World
Suicide Prevention Day is observed on 10th 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.
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