34.9%) (19.7%) (7.4%)

75702 (64.1%) 42410 (35.9%) 2464 42216 40699 23606 9127 (2.1%) (35.7%) (34.5%) (20.0%) (7.7%)

711 (70.6%) 131 (13.0%) 165 (16.4%) 521 176 90 56 94 70 516 142 114 210 25 556 131 105 154 61 (51.7%) (17.5%) (8.9%) (5.6%) (9.3%) (7.0%) (51.2%) (14.1%) (11.3%) (20.9%) (2.5%) (56.2%) (13.0%) (10.4%) (15.3%) (6.1%) 5108 2156 1468 512 429 3603 2759 1634 1016 5347 2510 (38.4%) (16.2%) (11.0%) (3.9%) (3.2%) (27.1%) (20.8%) (14.9%) (7.7%) (40.3%) (16.3%) 37862 25063 10577 5857 8886 29867 38706 20773 10243 22947 25443 (32%) (21.2%) (9.0%) (5.0%) (7.5%) (25.3%) (32.8%) (17.7%) (8.7%) (19.4%) (21.4%)

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occurring in the 1545 year age group. Most of the recorded attempts were at the residence of the victims (71%), committed mainly by daily wage workers (52%) using hanging and insecticide poisoning 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 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 selfharm (p < 0.001). An analysis of occupations showed that although hanging was the commonest method across all occupational groups, there were significant differences in other methods (p 0.017). While laborers, students and the unemployed 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,

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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 preferred 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 methodology, the estimated numbers across various age groups (per 1000 population) for both genders and for the total population 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

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

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

Hanging No

(%)/Mean

Factors

(S.D.)

1) Gender 88 (15.5) 54 (12.2) 68 (15.4) 78 (17.7) 8 (1.8) 46 (08.1) 132 (23.3) 17 (3.0) 19.1 4 0.001

Male

283 (50.0)

Female

233 (52.8)

2) Occupation 70 (13.4) 25 (14.2) 18 (20.0) 7 (12.5) 12 (12.8) 10 (14.3) 8 (11.4) 16 (22.9) 14 (14.9) 20 (21.3) 5 (8.9) 16 (28.6) 6 (6.7) 11 (12.2) 3 (3.3) 3 (5.4) 1 (1.1) 6 (8.6) 26 (14.8) 29 (16.5) 0 (0) 55 (10.6) 118 (22.6) 12 (2.3) 35.5 20 0.017

Laborer

266 (51.1)

Housewife

96 (54.5)

Business

52 (57.8)

Student

25 (44.6)

Unemployed

47 (50.0)

Others

30 (42.9)

3) Area 131 (14.9) 11 (10.3) 0 (0) 0 (0) 7 (31.8) 16 (15.0) 16 (15.0) 98 (11.2) 187 (21.3) 17 (1.9) 6 (5.6) 2 (9.1) 21.2 8 0.007

Rural

445 (50.7)

Urban

58 (54.2)

Tribal

13 (59.1)

4) Age of patient 16 (53.3) 71 (14.3) 32 (9.6) 12 (12.1) 11 (22.4) 4 (08.2) 7 (07.1) 43 (12.9) 56 (11.3) 4 (13.3) 9 (30.0) 102 (20.6) 67 (20.1) 21 (21.2) 11 (22.4) 0 (0.0) 14 (2.8) 6 (1.8) 1 (1.0) 4 (8.2) <0.001 25 (27.8) 25 (27.8) 44 (57.1) 20 (26.0) 25 (28.9) 14 (15.6) 6 (40.0) 4 (26.7) 3 (20.0) 2 (13.3) 53.5 12 70.5 16 <0.001

ARCHIVES OF SUICIDE RESEARCH 17 (36.2) 13 (27.7) 14 (29.8) 3 (6.4) 4 (05.2) 9 (11.7)

Below 14

1 (3.3)

Years

1529 years

253 (51.0)

3044 years

185 (55.6)

4559 years

58 (58.6)

60 and above years

19 (38.8)

10) Victim status at 48 hours (n 451)

All right & discharged

79 (35.6)

All right but still

54 (24.3)

in hospital

Critical

67 (30.2)

Expired

22 (9.9)

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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. Moreover, since earlier studies have demonstrated 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

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, selfpoisoning 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

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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 significant 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 suicide by hanging is equally preferred across all age groups except for the extremes of ages. It is possible to conjecture that modeling (based on media coverage) may play a role in this choice of method, but as it is less lethal than the other methods, it possibly reflects the lack of planning for such victims who may have decided on attempting 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, selfimmolation was also one of the methods favored mainly by women, which is a unique phenomenon in the Indian subcontinent (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, restricting access to poisonous substances or prescription drugs may be less effective in preventing suicidal behavior. However, in such circumstances, the role of psychoeducation 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

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 readily available at low cost in the market. It is also important to improve treatment facilities 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 attempting 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 literature. 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 generalizations of the results. We also believe that our data may be limited by the fact that the study may have missed cases of

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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 financial distress, the use of alcohol and issues related to gender have all been associated 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 & Neurosciences (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
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