Suicide prevention needs State intervention

World Suicide Prevention Day is observed on 10^th of September each year to raise awareness and prevent deaths from suicide.  This year’s theme for World Suicide Prevention Day was ‘Preventing Suicide: Reaching Out and Saving Lives’.  As per the WHO estimates, more than 3,000 people die of suicide every day or more than 800,000 people every year.  For every 20 people who attempt suicide, one succeeds.  Sadly, suicide is the second leading cause of death in the age group 15-29.  More people die due to suicide worldwide, than due to wars and homicide combined, and around 75% of the deaths by suicide occur in low and middle income countries.

In India every year around 135,000 people end their life by suicide which is about 17% of the total suicides worldwide.  Some estimates suggest suicide rate of 10-11 per 100,000 of population.  As per a report by the National Crime Records Bureau (NCRB), Sikkim has the highest suicide rate at 29 per 100,000 of population and Bihar was at the lowest 0.8 per 100, 000.  Jammu and Kashmir has a suicide rate of 3.5 per 100, 000 as per this report.

Historically, Kashmir is known for low suicide rates and I am not sure if a word for suicide exists in the Kashmiri language.  Various factors have prevented serious escalation in deaths by suicide in spite of ongoing conflict and high prevalence of mental health problems in the Valley.  Being a predominantly Muslim population, religion acts as a protective factor.  The social structure and close knit families provide a protective environment.  People are also known for their resilience which could also be responsible for some protection against escalating suicide rate.

Lately there are frequent reports in newspapers about increasing rates of suicides in the Valley.  Some estimates have suggested suicide rate of around 13 per 100,000 in the Valley.  As per a study by Dr Arshad Hussain, 3-4 patients attend the SMHS emergency department daily, with attempted suicide.  In 2012, about 836 cases of attempted suicide by poisoning were treated at SMHS and more than a thousand such cases have been treated since 2013.  There is hardly any data available from other hospitals across the valley, neither is there any central suicide data base.  Recording suicide is difficult because of the tag of criminality associated with it.  Hence, the actual suicide rate can be much higher than we know. 

When it comes to the method of attempting suicide, use of pesticides remains the leading cause in most Asian countries, including India and same is true about Kashmir.  Hanging remains another common mode of suicide followed by overdoses with prescription and recreational drugs.  Attempted suicide is more common in women than men, but death by attempted suicide is more common in men.  Suicide is also common in urban, literate population than rural areas.

The common reasons for attempting suicide are mental health disorders followed by drug abuse and family problems.  India uniquely poses other reasons for suicide like poverty in farmers.  When it comes to Kashmir, we do not have any robust data to suggest the pattern and causes.  It is a well-established fact that there has been an escalation in mental health problems due to ongoing conflict and mass exposure to psychological trauma.  The rates of depression and PTSD have significantly increased.  Drug and alcohol use is common, making people more vulnerable towards attempting suicide and accidental overdoses.  

People are living in perpetual uncertainty.  There is an environment of fear and a sense of feeling trapped. This is worsened by poverty, little hope for future in terms of joblessness particularly in the youth.  Increased joblessness has also meant delay in settling down and getting married.  Many females are not able to get married due to poverty and huge social expectations.  The increased demands of a modern life coupled with a race to perform better increases the vulnerability of susceptible individuals.  Even children are under extreme pressure to outdo each other.  There is usually an escalation in the number of people attending hospitals for attempted suicides after exam results.  Relationship issues and breakdown in families is another reason.  Other important but hidden factors include domestic violence and sexual abuse. 

India is one of the last few countries in the world where attempting suicide is a criminal act. As per the Indian Penal Code 1860, section 309, ‘Whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for term which may extend to one year 1 or with fine, or with both.  Even the wordings like ‘commit’ and ‘offence’ brings in shame and stigma. This archaic law was enforced under British rule in 1860 and has still not been amended in spite of repeated calls to abolish it.  The Mental Health Care Bill 2013, suicide has been partly decriminalised and a presumption of mental illness has been added, meaning people will not be prosecuted if they attempt suicide.  But this Bill is yet to be passed in parliament.

The issue of criminality around suicide has meant the shame, and stigma getting worse for someone who is already feeling low, hopeless, and worthless with no motivation to carry on. There is an immediate need to decriminalise suicide completely, so that people are able talk about it openly.

Robust registration and documentation of every case should happen, which can help to plan future services.  This is not always easy as the culture of registration and documentation in our hospitals remains weak.  Undertaking community studies on such a subject is arduous and almost impossible in our setup.

Early identification and treatment, training of health workers, follow-up care and community support, introducing alcohol policies, restricting access to means and lastly responsible media reporting are some of the strategies advocated by the WHO to prevent suicide.

Many lives can be saved if people get right support and help at right time.  Awareness of public and health workers with an acceptance that suicide is real but preventable can make a big difference.  Any patient of attempted suicide, who is brought to emergency department in any hospital, should not be discharged home unless seen by a mental health professional for thorough psychiatric assessment to assess further risk and formulate a management plan.  

In the SMHS hospital patients are referred to psychiatry OPD for such assessments during working hours, but there is no such provision during night time and holidays.  I am not sure other major hospitals in the Valley including SKIMS have developed any such protocol for dealing with suicide cases.  There is a need of developing close liaison between various departments and psychiatry.  Ideally, every emergency department should have access to a psychiatrist all the time.  In the absence of such facility, all cases should be admitted overnight and referred to psychiatry next day so that they receive appropriate treatment and have a safety plan before going home.  Some people do need inpatient treatment if severely suicidal, but unfortunately we do not have such wards or setup in the valley yet, and it is often families who have to deal with the crisis situation.

It is also important that people seek timely help for psychological problems and not let it go to the stage when one starts feeling suicidal. Non Judgemental support from family, and friends helps people suffering from depression and other such problems to recover, without feeling rejected and looked down.  Avoiding drugs and alcohol is another way of preventing suicide.  Improving ones spiritual wellbeing and faith is a great support and gives hope to many who are not able see any other way out.

Easy access to drugs and poisons is a problem in our society which is hard to tackle.  Some have suggested creating pesticide banks, which sounds appealing but rather impractical in our setup.  Here also, awareness of family and friends is important so that if they know someone is at risk of suicide, they can keep such articles under lock and key and supervise the person till they become safe.

In conclusion suicide prevention needs comprehensive multi-sectoral approach from the State, policy makers, and health services including psychiatrists, police, religious leaders and society in general.  It is important to take on board that none of us is immune to such difficult situations.  Anyone of us can fall victim to this hard hitting BUT preventable condition. 

http://www.risingkashmir.com/news/suicides-prevention-needs-state-intervention/  

Conspiracy of Silence- Childhood sexual abuse is a hidden epidemic withlack of recognition and safeguards

In 2007 Government of India authorised a survey into the childhood sexual abuse. The results were alarming describing ‘conspiracy of silence’ around the issue. Out of 13500 children surveyed in 13 states, about 20% were subjected to severe sexual abuse.

Around 31% of such assaults were by a neighbour or a close relative in family. Childhood sexual abuse is unfortunately common and usually perpetrated by someone known to the victim within or outside family. From scientific literature, it is evident that childhood sexual abuse is widespread in all cultures irrespective of religion, values, society, social class, geographical area and Kashmir is no exception. From our own clinical practice and research in the Valley, it is clear that childhood sexual abuse is a common occurrence and is not restricted to any social class.

Unlike other forms of physical or sexual abuse, nothing seems to be protective here as anyone can be the perpetrator. If a parent or guardian is the culprit, it makes this kind of trauma worse than any form of brutal torture. When someone is abused by a ‘person in trust’, the impact of the horrifying experience is profound and leads to lifelong psychological and emotional scarring which is hard to heal. Such children become confused as the boundaries of relationships get blurred and they struggle to comprehend the meaning of social norms. This shatters their core belief of depending on someone or finding emotional comfort. The victim loses all hope and is never able to trust anyone anymore. This gives rise to very complex situation for a child, who may not be able to understand what’s happening at the time.

As the trust is first causality here, children are afraid to approach anyone for help. If ever they do get some courage or in naivety do mention it to a parent, the outcome is not as you may be expecting. Sometimes it can take decades for them to come out if at all. One would assume that immediately the child will be made safe, reassured and the perpetrator brought to books, but that is not the usual outcome. After a brief phase of anger or frustration, the adults in most cases go into a denial mode and refuse to entertain the idea consciously or unconsciously. Children are even threatened with their life, to keep quite. The elders do not listen to their children in such matters and usually the allegation is out rightly rejected. At times their own mothers shut them up due to fear of stigma, guilt, shame and in a false belief to save the future, both of the child and family. This shatters the abused children of any remaining hope and sends them back into a state of perpetual fear, and at times exposes them to continuous and long term abuse. It also reinforces the feelings of rejection, guilt and belief that no one can be trusted.

The golden rule, ‘always believe the child whatever he or she is saying’ needs to be followed in all cases. Children do not lie is these matters and they do not invent stories. It does not matter whom they are referring to and how respectable and trustworthy the said person is in your eyes. He may be a highly respected social worker, religious leader, faith healer (peer), teacher, doctor, freedom fighter, village elder, politician, father, grandfather, brother, cousin or anyone. The child needs to be taken seriously and saved from any further trauma. In addition to ill formed beliefs, the adverse social and cultural pressures about sexual abuse in our society make it difficult to deal with this subject.

Children can display various symptoms and behaviours if they are being sexually abused within or outside family. Children can present withdrawn, aloof, depressed, angry, challenging, refusing school, start bedwetting, not eating, weight loss, always on edge and fearful, lose interest in activities which they usually enjoy, tearful, not sleeping, stop playing and the list goes on. Some children may start self-harming by head banging, cutting on their arms, or putting themselves in dangerous situations. Some fall into the trap of drug addiction and self-medication. It has varying long term consequences. The outcome is grave if child is not believed by their loved ones, breakdown in trust, and lack of emotional support, repeated and prolonged abuse. People can develop severe forms of post-traumatic stress disorder, personality change, dissociative disorder, depression, anxiety, panic attacks, phobias to name a few. Self-harm and suicidal attempts are common as people see little hope in future. There is severe lack of confidence with poor self-image which can lead to failure in studies leading to school dropout and inability to achieve professionally. They find it difficult to form long term relationships and may avoid marriage. In summary the whole life is shattered, leading to poor outcomes both in terms of health and quality of life, failing to achieve to their potential, may not be able to work and lead a miserable life for no fault of their own.

In our society, there is a strong taboo for any kind of sexual abuse and unfortunately the victims are on the receiving end. They are made to believe that somehow they are not equal or dignified anymore. There is no legal recourse and we do not have systems in place which can help such children. Suppose if a child somehow makes to police and narrates the ordeal, what are they supposed to do? What if a parent is involved, where would the child go? In a country where judges advocate that a rapist should marry his victim, there is little hope for such lonely children. There is no recognised system to deal with perverted people like paedophiles and neither are they identified. And let’s not be naïve they don’t exist in our society.

The Protection of Children from Sexual Offences Act (POSCO) was enacted in all states of India in 2012 except Jammu and Kashmir. It seems that nothing has been done in this matter by the Jammu and Kashmir Government till date and there is no legal framework or procedure in place to safeguard children from sexual abuse. The Jammu and Kashmir Juvenile Justice ( Care and Protection of Children) Bill was passed in 2013 which classifies sexually abused children as ‘child in need’ but does not say anything further about safeguarding or management of such cases and seems more interested in arresting juveniles who are allegedly involved in unlawful activities against the state.

There is a need to recognise the problem and help the victims than going into a denial mode. Work needs to be done on the stigma and social attitude so that when these children do seek help, they are taken seriously and not rebuked. It is better to keep the children’s interest at heart and not the family and society in such cases. One would be doing more disservice by not helping children in crisis and worrying about family name or the accused. It is time to come out of any false belief that such acts don’t happen in our society or culture. It can be happening in your house or the house next door. It is not uncommon in institutions housing large number of children, whether run for imparting mainstream or religious education, or the institutions which bring up underprivileged and orphan children. Unfortunately our state has hundreds of such institutions but there are no checks or procedures in place.

Parents and professionals (teachers, doctors, and police etcetera) should always keep abuse as a possibility if there is such presentation and explore actively to prevent any further damage and long term consequences. Teachers have got the bigger responsibility and should be concerned if a child has suddenly started showing any changes in behaviour or decline in academic performance. Doctors should always keep this possibility in mind while treating young people and children.

Training of professionals including doctors, police, teachers and social workers is needed to help such children with sensitivity, compassion and an effective outcome. Civil society has a big role to play in breaking the shackles, creating conducive environment and raising awareness. There is need of policy and procedure from the State for identifying, treating and safeguarding such children.

http://www.greaterkashmir.com/news/opinion/conspiracy-of-silence/195664.html