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September 13, 2019 Friday 10:48:14 AM IST

A Question of Life and Death


    • The man who kills himself kills all men. As far as he is concerned, he wipes out the world” - G.K. Chesterton
  •   “But in the end, one needs more courage to live than to kill himself”-Albert Camus

Suicide is a global public health concern. Close to 8 lakh people lose their lives in suicide incidents across the world every year. Suicide is estimated to contribute more than 2% of the global burden of diseases by 2020. Suicide impacts the most vulnerable of the world’s population and places a larger burden on low and middle-income countries, which are often ill-equipped to meet the general health and mental health needs. Suicide knows no boundaries and cuts across every socio-demographic level and regions of the world. Suicide is now one of the leading causes of mortality among 15 to 29-year-old around the world; young women and men in most productive years of their lives. A suicide takes place every 40 seconds globally, men leading with suicide committed and women with suicide attempted. This is a huge public health problem, calling for urgent attention and intervention by policymakers, clinicians, educators, scholars, spiritual leaders and others with a focus on prevention, services, research, education and appropriate allocation of resources - human and financial - to successfully achieve these tasks.

Definition and terms


Suicide is as an act with a fatal outcome that is deliberately initiated and performed by the person in the knowledge or expectation of its fatal outcome.Suicidal attempt is the act that happenswhen the person fails in his/ her bid to commit suicide. Deliberate Self Harm (DSH)occurs when the person harms himself with injuries, when there may or may not be an intention to die. Suicidal behaviourspectrum includes suicidal ideation, plan, attempt, gesture or completed suicide. Suicide crisis is the brief situation where the balance of suicidal behaviour process dangerously tilts towards suicide, often triggered by some incident.


 Suicide is a complex phenomenon. The insurmountable disparity between expectations and outcome, real or imagined, puts tremendous pressure on the mind, blinding its logic, forcing it to a conclusion of escape, by suicide. The extent and irrationality of expectations can break all plausible boundaries, and can be the result of faulty learning or faulty cognition - often may be named as illness, and often amenable to correction. The stress, strains and influences - of culture, belief system, and globalisation - on individual human beingwill be unfathomable,unless the modern man is trained to handle them, so that his strained mind can sufficiently rest to get itself rejuvenated.

Suicide being a sensitive issue, and even illegal in some countries, it is very likely that it is under-reported. In richer countries, male-to-female suicide ratio is 3:1, whereas in the lower and middle-income countries, it is much lower.Globally, suicide accounts for 50% of all violent deaths in men and 71% in women. Suicide rates are highest among the young; suicide is the second leading cause of death among 15-29-year-olds, globally. Suicide is the second leading cause of death among children, adolescents, and young adults in theage group of 5to24years. For every suicide, there are many more people who attempt suicide.

Myths about suicide

There are several myths about suicide; the leading ones are listed below:

  • Myth: People who talk about suicide do not mean to do it. Fact: People who talk about suicide may be reaching out for help or support. A significant number of people contemplating suicide are experiencing anxiety, depression and hopelessness and may feel that there is no other option.
  •  Myth: Most suicides happen suddenly without warning. Fact: The majority of suicides have been preceded by warning signs, whether verbal or behavioural. It is important to understand what the warning signs are and look out for them.
  •  Myth: Once someone is suicidal, he or she will always remain suicidal. Fact: Heightened suicide risk is often short-term and situation-specific. While suicidal thoughts may return, they are not permanent and an individual with previously suicidal thoughts and attempts can go on to live a long life.
  •  Myth: Talking about suicide is a bad idea and can be interpreted as an encouragement. Fact: Given the widespread stigma attached to suicide, most people who are contemplating suicide do not know whom to speak to. Talking openly can give an individual other options or the time to rethink his/her decision, thereby preventing suicide, rather than encouraging suicidal behaviour.
  • Risk factors

    An earlier suicide attempt isgenerally a prominent factor for committing suicide. Risk factors at the individual level include previous suicide attempts, mental disorders, harmful use of alcohol, financial loss, chronic pain and a family history of suicide.Risk factors at the level of society include difficulties in accessing health care and in receiving proper care; easy availability of the means for suicide; inappropriate media reporting that sensationalizes suicide,thereby increasing the risk of ‘copycat’ suicides; and stigma against people who seek help for suicidal behaviours as well as mental health and substance abuse problems. Risks linked to the community and relationships include war and disaster, stresses of acculturation (such as among indigenous peoples or displaced persons), discrimination, a sense of isolation, abuse, violence and conflictual relationships. It has been reported that abused girls (both emotionally, sexually and physically) are prone to depression and other mental health issues which increase the suicidality.

    Causes of suicide

    Stress diathesis models suggest that negative results of all the predisposing factors are activated by stress. Exam-related suicide cases are rising in India. As many as 2,646 people killed themselves in 2015 due to 'failure in examination'which accounted for 2 per cent of all the suicide incidents that occurred that year. Adolescence is a period of life which is exciting as well as a time of significant changes in life. Stress factors for youngstersinclude extreme pressure to perform academically, bullying at school, and violence and abuse both at home and community.

    The majority of children and adolescents who attempt suicide have a significant mental health disorder, usually depression. Other risk factors include family history of suicide attempts, exposure to violence, impulsivity, aggressive or disruptive behaviour, access to firearms, bullying, feelings of hopelessness or helplessness and acute loss or rejection.

    Warning signs

    Among younger children, suicide attempts are often impulsive. They may be associated with feelings of sadness, confusion, anger, or problems with attention and hyperactivity. Among teenagers, suicide attempts may be associated with feelings of stress, self-doubt, pressure to succeed, financial uncertainty, disappointment, and loss. For certain teens, suicide may appear to be a solution to their problems.Children and adolescents thinking about suicide may make openly suicidal statements or comments such as, "I wish I was dead," or "I won't be a problem for you much longer." Other warning signs associated with suicide may include changes in eating or sleeping habits, frequent or pervasive sadness, withdrawal from friends, family, and regular activities, frequent physical complaints such as stomach-aches, headaches and fatigue, decline in the quality of schoolwork and preoccupation with thoughts on death and dying.

    A direct statement about the intention to die or kill oneself is the most important predictive factor for suicide. It should be taken seriously and urgent care and help should be given.


    Management of suicidal problems

    Depression and suicidal feelings are treatable mental disorders. The child or adolescent needs to have his or her illness recognized and diagnosed, and appropriately treated with a comprehensive treatment plan. Most persons who engage in suicidal behaviour are ambivalent about wanting to die at the time of the act, and some suicidal acts are impulsive responses to acute psycho-social stressors.

    It is well known that 80% of people who commit suicide do so due to emotional and mental problems. Depression is the single biggest cause for suicide. We must know Depressive Disorders are eminently treatable. Getting them professional help remains crucial. We have several instances, when even medical personnel have not referred people with severe depression for psychiatric help. This may be due to stigma or because we are not trained to communicate properly regarding diagnosis of mental problems to patients.

    Many doctors may not like to take up the responsibility of communicating unpleasant truths. Family members should also share an equal blame. Often, they allow the depressed person to suffer in silence, without getting him psychiatric help. This may end up in suicide, thus ending a valuable and productive life. This irreparable loss will shatter the family. We must all act before this tragedy happens.

    Another major cause of suicide is alcoholism and drug addiction. Nearly 10% of all alcoholics commit suicide. Thus, public awareness about the risk of alcohol and drug abuse is very important.

    Suicide prevention

    It is an umbrella term which includes all activities thataim at decreasing the incidence of suicidal behaviour. It should include mental health and the health system in general, education system, policy makers, media, police and general public. It should also include prevention strategies and pro-active measures.

    Strategies to counter the risk factors can be approached in three ways. The ‘Universal’ prevention strategies, which are designed to reach an entire population, may aim at increasing access to healthcare including mental health, reducing substance abuse,limiting access to the means for suicide and promotion of responsible media reporting. The ‘Selective’ prevention strategies target the vulnerable groups such as persons who have suffered traumaor abuse, those affected by conflict or disaster, refugees andmigrants, and persons bereaved by suicide, apart from training ‘gatekeepers’ who assist the vulnerable, and offeringhelping services such as helplines. The ‘Indicated’ strategies target specific vulnerable individuals, with community support,follow-up for those leaving healthcare facilities, education andtraining for health workers, and improved identification andmanagement of mental disorders including substance abuse, encouragingprotective factors such as strong personal relationships, personal belief system and positive coping strategies.

    Means restriction (restricting access to the means of suicide - limiting access to pesticides and firearms; putting barriers on subways, bridges and iconic buildings; changing packaging regulations for medication) is a key component of suicide prevention. It provides an opportunity for these individuals to reflect on what they are about to do and, hopefully, for the crisis to pass.

    Parents have a major role in protecting their children from abuse, as well as providing emotional support when depressive symptoms and ultimately suicidal thoughts arise. Reducing the parental pressure, especially on academic performance, has a key role in reducing stress. Young people should feel free to talk and seek the necessary help they want which requires de-stigmatisation of suicidal behaviours and mental health issues.


    World Suicide Prevention Day

    September 10is being organized by the International Association for Suicide Prevention (IASP), co-sponsored by WHO, every year, highlighting its public health importance. Decriminalisation of suicide is an important legal move towards the preventive approach, which will increase the reporting of incidents of suicide once fear of legal recriminations is eliminated. This allows for more accurate estimates of the true extent of the issue.


    Suicide is a major public health problem of our times. It is one among the 10 leading causes of death. It is the third major cause of ‘Life Years Lost’, next only to heart disease and cancer. The highest risk of suicide is among the adolescents and old people. People who are divorced, separated or living singly also show a high incidence. The suicide rate among young people is strikingly high in Southern India. Most of them commit suicide on an impulse. Hence bringing help to them, during times of crisis, will be a life-saving act.

    Unfortunately, suicide prevention is too often a low priority for governments and policy-makers. Suicide prevention needs to be prioritized on global public health and public policy agendas and awareness of suicide as a public health concern must be raised by using a multi-dimensional approach that recognizes social, psychological and cultural factors. Given the magnitude of suicidal behaviours, there is an urgent need for governments to develop a comprehensive national suicide prevention strategy that contextualizes the problem and outlines specific actions that can be taken at multiple levels. Suicide prevention is a collective responsibility and must be spearheaded by governments and civil society together throughout the world.

    Prof Roy Abraham Kallivayalil & Dr Soumya P Thomas

    *Prof. Roy Abraham Kallivayalil MD,DPM
    Secretary General, World Psychiatric Association   
    Professor & Head, Dept of Psychiatry

    Pushpagiri Institute of Medical Sciences,  

    Tiruvalla, Kerala- 689 101, India


    **Dr Soumya P Thomas MD

    Senior Resident

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