Problem Statements

“He was such a coward.”

“She was an escapist.”

“Don’t talk such rubbish, you are strong enough and can handle such stress!”

What are these sentences talking about?

These are some common statements that we hear in conversations with a person who is ‘suicidal’. “Suicidal” - such a misleading label! As if the person was bent upon committing suicide since the time they was born.

Suicide means, in simple language, killing or injuring oneself, with the explicit intention to kill oneself. There are many underlying psychological and social factors behind the thought of killing or harming oneself. Let’s try to go deep into the ocean to get a glance of the iceberg.

How severe is the problem? Suicide is the leading cause of death for those below forty years of age, but elderly people are also at risk (or rather an increased risk). One in sixty persons is affected by suicide, directly or indirectly. Now, consider the 1.2 billion of country’s population to get an idea of the magnitude. Besides, for every death due to suicide, there are 8-10 other unsuccessful suicide attempts which lead to marked guilt, shame and stigma.

Is this kind of behaviour unique to humans? Not exactly. There are instances of other mammals, reptiles and insects indulging in similar types of behaviour. A wasp mother’s sacrifice of her body for her younger ones; a male spider’s endangering of its life for the sake of reproduction; a meercat’s fight against a predator to save rest of the herd; a crane’s killing itself while mourning the death of the partner; a snake’s fatalistic attitude when deserted from its mate - and the list goes on. It makes us question whether ‘suicide’ is indeed an evolutionary form of maladaptive behaviour prevalent in all species.

The Why and How of Suicides

Various theories have attempted to explain suicide. Durkheim’s social theory talks about the typology of suicide.

In altruistic suicide, a person sacrifices him/her self for a greater cause (such as self-immolation of a protestor, suicide bombing (controversial) or a service person, particularly frontline workers.)

Egoistic suicide: A person who is feeling socially lonely or outcasted may end one’s life (such as age and gender minorities, socially impoverished groups, suicide in elderly/ abandoned family members, most recent example being suicidal tendencies in people under isolation/quarantine.)

Anomic suicide: Drastic and severe change in socioeconomic situation, including academic, occupational, romantic, interpersonal relationships, etc., may lead to intense stress (such as farmer suicides following crop failure, student suicides after failing in academic commitments, suicides in break-up or divorce or in rape victims.)

Fatalistic suicide: When a person feels trapped in a rigid and distressing situation (debt trap, domestic violence or dowry are important predictors of suicide). Situations are perceived as being ‘ultimate’ without any visible and possible escape.

There are many other social and psychological theories that can be used to explain suicide. However, practically and pragmatically, these factors and types are mixed and rarely come in isolation.

Medicine and psychiatry try to explain the behaviour through biological, psychological and social factors and their interactions, such as a tendency of clustering of suicide events in blood-related family members, alteration of some brain chemicals, low mood or depression, feelings of hopelessness, helplessness and worthlessness, as well as personality traits.

An example of the same may be a major stressor (divorce, failure, bereavement, or any other event) that triggers a series of processes - irregularities of daily routines, sleep cycle- low mood - ‘not so good’ coping mechanisms, maladaptive behaviour patterns or personality style, improper social support - causing altered neuronal activities in the brain such as deterioration in thinking capacity and judgement and increase in negative thoughts and behaviours.

It is important however to stress on the fact that though psychiatric problems (like severe depression and schizophrenia) can be vital risk factors for suicide, all individuals who attempt suicide are not suffering from a mental disorder. This misconception often stigmatizes suicide and creates barriers in timely help-seeking.

There are other scenarios which may lead to suicide. One of them is ‘copycat suicide’ where there can be many suicides linked temporally and geographically to a well-publicised suicide event. For example - suicide clusters in nationwide mourning or protests. Copying the typology of suicide from the media is also known as the Werther Effect.

It is important to distinguish people (especially youth) who frequently superficially cut their body parts or indulge in other injurious behaviours including threats to injure or kill self, but they never do kill themselves. These are called deliberate self harms (DSH), where the intention, unlike suicide, is not to kill self, but rather to relieve distress or gain attention, or to express an emotional need.

The ‘Untouchability’ of Suicides

Now, coming to societal attitudes toward suicide - people try to be supportive to their near and dear ones. While doing so, many a times, due to lack of knowledge, we may land up mismanaging the situation. For example, out of fear or shame, we may ignore a person who talks about such thoughts or feels very low.

Common replies are “You are not thinking about suicide, are you?” or “Only weak people talk like this” or “Be strong and live. There are many things to live for.” We fear digging into such thoughts, when emotional support and lending a helping hand can do much better than judgemental comments or advice.

We often start labelling persons using derogatory terms like ‘suicidal,’ ‘mental’, ‘insane,’ ‘failure,’ ‘escapist,’ ‘hit wicket,’ ‘zero,’ ‘weak minded’ and so on. Rumours and misinformation convert facts to myths that may further deepen the abyss of stigma, segregating already distressed individuals.

We live in a society of differentiation. A farmer or student dies by suicide and our reactions are, “Oh! S/he was a farmer and farmers die by suicide” or “The students cannot handle stress.” We justify them.

On the flip side, when a celebrity dies by suicide, our reactions are different, “We are shocked,” “S/he can’t do this,” “S/he had everything. Why did s/he do it?” We try to challenge them. These labels push the individuals to be more secretive, ashamed of themselves, more distressed - and increase the risk of suicide. Events in the recent past have brought this dichotomy to light yet again.

There is another societal trend of rationalisation or romanticization of suicide. This implies that the person has chosen death out of their voluntary and free choice. In popular books and movies, suicide is portrayed as a glamorous end to life.

The first idea is controversial (like the concept of euthanasia), while the second is outright maladaptive as it portrays suicide as a healthy coping strategy. People who are depressed may often lose self-judgement thereby acting on emotional impulses which could have been prevented.

Every Life is Worth Living

10th September is considered as the “World Suicide Prevention Day” and for the last three years, the theme for the same has been “Working together to prevent suicide.”

This is not the work of a single sector of people, but a collective responsibility of many - the individual, family, friends, local communities, cultures, society, political, economic, health, legal system, education and many more. Each individual irrespective of their profession, ability, or social status can serve as a potential gatekeeper against a premature death due to suicide.

In universal prevention, the aim is not only to prevent death, but also to make life more enriched for the population as a whole. We can target the universal stresses for this. Government and NGOs can work together in creating social security, enforcing laws against exploitation, educating people, preventing domestic abuse, encouraging life skills training of students, informing the public about causes of suicide, the warning signs and services available.

Creating a national suicide prevention plan as pervasive as the Pulse Polio Programme is also needed. Various Western nations have a systematic suicide audit, which serves both for adequate reporting as well as providing data for research.

The inclusion of Suicide Prevention in the National Mental Health Policy (NMHP) of our country and de-criminalizing suicide in the Mental Healthcare Act (MHCA), 2017 have been welcome reforms, which can prevent under-reporting and promote help-seeking. However, the practical implementation of these legislations are far from optimal even today.

Selective interventions target people who are experiencing distress right now. Early identification of such individuals and prompt treatments along with mitigation of external factors may help. It is time to de-mystify the management of suicide, to help understand that prevention is possible.

Fighting stigma and raising awareness will help prompt detection and early intervention. Most suicides can be prevented, but only if we are aware and sensitive. Retrospective speculation and theorizing the likely possibilities after a death that has already occurred benefits no one.

Media has an important role to play here, specifically while reporting suicides. Akin to discussing any injustice in the societal system, it needs to take care that unintentional labelling or glorifying a suicide event is avoided. The proper manner of reporting needs to be kept in mind - instead of “The person committed suicide due to a debt trap,” it can be better reported as “The person was in distress due to debt trap and died by suicide.”

Every life is worth living and hence, worth saving!

Help lines: There is no pan India government helpline till now. However, many NGOs have come forward to compensate for this lack, and their services can be looked up on the internet. 104 is a toll-free help line used by some states. Various Central Mental Healthcare institutes have certain helplines (not specific to suicide), which are available at their respective websites.

Warning Signs of Suicide

These may come in clusters or singly

Personal factors-

1. Age extremes

2. Staying alone

3. Loneliness

4. Separated, widowed or divorced

5. Financial burden or debt

6. Abuse

7. Mental illness

[ It is important to understand that not all people with these risks attempt suicide. However, these factors increase the chances of the same.]

Talking about-

1. Wanting to die

2. Overwhelming guilt or shame

3. Being a burden to others

Feeling-

1. Empty, hopeless, trapped or having no reason to live

2. Extremely sad, more anxious, agitated or full of rage

3. Unbearable emotional or physical pain

New changes in behaviours such as-

1. Making a plan or researching ways to die

2. Withdrawing from friends or family members, saying goodbye, giving away important items or having a will

3. Risky and reckless behaviours like driving in excessive speed, substance abuse, etc.

4. Showing extreme mood swings.

5. Eating or sleeping too much or too less

6. Consuming drugs or alcohol more often

(Dr Nirmalya Mukherjee and Dr Debanjan Banerjee are psychiatrists at National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru)