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Archives of Suicide Research


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Attempted Suicides in India: A


Comprehensive Look
a b c
Sahoo Saddichha , M. N. V. Prasad & Mukul Kumar Saxena
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

Available online: 27 Jan 2010

To cite this article: Sahoo Saddichha, M. N. V. Prasad & Mukul Kumar Saxena (2010): Attempted
Suicides in India: A Comprehensive Look, Archives of Suicide Research, 14:1, 56-65

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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.
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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 character-
istics 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

INTRODUCTION which implies an annual global mortality


of about 14.5 per 100,000 population.
Suicides continue to be one of the largest Suicide is the thirteenth leading cause of
contributors to the global mortality rate death worldwide and it is predicted that
with approximately one million people the current rate of one death every 40
dying from suicide each year (WHO, seconds will increase to one every 20
2003). The World Health Organization seconds by 2020 (WHO, 2003). The rates
(WHO) estimated that there were 877,000 are no different for India, with suicide rates
suicides worldwide in 2002 (WHO, 2003) varying between 8.1 and 58.3=100,000

56
S. Saddichha et al.

population for different parts of India making it essential to study this region,
(Gururaj & Isaac, 2001). not just for suicides but also for attempted
In India, suicide is a multi-dimensional suicides.
issue with inter-sectoral reach cutting Although there are data available,
across diverse disciplines such as health, however insufficient, on suicides, there is
religion, spirituality, law and welfare. The a serious dearth of knowledge on attempted
number of suicides in the country during suicides. Different small studies around
the last decade (19962006) has recorded the world have observed a frequency of
an increase of 33.9% from 88,241 in 1996 suicide attempts as being up to 1040 times
to 118,112 in 2006. The official adjusted more than completed suicides (Platt, Bille-
suicide rate in India, according to National Brahe, Kerkhof et al., 1992; Schmidtke,
Crime Research Bureau (NCRB) was esti- Bille-Brahe, De Leo et al., 2004). The bur-
mated to be 10.5 per 100,000 population den of such attempts is expected to increase
(NCRB, 2007), although these are widely to 2.4% in 2020 with about 5% to 25% of
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believed to be under-reported. India the population harboring suicidal thoughts


currently occupies the 45th position at any given time and the ratio between an
globally and the 2nd position in the SEAR act, an attempt and a thought believed to
region with respect to suicides committed be in the range of 1:10:100, respectively
(WHO, 2003). The latest data reveal an (WHO, 2003). Cross-national comparisons
alarming rise of suicides with 118,112 of suicide attempts have shown lifetime
persons having committed suicide in 2006 prevalence rates to be between 0.7% and
(NCRB, 2007). If the trend continues, the 5.9% (Weissman, Bland, Canino et al.,
projected figures for 2007 would be around 1999; Welch, 2001). The SUPRE-MISS
119,350 deaths due to suicide. In India, study across 10 sites across the world also
however, suicide is declared legally punish- observed a 0.44.2% prevalence across the
able so there is a great degree of under- sites (Bertolote, Fleischmann, De Leo
reporting (Joseph, Abraham, Muliyil et al., et al., 2005). Although this study was one
2003). Many deaths, particularly in the rural of the largest ever to report on attempts,
areas, are not registered at all (Jha, it was limited by its urban focus which
Gajalakshmi, Gupta et al., 2006), partly may not have been a true representation
because of an inefficient registration system of the actual scenario.
(Bose, Konradsen, John et al., 2006) and With existing resources designed to
partly because families fear the social and identify suicides being few and far between,
legal consequences associated with suicide. health care and registration systems cater-
Andhra Pradesh (AP), the fourth ing only to completed suicides, and with
largest state in India, with a population of the fear of social and legal consequences,
81,554,000 (Population Projection, 2006) it is even more imperative that attempted
ranks third in the number of suicides in suicides be studied. This study aims to
India (13,276)contributing more than add to the existing knowledge by compiling
11% of the total suicides in India. The the first ever comprehensive report on
annual prevalence rates of suicide in AP attempted suicides, hoping to reduce the
are 16.4 per 100,000 population which is lacunae currently existing. Since the
distinctly higher than the national average Emergency Management and Research
of 10.5 per 100,000 population (NCRB, Institute (EMRI) runs a state wide emerg-
2007). The southern part of India, in which ency response services, attempted suicides
this region is located, has in fact, documen- get recorded as medical emergencies. The
ted to have the highest rates of suicide institutional database which has been
(Aaron, Joseph, Abraham et al., 2004), recording all emergencies since mid-2006,

ARCHIVES OF SUICIDE RESEARCH 57


Attempted Suicides in India

therefore serves as a valuable resource to also scrutinized, collated and data entered
compile data on attempted suicides. The into a central database.
research team at the institute therefore As part of the research project, all
aimed to study the demographics of PCRs were reviewed by the research team
attempted suicides in Andhra Pradesh, for the period JanuaryDecember 2007,
and compared then with existing suicide with case records included if they involved
data for the state and India. Further, as emergencies which could be a possible
secondary data analysis, estimated projec- suicide. Since, as has been noted above,
tions of attempts were made for the relatives are wary of reporting suicides,
year 2008, using databases of EMRI and such an exercise was necessary to broaden
NCRB. the database. Once the PCRs had been
reviewed, data were evaluated for com-
pleteness. At the end of the exercise, a total
METHOD of 1007 cases were left for which complete
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data was available and this was compared


Emergency Management and Research with existing resources for the state of
Institute (EMRI), since mid-2005, has been Andhra Pradesh and India.
running the first professional and compre- We recorded all details of the victims,
hensive free emergency services in India, in including socio-demographics, methods of
partnership with different state govern- suicide and 48 hour follow up. Data analy-
ments, by running a single toll-free sis was performed for the primary dataset
number, 108. Currently, 108 services as well as secondary comparisons with
several states including the whole state of NCRB data. Using external data obtained
Andhra Pradesh which is the fifth largest from AP population projections, NCRB
state in India with an area of 276,754 figures for AP as well as total emergencies
sq. km, accounting for 8.4% of Indias attended to by EMRI for the period of
territory. With a fleet of nearly 600 mobile JanuaryDecember 2007, we attempted to
emergency units and an emergency data- estimate the attempted suicides for the per-
base since mid-2006, the research team at iod of 2008 using a 2 stage sampling based
the institute compiled data from January on the following formula (Cochran, 1997):
December 2007 for all cases recorded as The sample mean per subunit in the ith
possible suicide attempts. primary unit,
As a routine, all medical emergencies
X
m
yij
are attended by the EMRI Emergency yi
Services after the call is recorded on dialing j1
m
108. The paramedics attending such calls
are dispatched to the scene of emergency where, yij Value obtained for the jth
and then provide medical interventions subunit in the ith primary unit (Recorded sui-
while filling in all details in the ambulance cides), m Total number of subunits selec-
patient care record (PCR) form. After the ted in the sample from each primary unit.
patient is attended to and delivered to a Overall sample mean per subunit,
hospital if required, these PCRs are
returned to the Institute. Follow up calls X
n
yi
y
are made for each and every patient 48 i1
n
hours later to determine the clinical status
of the individual. The calls, in cases of sus- where, yi The sample mean per subunit
pected suicides, also confirm the clinical in the ith primary unit, n Total number
suspicion of suicide attempt. The PCR is of primary units selected in the sample.

58 VOLUME 14  NUMBER 1  2010


S. Saddichha et al.

b representing number of suicides can


Y RESULTS
be estimated as,
We recorded a total of 1007 attempts at
bN y
Y  suicide. The male:female ratio was about
1.27:1 (Table 1). The age distribution
where N is the Population of Andhra revealed a trend towards the younger
Pradesh (in 000). age group, with most suicide attempts

TABLE 1. Socio-Demographic Characteristics of Attempted Suicides with State and National


Comparisons of Completed Suicides

AP (EMRI) AP (NCRB 2006) All India (NCRB 2006)

Gender
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Male 566 (56.2%) 8863 (66.8%) 75702 (64.1%)


Female 441 (43.8%) 4413 (33.2%) 42410 (35.9%)
Age distribution
Below 14 years 30 (3.0%) 364 (2.7%) 2464 (2.1%)
1529 years 496 (49.3%) 4683 (35.3%) 42216 (35.7%)
3044 years 333 (33.1%) 4635 (34.9%) 40699 (34.5%)
4559 years 99 (9.8%) 2615 (19.7%) 23606 (20.0%)
Above 60 years 49 (4.9%) 979 (7.4%) 9127 (7.7%)
Location of suicide
Residence 711 (70.6%)
Roadside 131 (13.0%)
Others 165 (16.4%)
Occupation
Daily wage worker 521 (51.7%) 5108 (38.4%) 37862 (32%)
Housewife 176 (17.5%) 2156 (16.2%) 25063 (21.2%)
Self-employed 90 (8.9%) 1468 (11.0%) 10577 (9.0%)
Student 56 (5.6%) 512 (3.9%) 5857 (5.0%)
Unemployed 94 (9.3%) 429 (3.2%) 8886 (7.5%)
Others 70 (7.0%) 3603 (27.1%) 29867 (25.3%)
Method of suicide
Hanging 516 (51.2%) 2759 (20.8%) 38706 (32.8%)
Drugs and poisons 142 (14.1%) 1634 (14.9%) 20773 (17.7%)
Burns 114 (11.3%) 1016 (7.7%) 10243 (8.7%)
Insecticide Poisoning 210 (20.9%) 5347 (40.3%) 22947 (19.4%)
Others 25 (2.5%) 2510 (16.3%) 25443 (21.4%)
Victim status at 48 hrs
Left hospital 556 (56.2%)
All right and discharged 131 (13.0%)
All right but still in hospital 105 (10.4%)
Critical 154 (15.3%)
Expired 61 (6.1%)

ARCHIVES OF SUICIDE RESEARCH 59


Attempted Suicides in India

occurring in the 1545 year age group. there were significant differences noted
Most of the recorded attempts were at among different age-groups. While the
the residence of the victims (71%), com- younger victims (those below 14 years)
mitted mainly by daily wage workers used drugs and insecticide poisoning, the
(52%) using hanging and insecticide poi- elderly age-group (those above 60 years)
soning as the most common methods used hanging and drug overdoses as pre-
(72%). When followed up at 48 hours, ferred methods (p < 0.001). The rest of
about a half of all victims had left hospital the age groups commonly used hanging
with no further details available, and 61 had as the most common method of suicide.
expired. Forty-eight hour follow up status revealed
Completed suicide data available from the highest mortality with self-immolation
the National Crime Research Bureau for and insecticide poisoning. Drug overdoses
the state of Andhra Pradesh and for the and other methods of poisoning appeared
entire country has also been provided for to be the most non-lethal methods.
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easy comparisons (Table 1). As can be Since the distribution of total attempts
noted, the gender and age distribution of matched the number of total emergencies
attempted suicides as recorded by us and serviced by us and the total suicides in
completed suicides as recorded by NCRB AP according to NCRB (Table 1), we then
are similar. However, we noted a higher attempted to estimate the number of
prevalence of attempts among daily wage attempts for the forthcoming year 2008.
workers than was noted by the NCRB data Using the formula mentioned in the meth-
set, although all other groups were similar. odology, the estimated numbers across
Similarly, in methods of suicide, we noted a various age groups (per 1000 population)
higher prevalence of hanging with other for both genders and for the total popu-
groups remaining near-similar. lation has been given in Figures 1(a, b &
Using co-relations between various c). The mean estimated attempts for males
groups and method of attempts (Table 2), was 3.23.8 per 1,000 population, for
it was observed that there was a significant females was 3.33.7 per 1,000 population
difference in gender, with males preferring and for the total population was 6.47.6
hanging and insecticide consumption as per 1,000 population.
methods while females preferred hanging
and self-immolation as methods of self-
harm (p < 0.001). An analysis of occupa- DISCUSSION
tions showed that although hanging was
the commonest method across all occu- Suicide is an important, largely preventable
pational groups, there were significant public health problem. Suicide attempters
differences in other methods (p 0.017). often outnumber completed suicides by a
While laborers, students and the unem- ratio of 10:1 (WHO, 2003). As literature
ployed preferred insecticide consumption, on this phenomenon is relatively rare
housewives preferred self-immolation and (Diekstra, 1993; Latha, Bhat & DSouza,
students overused drugs and poisons as 1996; Schmidtke, Bille-Brahe, De Leo
common methods of attempting suicide. et al., 1996; Thanh, Jiang, Van et al.,
Area-wise distribution revealed hanging to 2005), we believe that our study, being
be once again the most common method the first comprehensive study of suicide
followed by insecticide poisoning across attempters in India, could shed light on a
all areas, however, significantly, there were hitherto unexplored area. Since the only
no cases of self-immolation or overdose of other study came from Chennai, which is
drugs in tribal areas (p 0.007). Similarly, a single metropolitan city in South India

60 VOLUME 14  NUMBER 1  2010


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

Hanging No Drugs and Insecticide


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

1) Gender
Male 283 (50.0) 88 (15.5) 46 (08.1) 132 (23.3) 17 (3.0) 19.1 4 0.001
Female 233 (52.8) 54 (12.2) 68 (15.4) 78 (17.7) 8 (1.8)
2) Occupation
Laborer 266 (51.1) 70 (13.4) 55 (10.6) 118 (22.6) 12 (2.3)
Housewife 96 (54.5) 25 (14.2) 26 (14.8) 29 (16.5) 0 (0) 35.5 20 0.017
Business 52 (57.8) 18 (20.0) 6 (6.7) 11 (12.2) 3 (3.3)
Student 25 (44.6) 7 (12.5) 5 (8.9) 16 (28.6) 3 (5.4)
Unemployed 47 (50.0) 12 (12.8) 14 (14.9) 20 (21.3) 1 (1.1)
Others 30 (42.9) 10 (14.3) 8 (11.4) 16 (22.9) 6 (8.6)
3) Area
Rural 445 (50.7) 131 (14.9) 98 (11.2) 187 (21.3) 17 (1.9) 21.2 8 0.007
Urban 58 (54.2) 11 (10.3) 16 (15.0) 16 (15.0) 6 (5.6)
Tribal 13 (59.1) 0 (0) 0 (0) 7 (31.8) 2 (9.1)
4) Age of patient
Below 14 1 (3.3) 16 (53.3) 4 (13.3) 9 (30.0) 0 (0.0)

ARCHIVES OF SUICIDE RESEARCH


Years
1529 years 253 (51.0) 71 (14.3) 56 (11.3) 102 (20.6) 14 (2.8) 70.5 16 <0.001
3044 years 185 (55.6) 32 (9.6) 43 (12.9) 67 (20.1) 6 (1.8)
4559 years 58 (58.6) 12 (12.1) 7 (07.1) 21 (21.2) 1 (1.0)
60 and above years 19 (38.8) 11 (22.4) 4 (08.2) 11 (22.4) 4 (8.2)
10) Victim status at 48 hours (n 451)
All right & discharged 79 (35.6) 17 (36.2) 4 (05.2) 25 (27.8) 6 (40.0) 53.5 12 <0.001
All right but still 54 (24.3) 13 (27.7) 9 (11.7) 25 (27.8) 4 (26.7)
in hospital
Critical 67 (30.2) 14 (29.8) 44 (57.1) 25 (28.9) 3 (20.0)
Expired 22 (9.9) 3 (6.4) 20 (26.0) 14 (15.6) 2 (13.3)

61
Note.  p < 0.05.
Attempted Suicides in India
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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., et al., 2005), primarily composed of young


2005), we believe that it may not have adults. The male:female gender ratio is
represented the true picture of suicide around 1.27:1, which is similar to that of
attempters. This study has, we believe, the NCRB data set available for the state
tapped all suicide attempters which have and India (NCRB, 2007) and the WHO=
been attended to by our 108 service, EURO multicentre study which observed
thereby making it possible that it may have a ratio of 1:0.7 to 1:2.3 (Schmidtke,
succeeded in compiling a comprehensive Bille-Brahe, De Leo et al., 2004).
report on attempts which may have escaped Similar to other countries, self-
the catchment of previous studies. More- poisoning and hanging were observed as
over, since earlier studies have demon- the most common methods of suicide
strated that most suicides in India come to attempts. The ingestion of insecticides,
medical attention (Bertolote, Fleishmann, medications or other poisons accounted
De Leo et al., 2005), we believe that the for more than a third of all suicide attempts
number of victims missed may have been identified by the emergency services,
small. This sample of attempted suicides similar to other studies from India (Arun,
identified by our emergency services is like Yoganarasimha, Kar, et al., 2007; Bhatia,
those identified in developed countries in Aggarwal, & Aggarwal, 2000; Gajalakshmi
other studies (Diekstra, 1993; Latha, Bhat, & Peto, 2007; Joseph, Abraham, Muliyil
& DSouza, 1996; Schmidtke, Bille-Brahe, et al., 2003). Although suicide by pesticide
De Leo et al., 1996; Thanh, Jiang, Van poisoning is a common method adopted

62 VOLUME 14  NUMBER 1  2010


S. Saddichha et al.

by developing countries, particularly in prevented with certain public health


China, India, and Sri Lanka (Eddleston & policies. Since restricting the access to and
Phillips, 2004; Gunnell & Eddleston, the availability of prevailing methods such
2003; Latha, Bhat, & DSouza, 1996; as insecticides and drugs can be effective in
Phillips, Yang, Zhang et al., 2002; reducing the frequency of suicide attempts
Somasundaram & Rajadurai, 1995), we (Bowles, 1995; Roberts, Karunarathna,
have also observed an increasingly signifi- Buckley et al., 2003), there is an urgent need
cant number attempting suicide by hanging. to regulate the distribution, packaging and
This may possibly be due to the fact that sale of these substances since these are read-
many of our suicide attempters are from ily available at low cost in the market. It is
the urban areas where the use of pesticide also important to improve treatment facili-
is uncommon. However, it appears that sui- ties available without increasing the stigma
cide by hanging is equally preferred across since many of those who attempt suicide
all age groups except for the extremes of require medical attention and they are at high
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ages. It is possible to conjecture that mod- risk for completed suicide. Policies also need
eling (based on media coverage) may play a to take in consideration the prevailing social,
role in this choice of method, but as it is economic and cultural factors when attempt-
less lethal than the other methods, it poss- ing to tackle suicides due to impulsivity and
ibly reflects the lack of planning for such stress and factor in the apparent widespread
victims who may have decided on attempt- acceptability of such an option in society
ing suicide on an impulse (Kim & Singh, (Jacob, Jayakaran, & Manoranjitham, 2006).
2004). This calls for developing prevention After medical intervention, brief
programs for those who express suicidal intervention in the form of individual
thoughts with or without a plan since every information sessions at time of discharge
attempt is a cry for help. and appropriate follow up has proved
Among the other methods, self- effective even in developing countries
immolation was also one of the methods (Fleischmann, Bertolote, J.M., Wasserman
favored mainly by women, which is a et al., 2008). In addition, a tele-help
unique phenomenon in the Indian subcon- service could also significantly reduce the
tinent (Batra, 2003), and unfortunately also number of suicide deaths by providing
the most lethal. This calls for a different support and counseling with maintenance
approach as women use easily available of complete anonymity and confidentiality
means to end their lives, therefore, restrict- (De Leo, Dello Buono, & Dwyer, 2002).
ing access to poisonous substances or This article presents, for the very first
prescription drugs may be less effective in time, the unique characteristics of
preventing suicidal behavior. However, in attempted suicides for a large population
such circumstances, the role of psycho- comprising both urban and rural areas,
education and community-based agencies something which has been lacking in litera-
can be of immense help to those in distress. ture. Numerous difficulties of a logistic and
Based on the projected estimates, the methodological nature have to be accepted,
mean estimate for males calculates to and the present data will have to undergo
around 3.23.8 per 1000 population and rigorous and critical appraisal before any
that for females around 3.33.7 per 1000 attempt can be made to specifically address
population, giving a mean of around 7 the issues of comparing the results with
per 1000 for the entire population. This those of other studies, or of making gener-
amounts to a serious epidemic of suicides alizations of the results. We also believe
in the coming years, which could result in that our data may be limited by the fact that
a number of deaths that can be easily be the study may have missed cases of

ARCHIVES OF SUICIDE RESEARCH 63


Attempted Suicides in India

attempted suicide which are self-referred to Accidental Deaths and Suicides in India 2006. New Delhi:
the hospitals or brought there by other National Crime Records Bureau Ministry of
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