AUGUST 06, 2017 23:58 IS
A systems-based approach is needed, and we need to start now
Mumbai: Let me start bluntly. We sit atop the global suicide table. But we are in denial of this fact, despite annual and decadal growth of suicide and suicide attempts.
For last the few months, a fundamental question has lurked in my disrupted mind. (I am a sufferer of bipolar disorder for decades. I have lived life with suicidal ideation and more than one failed suicide attempt.) Has the time arrived for the nation to do an about-turn, to usher in a paradigm shift in the way suicidal ideation, suicide attempts and completed suicide is viewed in the country? Can we take a U-turn adopting a Mission Zero Suicide India?
When I first broached this idea in a conference called, ‘Depression: Let us Talk’ on this year’s World Health Day celebration at Bombay Hospital, a noted psychiatrist friend whispered in my ears, “Zero suicide is utopia.”
But I dare to say that this mission is neither utopian nor a pipe-dream. It is aspirational and audacious, but it is a goal whose time has come.
Setting goals
For a start, it aims to get us to shed old beliefs and dogmas about suicide. It calls for eschewing incrementalism in favour of radical, transformational, and systematic preventive agenda. In the Indian context, it also means letting go of the long-held belief that some people are programmed to commit suicide, that in a country of 130 crore persons, it is inevitable that some will invariably take their lives. In a nutshell, it calls for brand new thinking in suicide care, one in which suicide elimination becomes the central goal at national, state, city and village levels.
Why must we aim for elimination instead of reduction?
If instead of banishing suicide, the national agenda is to reduce it below, say, 1 per 10,000, it would still be commendable. But think: what if that one is your spouse? Your parent or your child? Your friend? The goal has humungous personal, familial, societal, and national benefits. Is that not it in itself a sufficient reason?
I will return to this a little later. Let us first get an idea of how serious the Indian suicide problem is.
Akhileshwar Sahay.
The numbers
While the causes — or sets of causes — of suicide are complex, analysis of the patterns, causes, and effects need not be. Unfortunately, there are no reliable statistics of how many Indians commit suicide annually. Data on suicide attempts is so opaque that any attempt to understand it is like groping inside a black box in the dark.
Here is what we do know.
The first representative research on the prevalence of suicide in India, by my friend Dr. Vikram Patel and his colleagues, was published in the reputed British medical journal Lancet in 2012. The paper said that in 2010, an estimated 1,87,000 persons aged 15 years or older committed suicide (1,15,000 men and 72,000 women). The age-standardised suicide rate per 1,00,000 is 26.3 for men and 17.5 for women. The worst finding, for me, is 40% (45,100 of 1,14,800) of suicide deaths in men and 56% (40,500 of 72,100) in women occurred between ages 15 and 29.
If this is not damning enough, a first-of-its-kind comprehensive report, Preventing Suicide: A Global Perspective, published by WHO in 2014, reported that 2,58,057 (158,098 men and 99,977 women, 61.26%:38.74%) Indians committed suicide in 2012, the largest number for any country in the world. India is the secondmost-populous country, but the absolute number is much higher than China, the most populous. It also confirmed the findings of the Lancet study about the very high suicide rate in the 15–29 age group. The study added the caveat that the rate of suicide in developing countries, including India, was highly underreported.
WHO estimates of global suicide numbers are between 800,000 to a million people a year. Indian suicides, it says, are more than 25% of global numbers. (Whereas we are around 17% of the world’s population.)
Official numbers in India, however, differ. The latest suicide data, for the year 2015, compiled by National Crime Record Bureau (NCRB), puts the total number of suicides at a measly 1,33,623, a little more than half the WHO number. It does admit, though, to an increase of 17.3% since 2005 (when there were around 1,13,914 suicides). The data says the male to female ratio for 2015 was 68.5%:31.5%, a significantly greater ratio of male suicides than the WHO figures.
The flaws in our data
However hard I attempt to digest this data, even granting it the status of a half-truth, it still presents itself to me as a blatant lie perpetrated on the nation. I have informed reasons to say so.
One, in a country where citizens are taught to fear the police, data calculated from police records is bound to be unreliable. Two, suicide numbers reported by WHO and in Lancet research mock the veracity of NCRB data. Three, Section 309 of the Indian Penal Code criminalises suicide attempts, resulting in gross underreporting of suicides and attempted suicides. Four, aside from the law, the stigma stops families from reporting suicide and suicide attempts. Five, our unreliable death registration process ensures that a large number of actual suicides simply die uncounted.
More than the numerical blunder, NCRB data scores atrociously high on the callousness with which it reports the causes of suicide. It lists a disparate set of 29 reasons (including nine sub-reasons) in the heartless manner that only the Indian police system is capable of. They are, indebtedness, four distinct marriage-related issues, family problems, impotency, five chronic illnesses, bereavement, drug abuse/alcohol addiction, fall in social reputation, failure in love affairs, poverty, unemployment, property dispute, illicit relation, physical abuse and career problems. Ironically, one of the causes it lists is the insane word ‘insanity.’ (The correct term is mental illness; words like insanity and lunacy — as in the Luncacy Act, 1912 — do not have a place in independent India.
Also, while providing this large inventory of reasons, NCRB misses the big picture. That is, in every reason for suicide reported by it, stress, distress and depression are constants.
An alternative study
Dismayed by the paucity of reliable data, the lack of authenticity of the aetiology, and, if I may say so, the incompetence of the NCRB, I conducted my own small study. I recorded media-reported suicides, along with possible reasons for the suicides, of the current year. The size of my sample is a little over 2,000. The people varied from an eight-year-old child in north-east India to an 85-year-old from Mumbai.
The list included school, college, nursing, medical and engineering students (including from the prestigious IITs and Banaras Hindu University), aspiring PhDs, journalists, blue- and white-collar workers, labourers, maids, farmers, government employees, film and TV actors, military, paramilitary and other uniformed personnel, homemakers, wives and husbands, even suicides by full families, including grandparents and even a great-grandfather. They represented both sides of the so-called ‘Bharat versus India’ schism. Their circumstances and their methods differed: some were on impulse and others clearly pre-meditated or well-planned, some seemed of ‘sound mind’ and others seemed in some way mentally unstable to those who knew them.
But there was one strong causative factor unifying all the cases: extreme distress and stress.
Some learnings from my data and other sources are sobering.
Every hour, two, may be more, young Indians commit suicide.
Every year, more than 20,000 Indian homemakers — housewives in older parlance — take their lives.
As per a Government of India affidavit to the Supreme Court in 2017, during recent years, 12,000 farmers have committed suicide annually.
While suicide rates in the 30-50 age group are alarming, and geriatric suicide too shows an uptick, the rate in the 15–29 age group has reached monstrous proportions.
The economic imperative
Naysayers will say that none of these is a valid reason to find money in the exchequer for costly solutions like the elimination of suicide.
I humbly posit that aside from the humanitarian reasons, there is a good economic reason to address the issue. Here are my ballpark numbers and reasoning.
Based on the WHO, Lancet, and NCRB data, if I conservatively estimate an annual suicide number of 2,00,000, with a 35-year median age, the lifetime annual productivity loss to the nation is 50 lakh person-years.
Assuming — again, conservatively — that as many as 50% of those who commit suicide annually would have had no earnings if they had lived their full lifespans, the approximate loss to the economy at current per capita income from the loss of the other 50% would be ₹25,000 crore.
These numbers do not slow down: next year another 2,00,000 people will get added to the count, and the next, adding to the lifetime economic loss. It is a vicious cycle.
It makes sound economic sense, in other words, to eliminate suicide.
Is it possible?
What would Mission Zero Suicide entail? Is it even workable in Indian conditions?
Mission Zero Suicide is a systems-based approach that that starts by saying every suicide death is preventable. It employs a holistic strategy for suicide prevention: one that is timely, patient-centric, and equitable.
It then asks, what proximate and long-term strategies and interventions are needed to disarm, wean away, or engineer away a suicidal person from stress, distress, depression, anxiety, a deep sense of loneliness, nothingness, social and other alienation, traumatic conditions and/or other severe psychiatric disorders that propel humans towards suicidal ideation and suicide attempts?
Has such an approach ever worked?
Let me give two examples in which I believe the learnings are replicable.
In the first, the Henry Ford Health System, a non-profit healthcare provider in Detroit, Michigan, USA, introduced an innovative holistic suicide care system in 2001, called Perfect Depression Care Intervention. The approach included six major tactics: committing to perfection (zero care-processes defects, or zero suicides) as a goal; mapping current care processes and developing a clear vision of how patient care must change; partnering with patients to ensure their voice in care redesign; conceptualising, designing, and testing strategies for improvement in four areas identified in the mapping of current care (patient partnership, clinical practice, access to care, and information systems); implementing relevant measures of care quality, continually assessing progress, adjusting the plan as needed, communicating the results and celebrating the victories.
This systematic quality improvement brought about a dramatic reduction in suicide; its high points were in 2008 and 2009, which witnessed zero suicides; since then, while the rate has inched up to 5%, but that number is less than half the US national average.
Detroit’s success has propelled many organisations, cities and countries in the Americas, Europe and Oceania to pursue zero suicide missions. Theirs is not a magic bullet; to achieve even half Detroit’s success, and to sustain it, needs coherent strategy and dogged pursuit. Also, one must insulate such programmes from vested interests, like the pharma industry.
The second example did not start with suicide prevention. Sweden’s Vision Zero’s initial premise was that traffic deaths and car accidents were unacceptable, that the state should go to great lengths to prevent them. Through an act of Parliament in 1997, Sweden called for an end to deaths and serious injuries on Swedish roads.
The improvement happened because of a drastic change of thinking. It widened the responsibility for road safety, from the road user alone, to include road designers. The vision was implemented around ‘plank’ strategies, and it had an action plan that helped it focus. The results: from seven road deaths per 100,000 population in 1997, today they are around two. Vision Zero thinking is now embedded in every part of Swedish life.
In 2008, Sweden adopted Vision Zero for suicide prevention, with these nine strategic interventions.
Promoting better life opportunities in order to support the groups that are most in need
Minimising alcohol consumption in target and high-risk groups
Reducing the availability of means to commit suicide
Educating gatekeepers about effective management of persons with suicide risks
Supporting medical, psychological and psychosocial services in suicide prevention
Disseminating knowledge about evidence-based methods for reducing suicide
Raising competence of key healthcare and prison staff who care for people with suicidal problems
Analysis of suicide cases which occurred within the healthcare system and 28 days after discharge
Supporting voluntary organisations.
A key feature of Vision Zero Suicide is the promotion of the ideal: that suicide is everyone’s responsibility, and first-aid training to help suicidal persons is provided for every citizen. Though it has not met its desired success rate, application of its methods has spread to Singapore, the USA and Europe and West Asia.
Intent, I must add, is not enough.
For example, America as a whole has employed the most tools for suicide prevention, right down to the provincial level, and including a 24/7 national helpline, but in the last decade, the suicide rate has gone up, not down. Thomas Insel, long-time (and now former) director of the USA’s National Institute of Mental Health, considers this his key sorrow.
A plan for India
What can we learn from initiatives in other parts of the world, and replicate here in India?
This is my nine-point programme for India. Let’s call it Nine to Zero.
Make the elimination of suicide not just a national mission but also every citizen’s mission
Jump-start the National Alliance for Suicide Prevention in public, private and NGO-coalition mode
Invest in multidisciplinary research: suicide has a complex aetiology
Think global but act local: Indian states are as different from each other, if not more, than some countries are, and one size will not fit all
A dovetailed suicide prevention strategy is needed at central, state, city and village level; this is a long-haul effort
Learn from the successes and failures of others
and urgently create a National Task force for formulating suicide prevention strategies and implementation plans
Adopt an empirical, evidence-based approach to intervention
Reduce access to the means of suicide, and use technology (to count suicides and suicide attempts, as well as to disseminate why and how it has to be eliminated) and introduce multidisciplinary review of suicide attempts
There is a crying need for a best practices communication strategy, including for media and social media
And Point Ten, or should I say, Point Zero: we must start now.
